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Rafik ST, Vaidya JS, MacRobert AJ, Yaghini E. Organic Nanodelivery Systems as a New Platform in the Management of Breast Cancer: A Comprehensive Review from Preclinical to Clinical Studies. J Clin Med 2023; 12:jcm12072648. [PMID: 37048731 PMCID: PMC10095028 DOI: 10.3390/jcm12072648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/20/2023] [Indexed: 04/05/2023] Open
Abstract
Breast cancer accounts for approximately 25% of cancer cases and 16.5% of cancer deaths in women, and the World Health Organization predicts that the number of new cases will increase by almost 70% over the next two decades, mainly due to an ageing population. Effective diagnostic and treatment strategies are, therefore, urgently required for improving cure rates among patients since current therapeutic modalities have many limitations and side effects. Nanomedicine is evolving as a promising approach for cancer management, including breast cancer, and various types of organic and inorganic nanomaterials have been investigated for their role in breast cancer diagnosis and treatment. Following an overview on breast cancer characteristics and pathogenesis and challenges of the current treatment strategies, the therapeutic potential of biocompatible organic-based nanoparticles such as liposomes and polymeric micelles that have been tested in breast cancer models are reviewed. The efficacies of different drug delivery and targeting strategies are documented, ranging from synthetic to cell-derived nanoformulations together with a summary of the interaction of nanoparticles with externally applied energy such as radiotherapy. The clinical translation of nanoformulations for breast cancer treatment is summarized including those undergoing clinical trials.
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Affiliation(s)
- Salma T. Rafik
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
- Department of Clinical Pharmacology, Faculty of Medicine, Alexandria University, Alexandria 21516, Egypt
| | - Jayant S. Vaidya
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
| | - Alexander J. MacRobert
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
| | - Elnaz Yaghini
- Division of Surgery and Interventional Science, Faculty of Medical Sciences, University College London (UCL), London W1W 7TY, UK
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Kolberg HC, Niesing H, Vaidya JS, Akpolat-Basci L, Maguz A, Hoffmann O, Loevey G, Stephanou M, Kolberg-Liedtke C. Breast Conserving Surgery in Combination With Targeted Intraoperative Radiotherapy Compared to Mastectomy for In-breast-tumor-recurrence. Anticancer Res 2023; 43:733-739. [PMID: 36697057 DOI: 10.21873/anticanres.16212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND/AIM Mastectomy is the standard treatment of in-breast-recurrence of breast cancer after breast conserving surgery (BCS) and external beam radiation therapy (EBRT). In selected cases, it is possible to preserve the breast if targeted intraoperative radiotherapy (TARGIT-IORT) can be given during the second lumpectomy. This is a comparative analysis of overall survival and quality of life (QoL). PATIENTS AND METHODS Patients in our database with in-breast-recurrence and either mastectomy or BCS and TARGIT-IORT were included. Identified patients were offered participation in a prospective QoL-analysis using the BREAST-Q questionnaire. The cohorts were compared for confounding parameters, overall survival, and QoL. RESULTS Thirty-six patients treated for in-breast-recurrence were included, 21 had received a mastectomy and 16 patients had received BCS with TARGIT-IORT. Mean follow-up was 12.8 years since primary diagnosis and 4.2 years since recurrence. Both groups were balanced regarding prognostic parameters. Overall survival was numerically longer for BCS and TARGIT-IORT, but the numbers were too small for formal statistical analysis. No patient had further in-breast-recurrence. Psychosocial and sexual wellbeing did not differ between both groups. Physical wellbeing was significantly superior for those whose breast could be preserved (p-value=0.021). Patient-reported incidence and severity of lymphedema of the arm was significantly worse in the mastectomy group (p=0.007). CONCLUSION Preserving the breast by use of TARGIT-IORT was safe with no re-recurrence and no detriment to overall survival in our analysis and led to a statistically significant improvement in physical wellbeing and incidence of lymphedema. These data should increase the confidence in offering breast preservation after in-breast-recurrence of breast cancer.
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Affiliation(s)
- Hans-Christian Kolberg
- Department of Gynecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany; .,Phaon Scientific GmbH, Wiesbaden, Germany
| | - Helena Niesing
- Department of Gynecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, U.K
| | - Leyla Akpolat-Basci
- Department of Gynecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany
| | - Abdrhman Maguz
- Department of Gynecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany
| | - Oliver Hoffmann
- Department of Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
| | | | - Miltiades Stephanou
- Department of Gynecology and Obstetrics, Marienhospital Bottrop, Bottrop, Germany
| | - Cornelia Kolberg-Liedtke
- Phaon Scientific GmbH, Wiesbaden, Germany.,Department of Gynecology and Obstetrics, University Hospital Essen, Essen, Germany
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Onal C, Sezen D, Oymak E, Bölükbasi Y, Spratt DE, Ward MC, Fasola CE, White RL, Bentzen SM, Khan AJ, Vicini F, Shah C, Vaidya JS, Bulsara M, Wenz F, Sperk E, Massarut S, Alvarado M, Williams NR, Brew-Graves C, Bernstein M, Holmes D, Vinante L, Pigorsch S, Lundgren S, Uhl V, Joseph D, Tobias JS. In Regard to Hammer et al. Int J Radiat Oncol Biol Phys 2023; 115:253-254. [DOI: 10.1016/j.ijrobp.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 10/03/2022] [Indexed: 12/15/2022]
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Vaidya JS, Bulsara M, Wenz F, Sperk E, Massarut S, Alvarado M, Williams NR, Brew-Graves C, Bernstein M, Holmes D, Vinante L, Pigorsch S, Lundgren S, Uhl V, Joseph D, Tobias JS. The TARGIT-A Randomized Trial: TARGIT-IORT Versus Whole Breast Radiation Therapy: Long-Term Local Control and Survival. Int J Radiat Oncol Biol Phys 2023; 115:77-82. [PMID: 35998867 DOI: 10.1016/j.ijrobp.2022.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 08/04/2022] [Accepted: 08/06/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- University Medical Centre Freiburg, University of Frieberg, Frieberg, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, California
| | | | | | | | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, California
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of RadioOncology and Radiotherapy, Technical University of Munich, Munich, Germany
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway
| | - Valery Uhl
- Radiation Oncology, Summit Medical Center, Oakland, California
| | - 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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Pickles K, Hersch J, Nickel B, Vaidya JS, McCaffery K, Barratt A. Effects of awareness of breast cancer overdiagnosis among women with screen-detected or incidentally found breast cancer: a qualitative interview study. BMJ Open 2022; 12:e061211. [PMID: 35676016 PMCID: PMC9185559 DOI: 10.1136/bmjopen-2022-061211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To explore experiences of women who identified themselves as having a possible breast cancer overdiagnosis. DESIGN Qualitative interview study using key components of a grounded theory analysis. SETTING International interviews with women diagnosed with breast cancer and aware of the concept of overdiagnosis. PARTICIPANTS Twelve women aged 48-77 years from the UK (6), USA (4), Canada (1) and Australia (1) who had breast cancer (ductal carcinoma in situ n=9, (invasive) breast cancer n=3) diagnosed between 2004 and 2019, and who were aware of the possibility of overdiagnosis. Participants were recruited via online blogs and professional clinical networks. RESULTS Most women (10/12) became aware of overdiagnosis after their own diagnosis. All were concerned about the possibility of overdiagnosis or overtreatment or both. Finding out about overdiagnosis/overtreatment had negative psychosocial impacts on women's sense of self, quality of interactions with medical professionals, and for some, had triggered deep remorse about past decisions and actions. Many were uncomfortable with being treated as a cancer patient when they did not feel 'diseased'. For most, the recommended treatments seemed excessive compared with the diagnosis given. Most found that their initial clinical teams were not forthcoming about the possibility of overdiagnosis and overtreatment, and many found it difficult to deal with their set management protocols. CONCLUSION The experiences of this small and unusual group of women provide rare insight into the profound negative impact of finding out about overdiagnosis after breast cancer diagnosis. Previous studies have found that women valued information about overdiagnosis before screening and this knowledge did not reduce subsequent screening uptake. Policymakers and clinicians should recognise the diversity of women's perspectives and ensure that women are adequately informed of the possibility of overdiagnosis before screening.
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Affiliation(s)
- Kristen Pickles
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jolyn Hersch
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brooke Nickel
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Kirsten McCaffery
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Alexandra Barratt
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Kolberg HC, Niesing H, Vaidya JS, Akpolat-Basci L, Maguz A, Hoffmann O, Loevey G, Stephanou M, Kolberg-Liedtke C. Breast preservation after local recurrence of breast cancer: Comparison of length and quality of life (QoL) between breast conserving surgery with intraoperative radiotherapy (TARGIT-IORT) versus mastectomy. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e12573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12573 Background: Mastectomy is the standard treatment of in-breast-recurrence of breast cancer after breast conserving surgery (BCS) and external beam radiation therapy (EBRT). In selected cases it is possible to preserve the breast if TARGIT-IORT can be given during the second lumpectomy. We present a comparative analysis of overall survival and QoL. Methods: We identified all patients who had local recurrence of breast cancer after BCS and EBRT in our prospectively maintained database. Patients were included if they had undergone either a mastectomy or BCS along with TARGIT-IORT. Patients with distant disease were excluded. Identified patients were contacted and offered participation in a prospective QoL-analysis using the BREAST-Q questionnaire. The cohorts were compared for confounding parameters, overall survival, psychosocial/physical/sexual wellbeing and satisfaction with the surgical result. Results: 36 patients treated for local recurrence were included in this analysis, 21 had received a mastectomy and 16 patients had chosen to preserve their breast and after due discussion, received BCS along with TARGIT-IORT. Mean follow-up was 12.8 years since primary diagnosis and 4.2 years since recurrence. There were no significant differences between both groups regarding age, ER, PR, HER2neu, tumor size or nodal status at primary diagnosis or at recurrence and the distribution of invasive versus non-invasive recurrences. 1 patient in the BCT and TARGIT-IORT group (6.7%) and 3 patients in the mastectomy group (14.3%) died during follow up. Overall survival was numerically longer for BCS and TARGIT-IORT either calculated from primary diagnosis (median 18 years versus 8 years) or from recurrence (median 5.1 years versus 3.2 years), but the numbers were too small for formal statistical analysis. No patient had further in-breast-recurrence of cancer. 12 patients in the mastectomy group and 10 patients in the BCS and IORT group returned the BREAST-Q questionnaire. Psychosocial wellbeing, sexual wellbeing and satisfaction with the surgeon did not differ between both groups. Physical wellbeing was significantly superior for those whose breast could be preserved (median score for BCS and TARGIT-IORT group was 91 (71-100) vs. 66 (14-100) for the mastectomy group, p-value = 0.021). Conclusions: Many patients who have local recurrence of breast cancer are reluctant to lose their breast. We found that preserving the breast by use of TARGIT-IORT was safe with no re-recurrence and no detriment to overall survival. This is necessarily a small series, because local recurrence is rare, yet, this novel approach led to a statistically significant improvement in physical wellbeing. These data should increase the confidence in offering breast preservation after in-breast-recurrence of breast cancer.
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Affiliation(s)
| | | | | | - Leyla Akpolat-Basci
- Marienhospital Bottrop, Klinik für Gynäkologie und Geburtshilfe, Bottrop, Germany
| | | | - Oliver Hoffmann
- Department of Obstetrics and Gynecology, University Hospital Essen, Essen, Germany
| | | | - Miltiades Stephanou
- Marienhospital Bottrop, Klinik für Gynäkologie und Geburtshilfe, Bottrop, Germany
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Kolberg HC, Gutberlet S, Vaidya JS, Krajewska M, Lövey G, Hoffmann O, Stephanou M, Kolberg-Liedtke C. Abstract P3-19-16: Impact of targeted intraoperative (TARGIT-IORT) tumor bed boost during breast conserving surgery for early breast cancer on breast cancer associated and non-breast cancer associated mortality and morbidity. Cancer Res 2022. [DOI: 10.1158/1538-7445.sabcs21-p3-19-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Targeted intraoperative radiotherapy (TARGIT - IORT) as a tumor bed boost during breast conserving surgery is an established option for women with early breast cancer. In a previous study our group could demonstrate a beneficial effect of TARGIT-IORT on overall survival after neoadjuvant chemotherapy driven by non-breast cancer mortality, especially from cardiac or pulmonary diseases. This was in line with results of TARGIT-A trial that demonstrated an improved overall survival after TARGIT-IORT that was driven by other causes of death than breast cancer but in our analysis we could not exclude a selection bias because we had no data regarding pulmonary and cardiac co-morbidities. In this study we present an analysis of breast cancer associated and non-breast cancer associated mortality and morbidity in a lower risk population treated with TARGIT-IORT boost or external boost (EBRT) and with a complete dataset of pulmonary and cardiac co-morbidities at baseline. Material/Methods: In this non-randomized cohort study involving 125 patients with early breast cancer we compared outcomes of 59 patients who received a tumor bed boost with IORT (TARGIT-IORT) during lumpectomy versus 66 patients with external (EBRT) boost. All patients received whole breast radiotherapy. Local recurrence rates, distant recurrence rates, mortality, causes of death and incidence of new pulmonary and cardiac morbidity were compared. The small event rate did not allow a formal comparison, so the results are reported descriptively. Results: There were no statistically significant differences between the two groups regarding age, menopausal status, nodal status, ER status, PR status, HER2 status, tumor size, grading, cardiac or pulmonary diseases and hypertension. Median follow up was 60 months. Local recurrence occurred in 3 cases in the EBRT group (4.5%) and 4 cases in the TARGIT-IORT group (6.8%). Distant recurrences were observed in 5 cases in the EBR group (7.6%) and 3 cases in the TARGIT-IORT group (5.1%). 9 patients in the EBRT group (13.6%) died in the follow-up of 60 months and 6 patients (10.2%) in the TARGIT-IORT group. No death from a pulmonary disease occurred and the incidence of new pulmonary and new cardiac diseases showed no difference between both groups with 3 cases in the EBRT group (4.5%) and 2 cases in the TARGIT-IORT group (3.4%). Death from cardiac disease occurred with an incidence of 7 cases in the EBRT group (10.6%) and only 2 cases in the TARGIT-IORT group (3.4%). 2 patients in the EBRT group died of breast cancer (3.0%) whereas this did not happen at all in the TARGIT-IORT group. Conclusion: This analysis of an average risk group of breast cancer patients well balanced for pulmonary and cardiac co-morbidities demonstrates that TARGIT-IORT as an anticipated boost is not inferior to external beam radiotherapy boost. Trends for an improved overall survival after TARGIT-IORT have been reported before. The trend for a lower incidence of death from cardiac disease is in line with earlier considerations that TARGIT-IORT may induce miR-223 in the peritumoral breast tissue resulting in a downregulation of the local expression of epidermal growth factor (EGF) and a decreased activation of epidermal growth factor receptor (EGFR). This mechanism could explain an effect of TARGIT-IORT on the vascular system. In the currently recruiting TARGIT-B study this aspect will be prospectively investigated.
Citation Format: Hans-Christin Kolberg, Stephanie Gutberlet, Jayant S Vaidya, Maja Krajewska, György Lövey, Oliver Hoffmann, Miltiades Stephanou, Cornelia Kolberg-Liedtke. Impact of targeted intraoperative (TARGIT-IORT) tumor bed boost during breast conserving surgery for early breast cancer on breast cancer associated and non-breast cancer associated mortality and morbidity [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-19-16.
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Joshi A, Vishnu G K A, Sakorikar T, Kamal AM, Vaidya JS, Pandya HJ. Recent advances in biosensing approaches for point-of-care breast cancer diagnostics: challenges and future prospects. Nanoscale Adv 2021; 3:5542-5564. [PMID: 36133274 PMCID: PMC9417675 DOI: 10.1039/d1na00453k] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/12/2021] [Indexed: 05/12/2023]
Abstract
Timely and accurate diagnosis of breast cancer is essential for efficient treatment and the best possible survival rates. Biosensors have emerged as a smart diagnostic platform for the detection of biomarkers specific to the onset, recurrence, and therapeutic drug monitoring of breast cancer. There have been exciting recent developments, including significant improvements in the validation, sensitivity, specificity, and integration of sample processing steps to develop point-of-care (POC) integrated micro-total analysis systems for clinical settings. The present review highlights various biosensing modalities (electrical, optical, piezoelectric, mass, and acoustic sensing). It provides deep insights into their design principles, signal amplification strategies, and comparative performance analysis. Finally, this review emphasizes the status of existing integrated micro-total analysis systems (μ-TAS) for personalized breast cancer therapeutics and associated challenges and outlines the approach required to realize their successful translation into clinical settings.
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Affiliation(s)
- Anju Joshi
- Department of Electronic Systems Engineering, Division of EECS, Indian Institute of Science Bangalore India
| | - Anil Vishnu G K
- Department of Electronic Systems Engineering, Division of EECS, Indian Institute of Science Bangalore India
- Centre for BioSystems Science and Engineering, Indian Institute of Science Bangalore India
| | - Tushar Sakorikar
- Department of Electronic Systems Engineering, Division of EECS, Indian Institute of Science Bangalore India
| | - Arif M Kamal
- Department of Electronic Systems Engineering, Division of EECS, Indian Institute of Science Bangalore India
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London 4919 London UK
| | - Hardik J Pandya
- Department of Electronic Systems Engineering, Division of EECS, Indian Institute of Science Bangalore India
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Pal UM, Vishnu Gk A, Varma M, Vaidya JS, Pandya HJ. Thermo-optic measurements and their inter-dependencies for delineating cancerous breast biopsy tissue from adjacent normal. J Biophotonics 2021; 14:e202100041. [PMID: 34042303 DOI: 10.1002/jbio.202100041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/17/2021] [Accepted: 05/25/2021] [Indexed: 06/12/2023]
Abstract
The histopathological diagnosis of cancer is the current gold standard to differentiate normal from cancerous tissues. We propose a portable platform prototype to characterize the tissue's thermal and optical properties, and their inter-dependencies to potentially aid the pathologist in making an informed decision. The measurements were performed on 10 samples from five subjects, where the cancerous and adjacent normal were extracted from the same patient. It was observed that thermal conductivity (k) and reduced-scattering-coefficient (μ's ) for both the cancerous and normal tissues reduced with the rise in tissue temperature. Comparing cancerous and adjacent normal tissue, the difference in k and μ's (at 940 nm) were statistically significant (p = 7.94e-3), while combining k and μ's achieved the highest statistical significance (6.74e-4). These preliminary results promise and support testing on a large number of samples for rapidly differentiating cancerous from adjacent normal tissues.
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Affiliation(s)
- Uttam M Pal
- Department of Electronic Systems Engineering, The Indian Institute of Science, Bengaluru, India
| | - Anil Vishnu Gk
- Department of Electronic Systems Engineering, The Indian Institute of Science, Bengaluru, India
- Center for BioSystems Science and Engineering, The Indian Institute of Science, Bengaluru, India
| | - Manoj Varma
- Centre for Nano Science and Engineering, The Indian Institute of Science, Bengaluru, India
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Hardik J Pandya
- Department of Electronic Systems Engineering, The Indian Institute of Science, Bengaluru, India
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10
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger H, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Blanc-Onfroy ML, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McReady D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph D, Tobias JS. New clinical and biological insights from the international TARGIT-A randomised trial of targeted intraoperative radiotherapy during lumpectomy for breast cancer. Br J Cancer 2021; 125:380-389. [PMID: 34035435 PMCID: PMC8329051 DOI: 10.1038/s41416-021-01440-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/26/2021] [Accepted: 05/13/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The TARGIT-A trial reported risk-adapted targeted intraoperative radiotherapy (TARGIT-IORT) during lumpectomy for breast cancer to be as effective as whole-breast external beam radiotherapy (EBRT). Here, we present further detailed analyses. METHODS In total, 2298 women (≥45 years, invasive ductal carcinoma ≤3.5 cm, cN0-N1) were randomised. We investigated the impact of tumour size, grade, ER, PgR, HER2 and lymph node status on local recurrence-free survival, and of local recurrence on distant relapse and mortality. We analysed the predictive factors for recommending supplemental EBRT after TARGIT-IORT as part of the risk-adapted approach, using regression modelling. Non-breast cancer mortality was compared between TARGIT-IORT plus EBRT vs. EBRT. RESULTS Local recurrence-free survival was no different between TARGIT-IORT and EBRT, in every tumour subgroup. Unlike in the EBRT arm, local recurrence in the TARGIT-IORT arm was not a predictor of a higher risk of distant relapse or death. Our new predictive tool for recommending supplemental EBRT after TARGIT-IORT is at https://targit.org.uk/addrt . Non-breast cancer mortality was significantly lower in the TARGIT-IORT arm, even when patients received supplemental EBRT, HR 0.38 (95% CI 0.17-0.88) P = 0.0091. CONCLUSION TARGIT-IORT is as effective as EBRT in all subgroups. Local recurrence after TARGIT-IORT, unlike after EBRT, has a good prognosis. TARGIT-IORT might have a beneficial abscopal effect. TRIAL REGISTRATION ISRCTN34086741 (21/7/2004), NCT00983684 (24/9/2009).
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Radiation Oncology, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Berlin, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, & Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, University of Southern California, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Fernando Bozza
- Department of Surgery, Instituto Oncologico Veneto (IVO) IRCCS, Padoa, Italy
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology University College London Hospitals, London, UK
| | - 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, UK
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Pal UM, Nayak A, Medisetti T, Gogoi G, Shekhar H, Prasad MSN, Vaidya JS, Pandya HJ. Hybrid Spectral-IRDx: Near-IR and Ultrasound Attenuation System for Differentiating Breast Cancer From Adjacent Normal Tissue. IEEE Trans Biomed Eng 2021; 68:3554-3563. [PMID: 33945469 DOI: 10.1109/tbme.2021.3077582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE While performing surgical excision for breast cancer (lumpectomy), it is important to ensure a clear margin of normal tissue around the cancer to achieve complete resection. The current standard is histopathology; however, it is time-consuming and labour-intensive requiring skilled personnel. METHOD We describe a Hybrid Spectral-IRDx - a combination of the previously reported Spectral-IRDx tool with multimodal ultrasound and NIR spectroscopy techniques. We show how this portable, cost-effective, minimal-contact tool could provide rapid diagnosis of cancer using formalin-fixed (FF) and deparaffinized (DP) breast biopsy tissues. RESULTS Using this new tool, measurements were performed on cancerous/fibroadenoma and its adjacent normal tissues from the same patients (N = 14). The acoustic attenuation coefficient (α) and reduced scattering coefficient (µ's) (at 850, 940, and 1060 nm) for the cancerous/fibroadenoma tissues were reported to be higher compared to adjacent normal tissues, a basis of delineation. Comparing FF cancerous and adjacent normal tissue, the difference in µ's at 850 nm and 940 nm were statistically significant (p = 3.17e-2 and 7.94e-3 respectively). The difference in α between the cancerous and adjacent normal tissues for DP and FF tissues were also statistically significant (p = 2.85e-2 and 7.94e-3 respectively). Combining multimodal parameters α and µ's (at 940 nm) show highest statistical significance (p = 6.72e-4) between FF cancerous/fibroadenoma and adjacent normal tissues. CONCLUSION We show that Hybrid Spectral-IRDx can accurately delineate between cancerous and adjacent normal breast biopsy tissue. SIGNIFICANCE The results obtained establish the proof-of-principle and large-scale testing of this multimodal breast cancer diagnostic platform for core biopsy diagnosis.
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Vaidya JS, Bulsara M, Baum M, Alvarado M, Bernstein M, Massarut S, Saunders C, Sperk E, Wenz F, Tobias JS. Intraoperative radiotherapy for breast cancer: powerful evidence to change practice. Nat Rev Clin Oncol 2021; 18:187-188. [PMID: 33495552 PMCID: PMC7830040 DOI: 10.1038/s41571-021-00471-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | | | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Elena Sperk
- University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, Freiburg, Germany
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
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Vaidya JS, Bulsara M, Sperk E, Massarut S, Douek M, Alvarado M, Pigorsch S, Holmes D, Bernstein M, Saunders C, Flyger H, Joseph D, Wenz F, Tobias JS. In Regard to Polgar et al. Int J Radiat Oncol Biol Phys 2021; 110:905-907. [PMID: 33640419 DOI: 10.1016/j.ijrobp.2021.01.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Steffi Pigorsch
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, California
| | | | - Christobel Saunders
- School of Surgery, University of Western Australia, Crawley, Western Australia, Australia
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | | | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
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Vaidya JS, Bulsara M, Baum M, Wenz F, Massarut S, Pigorsch S, Alvarado M, Douek M, Saunders C, Flyger HL, Eiermann W, Brew-Graves C, Williams NR, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Corica T, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer R, Kelemen P, Petralia G, Falzon M, Joseph DJ, Tobias JS. Long term survival and local control outcomes from single dose targeted intraoperative radiotherapy during lumpectomy (TARGIT-IORT) for early breast cancer: TARGIT-A randomised clinical trial. BMJ 2020; 370:m2836. [PMID: 32816842 PMCID: PMC7500441 DOI: 10.1136/bmj.m2836] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine whether risk adapted intraoperative radiotherapy, delivered as a single dose during lumpectomy, can effectively replace postoperative whole breast external beam radiotherapy for early breast cancer. DESIGN Prospective, open label, randomised controlled clinical trial. SETTING 32 centres in 10 countries in the United Kingdom, Europe, Australia, the United States, and Canada. PARTICIPANTS 2298 women aged 45 years and older with invasive ductal carcinoma up to 3.5 cm in size, cN0-N1, eligible for breast conservation and randomised before lumpectomy (1:1 ratio, blocks stratified by centre) to either risk adapted targeted intraoperative radiotherapy (TARGIT-IORT) or external beam radiotherapy (EBRT). INTERVENTIONS Random allocation was to the EBRT arm, which consisted of a standard daily fractionated course (three to six weeks) of whole breast radiotherapy, or the TARGIT-IORT arm. TARGIT-IORT was given immediately after lumpectomy under the same anaesthetic and was the only radiotherapy for most patients (around 80%). TARGIT-IORT was supplemented by EBRT when postoperative histopathology found unsuspected higher risk factors (around 20% of patients). MAIN OUTCOME MEASURES Non-inferiority with a margin of 2.5% for the absolute difference between the five year local recurrence rates of the two arms, and long term survival outcomes. RESULTS Between 24 March 2000 and 25 June 2012, 1140 patients were randomised to TARGIT-IORT and 1158 to EBRT. TARGIT-IORT was non-inferior to EBRT: the local recurrence risk at five year complete follow-up was 2.11% for TARGIT-IORT compared with 0.95% for EBRT (difference 1.16%, 90% confidence interval 0.32 to 1.99). In the first five years, 13 additional local recurrences were reported (24/1140 v 11/1158) but 14 fewer deaths (42/1140 v 56/1158) for TARGIT-IORT compared with EBRT. With long term follow-up (median 8.6 years, maximum 18.90 years, interquartile range 7.0-10.6) no statistically significant difference was found for local recurrence-free survival (hazard ratio 1.13, 95% confidence interval 0.91 to 1.41, P=0.28), mastectomy-free survival (0.96, 0.78 to 1.19, P=0.74), distant disease-free survival (0.88, 0.69 to 1.12, P=0.30), overall survival (0.82, 0.63 to 1.05, P=0.13), and breast cancer mortality (1.12, 0.78 to 1.60, P=0.54). Mortality from other causes was significantly lower (0.59, 0.40 to 0.86, P=0.005). CONCLUSION For patients with early breast cancer who met our trial selection criteria, risk adapted immediate single dose TARGIT-IORT during lumpectomy was an effective alternative to EBRT, with comparable long term efficacy for cancer control and lower non-breast cancer mortality. TARGIT-IORT should be discussed with eligible patients when breast conserving surgery is planned. TRIAL REGISTRATION ISRCTN34086741, NCT00983684.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Steffi Pigorsch
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | | | - Henrik L Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynaecology and Obstetrics, Red Cross Hospital, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, 43-45 Foley Street, London W1W 7JN, UK
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, UK
| | - Marc Sütterlin
- Department of Gynaecology and Obstetrics, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dennis Holmes
- University of Southern California, John Wayne Cancer Institute & Helen Rey Breast Cancer Foundation, Los Angeles, CA, USA
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, The Ludwig Maximilian University of Munich, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden Hospital, Charité, Medical University of Berlin, Berlin, Germany
| | - David McCready
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, NY, USA
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, UK
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
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Pal UM, Gk AV, Gogoi G, Rila S, Shroff S, Am G, Borah P, Varma M, Kurpad V, Baruah D, Vaidya JS, Pandya HJ. Towards a Portable Platform Integrated With Multispectral Noncontact Probes for Delineating Normal and Breast Cancer Tissue Based on Near-Infrared Spectroscopy. IEEE Trans Biomed Circuits Syst 2020; 14:879-888. [PMID: 32746350 DOI: 10.1109/tbcas.2020.3005971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Currently, the confirmation of diagnosis of breast cancer is made by microscopic examination of an ultra-thin slice of a needle biopsy specimen. This slice is conventionally formalin-fixed and stained with hematoxylin-eosin and visually examined under a light microscope. This process is labor-intensive and requires highly skilled doctors (pathologists). In this paper, we report a novel tool based on near-infrared spectroscopy (Spectral-IRDx) which is a portable, non-contact, and cost-effective system and could provide a rapid and accurate diagnosis of cancer. The Spectral-IRDx tool performs absorption spectroscopy at near-infrared (NIR) wavelengths of 850, 935, and 1060 nm. We measure normalized detected voltage (Vdn) with the tool in 10 deparaffinized breast biopsy tissue samples, 5 of which were cancer (C) and 5 were normal (N) tissues. The difference in Vdn at 935 nm and 1060 nm between cancer and normal tissues is statistically significant with p-values of 0.0038 and 0.0022 respectively. Absorption contrast factor (N/C) of 1.303, 1.551, and 1.45 are observed for 850, 935, and 1060 nm respectively. The volume fraction contrast (N/C) of lipids and collagens are reported as 1.28 and 1.10 respectively. Higher absorption contrast factor (N/C) and volume fraction contrast (N/C) signifies higher concentration of lipids in normal tissues as compared to cancerous tissues, a basis for delineation. These preliminary results support the envisioned concept for noninvasive and noncarcinogenic NIR-based breast cancer diagnostic platform, which will be tested using a larger number of samples.
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16
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Vaidya JS, Bulsara M, Saunders C, Flyger H, Tobias JS, Corica T, Massarut S, Wenz F, Pigorsch S, Alvarado M, Douek M, Eiermann W, Brew-Graves C, Williams N, Potyka I, Roberts N, Bernstein M, Brown D, Sperk E, Laws S, Sütterlin M, Lundgren S, Holmes D, Vinante L, Bozza F, Pazos M, Le Blanc-Onfroy M, Gruber G, Polkowski W, Dedes KJ, Niewald M, Blohmer J, McCready D, Hoefer R, Kelemen P, Petralia G, Falzon M, Baum M, Joseph D. Effect of Delayed Targeted Intraoperative Radiotherapy vs Whole-Breast Radiotherapy on Local Recurrence and Survival: Long-term Results From the TARGIT-A Randomized Clinical Trial in Early Breast Cancer. JAMA Oncol 2020; 6:e200249. [PMID: 32239210 PMCID: PMC7348682 DOI: 10.1001/jamaoncol.2020.0249] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Importance Conventional adjuvant radiotherapy for breast cancer given daily for several weeks is onerous and expensive. Some patients may be obliged to choose a mastectomy instead, and some may forgo radiotherapy altogether. We proposed a clinical trial to test whether radiotherapy could be safely limited to the tumor bed. Objective To determine whether delayed second-procedure targeted intraoperative radiotherapy (TARGIT-IORT) is noninferior to whole-breast external beam radiotherapy (EBRT) in terms of local control. Design, Setting, and Participants In this prospective, randomized (1:1 ratio) noninferiority trial, 1153 patients aged 45 years or older with invasive ductal breast carcinoma smaller than 3.5 cm treated with breast conservation were enrolled from 28 centers in 9 countries. Data were locked in on July 3, 2019. Interventions The TARGIT-A trial was started in March 2000; patients were randomized after needle biopsy to receive TARGIT-IORT immediately after lumpectomy under the same anesthetic vs EBRT and results have been shown to be noninferior. A parallel study, described in this article, was initiated in 2004; patients who had their cancer excised were randomly allocated using separate randomization tables to receive EBRT or delayed TARGIT-IORT given as a second procedure by reopening the lumpectomy wound. Main Outcomes and Measures A noninferiority margin for local recurrence rate of 2.5% at 5 years, and long-term survival outcomes. Results Overall, 581 women (mean [SD] age, 63 [7] years) were randomized to delayed TARGIT-IORT and 572 patients (mean [SD] age, 63 [8] years) were randomized to EBRT. Sixty patients (5%) had tumors larger than 2 cm, or had positive nodes and only 32 (2.7%) were younger than 50 years. Delayed TARGIT-IORT was not noninferior to EBRT. The local recurrence rates at 5-year complete follow-up were: delayed TARGIT-IORT vs EBRT (23/581 [3.96%] vs 6/572 [1.05%], respectively; difference, 2.91%; upper 90% CI, 4.4%). With long-term follow-up (median [IQR], 9.0 [7.5-10.5] years), there was no statistically significant difference in local recurrence-free survival (HR, 0.75; 95% CI, 0.57-1.003; P = .052), mastectomy-free survival (HR, 0.88; 95% CI, 0.65-1.18; P = .38), distant disease-free survival (HR, 1.00; 95% CI, 0.72-1.39; P = .98), or overall survival (HR, 0.96; 95% CI, 0.68-1.35; P = .80). Conclusions and Relevance These long-term data show that despite an increase in the number of local recurrences with delayed TARGIT-IORT, there was no statistically significant decrease in mastectomy-free survival, distant disease-free survival, or overall survival. Trial Registration ISRCTN34086741, ClinicalTrials.gov Identifier: NCT00983684.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Max Bulsara
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.,Department of Biostatistics, University of Notre Dame, Fremantle, West Australia, Australia
| | - Christobel Saunders
- University of Western Australia School of Surgery, West Australia, Australia
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, United Kingdom
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, West Australia, Australia
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Frederik Wenz
- University Medical Center Mannheim, Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Steffi Pigorsch
- Red Cross Hospital, Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany
| | | | - Michael Douek
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Wolfgang Eiermann
- Red Cross Hospital, Department of Gynecology and Obstetrics, Technical University of Munich, Munich, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Norman Williams
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Nicholas Roberts
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | | | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, United Kingdom
| | - Elena Sperk
- University Medical Center Mannheim, Department of Radiation Oncology, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Siobhan Laws
- Department of Surgery, Royal Hampshire County Hospital, Winchester, United Kingdom
| | - Marc Sütterlin
- University Medical Center Mannheim, Department of Gynecology and Obstetrics, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Steinar Lundgren
- Department of Oncology, St Olav's University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Dennis Holmes
- Helen Rey Breast Cancer Foundation, John Wayne Cancer Institute, University of Southern California, Los Angeles
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Montserrat Pazos
- University Hospital, Department of Radiation Oncology, Ludwig Maximilians Universitat, Munich, Germany
| | | | | | - Wojciech Polkowski
- Department of Surgical Oncology, Medical University of Lublin, Lublin, Poland
| | | | | | - Jens Blohmer
- Sankt Gertrauden-Krankenhaus, and The Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - David McCready
- Princess Margaret Cancer Centre Toronto, Toronto, Ontario, Canada
| | | | - Pond Kelemen
- Ashikari Breast Center, New York Medical College, New York, New York
| | - Gloria Petralia
- Department of Surgery, University College London Hospitals, London, United Kingdom
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, United Kingdom
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, West Australia, Australia
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Retsky M, Demicheli R, Hrushesky W, James T, Rogers R, Baum M, Vaidya JS, Erhabor O, Forget P. Breast cancer and the black swan. Ecancermedicalscience 2020; 14:1050. [PMID: 32565903 PMCID: PMC7289621 DOI: 10.3332/ecancer.2020.1050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 12/13/2022] Open
Abstract
Most current research in cancer is attempting to find ways of preventing patients from dying after metastatic relapse. Driven by data and analysis, this project is an approach to solve the problem upstream, i.e., to prevent relapse. This project started with the unexpected observation of bimodal relapse patterns in breast and a number of other cancers. This was not explainable with the current cancer paradigm that has guided cancer therapy and early detection for many years. After much analysis using computer simulation and input from a number of medical specialties, we eventually came to the conclusion that the surgery to remove the primary tumour produced systemic inflammation for a week after surgery. This systemic inflammation apparently caused exits of cancer cells and micrometastases from dormant states and resulted in relapses in the first 3 years post-surgery. It was determined in a retrospective study that the common inexpensive perioperative non-steroidal anti-inflammatory drug (NSAID) ketorolac could curtail the early relapse events after breast cancer surgery. A second retrospective study strongly confirmed this but an apparently underpowered prospective study showed no advantage. We are analysing these data and are now proposing to test the perioperative NSAID at Beth Israel Deaconess Medical Centre with triple-negative breast cancer (TNBC) patients, the category that could respond best to the perioperative NSAID. If this works as well as we expect, we would then transfer this technology to low- and/or middle-incomes countries (LMICs), starting with Nigeria where early onset type of TNBC is common. There is an unmet need in LMICs, especially in countries like Nigeria (190 million population), for a means to prevent surgery induced relapse that we are attempting to resolve. This work aims, thus, to describe eventual mechanisms, and ways to test a solution addressing an unmet need. But first, we consider the context, including within an historical perspective, important to explain how and why a Kuhnian paradigm shift may be considered.
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Affiliation(s)
- Michael Retsky
- Harvard T.H. Chan School of Public Health Boston, MA 02115-6021, USA
| | - Romano Demicheli
- University of Milan, Faculty of Medicine and Surgery, Milan 20133, Italy
| | | | - Ted James
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA 02215-5400, USA
| | - Rick Rogers
- Harvard T.H. Chan School of Public Health Boston, MA 02115-6021, USA
| | - Michael Baum
- Emeritus Prof, University College London, London N19 5LW, UK
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18
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Davis CR, Than PA, Khong SML, Rodrigues M, Findlay MW, Navarrete DJ, Ghali S, Vaidya JS, Gurtner GC. Therapeutic Breast Reconstruction Using Gene Therapy-Delivered IFNγ Immunotherapy. Mol Cancer Ther 2019; 19:697-705. [PMID: 31658961 DOI: 10.1158/1535-7163.mct-19-0315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/26/2019] [Accepted: 10/21/2019] [Indexed: 11/16/2022]
Abstract
After mastectomy, breast reconstruction is increasingly performed using autologous tissue with the aim of improving quality of life. During this procedure, autologous tissue is excised, relocated, and reattached using microvascular anastomoses at the site of the extirpated breast. The period during which the tissue is ex vivo may allow genetic modification without any systemic exposure to the vector. Could such access permit delivery of therapeutic agents using the tissue flap as a vehicle? Such delivery may be more targeted and oncologically efficient than systemic therapy, and avoid systemic complications. The cytokine IFNγ has antitumor effects, and systemic toxicity could be circumvented by localized delivery of the IFNγ gene via gene therapy to autologous tissue used for breast reconstruction, which then releases IFNγ and exerts antitumor effects. In a rat model of loco-regional recurrence (LRR) with MADB-106-Luc and MAD-MB-231-Luc breast cancer cells, autologous tissue was transduced ex vivo with an adeno-associated viral vector encoding IFNγ. The "Therapeutic Reconstruction" released IFNγ at the LRR site and eliminated cancer cells, significantly decreased tumor burden, and increased survival compared with sham reconstruction (P <0.05). Mechanistically, localized IFNγ immunotherapy stimulated M1 macrophages to target cancer cells within the regional confines of the modified tumor environment. This concept of "Therapeutic Breast Reconstruction" using ex vivo gene therapy of autologous tissue offers a new application for immunotherapy in breast cancer with a dual therapeutic effect of both reconstructing the ablative defect and delivering local adjuvant immunotherapy.
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Affiliation(s)
- Christopher R Davis
- Stanford University School of Medicine, Stanford University, Stanford, California. .,Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Peter A Than
- Stanford University School of Medicine, Stanford University, Stanford, California
| | - Sacha M L Khong
- Stanford University School of Medicine, Stanford University, Stanford, California
| | - Melanie Rodrigues
- Stanford University School of Medicine, Stanford University, Stanford, California
| | - Michael W Findlay
- Stanford University School of Medicine, Stanford University, Stanford, California.,The Peter MacCallum Cancer Centre, Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Daniel J Navarrete
- Stanford University School of Medicine, Stanford University, Stanford, California.,Department of Microbiology and Immunology, Stanford University, Stanford, California
| | - Shadi Ghali
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Geoffrey C Gurtner
- Stanford University School of Medicine, Stanford University, Stanford, California.
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Kolberg HC, Uhl V, Massarut S, Holmes D, Kolberg-Liedtke C, Kelly EW, Lövey G, Vaidya JS. Targeted Intraoperative Radiotherapy During Breast-conserving Surgery for Breast Cancer in Patients After Implant Augmentation. Anticancer Res 2019; 39:4215-4218. [PMID: 31366508 DOI: 10.21873/anticanres.13582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Targeted intraoperative radiotherapy (TARGIT IORT) is an option during breast-conserving surgery (BCS). No data have yet been published regarding the safety of TARGIT IORT with implants in situ. TARGIT IORT is an attractive option in this context because of the risk of capsular fibrosis following external beam radiotherapy (EBRT) in such patients. PATIENTS AND METHODS We are reporting a retrospective analysis of 16 patients who received TARGIT IORT during BCS for early breast cancer after previous implant-based breast augmentation. TARGIT IORT was performed using the Intrabeam™method. RESULTS Follow-up varied from 98 to 5 months. There were no procedure-related complications. One patient developed local recurrence after 36 months of follow-up. Among the remaining patients (15/16), no breast-cancer-related events occurred. CONCLUSION This series of patients with TARGIT IORT during BCS after implant-based breast augmentation revealed no safety concerns and gives some confidence in discussing this option with selected patients.
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Affiliation(s)
| | | | | | - Dennis Holmes
- John Wayne Cancer Institute, Santa Monica, CA, U.S.A
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Kolberg HC, Uhl V, Massarut S, Holmes D, Liedtke C, Whineray Kelly E, Lövey G, Vaidya JS. Abstract P3-12-22: Targeted intraoperative radiotherapy (TARGIT IORT) during breast conserving surgery for early stage breast cancer in patients with breast augmentation with implants. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p3-12-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Targeted intraoperative radiotherapy (TARGIT) has become a standard option during breast conserving surgery for selected cases of early breast cancer and over 20,000 patients have been treated in over 300 centers around the world. Although a growing number of patients are presenting with implant breast augmentation, no data has been published regarding the safety of TARGIT with implants in situ. TARGIT IORT as a replacement for whole breast irradiation is an important issue in this context because of the high rates of capsular fibrosis following EBRT in such patients.
Methods: We are reporting a case series of 12 patients who received TARGIT during breast conserving surgery for early breast cancer, had undergone breast augmentation with implants before and wanted their implants to stay in situ. Patients were informed that no published data existed and decided on this approach on an individual basis. 3 patients received additional EBRT after TARGIT IORT because of the presence of EIC or LVI. TARGIT IORT was performed using Intrabeam - 50 kV – X-rays delivering 20 Gy prescribed at the surface of the tumor bed during the initial lumpectomy procedure.
Results:Patient characteristics are given in table 1. Follow-up varied from 78 months to 3 months. 11 patients presented with invasive breast cancer, 1 patient with DCIS. There were no procedure related complications and none of the patients have needed their implant removed. 1/12 patients (ID 7) was diagnosed with a local recurrence in a distant quadrant after 36 months of follow-up. In 11/12 patients no breast-cancer-related events occurred.
Patient characteristicsIDER/PR/HER2GradeSentinel NodesTumor Size (mm)Distance Implant to Tumor (mm)EBRT after IORTFollow up time (months)1pos/pos/neg2pN1mi (sn)95No622pos/neg/neg2pN0 (sn)1913Yes543pos/pos/neg3pN0 (sn)0.85Yes324pos/pos/neg2pN0 (sn)611No155pos/pos/neg3pN0 (sn)71Yes146pos/pos/neg1pN0 (sn)515No117pos/pos/neg2pN0 (sn)7not reportedNo378pos/pos/na1 (DCIS)N/A8not reportedNo789pos/pos/neg2pN0 (sn)15not reportedNo1510pos/neg/neg1pN0 (sn)144No4411pos/pos/neg2pN0 (sn)91No1112pos/pos/neg2pN0 (sn)75No3Table 1
Conclusion: This series of patients with TARGIT during breast conserving surgery for early breast cancer after breast augmentation with implants in situ revealed no safety concerns. Our case series gives some confidence in discussing this option with suitable patients. To expand this series, we are gathering details about other cases from the whole TARGIT group worldwide.
Citation Format: Kolberg H-C, Uhl V, Massarut S, Holmes D, Liedtke C, Whineray Kelly E, Lövey G, Vaidya JS. Targeted intraoperative radiotherapy (TARGIT IORT) during breast conserving surgery for early stage breast cancer in patients with breast augmentation with implants [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-22.
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Affiliation(s)
- H-C Kolberg
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - V Uhl
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - S Massarut
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - D Holmes
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - C Liedtke
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - E Whineray Kelly
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - G Lövey
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
| | - JS Vaidya
- Marienhospital Bottrop, Bottrop, Germany; Summit Medical Center, Emeryville, CA; Centro di Riferimento Oncologico di Aviano, Aviano, Italy; John Wayne Cancer Institute, Santa Monica, CA; Charité - Universitätsmedizin Berlin, Berlin, Germany; Auckland Breast Centre, Auckland, New Zealand; BORAD, Bottrop, Germany; University College London, London, United Kingdom
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Retsky MW, Baum M, Vaidya JS, Rogers RA, Hrushesky WJ, Demicheli R, Forget P. Abstract P2-01-01: Early relapses in breast cancer can be prevented by a perioperative NSAID, which would be a solution to a 2000 year old problem. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p2-01-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
A bimodal pattern of hazard of relapse among early stage breast cancer patients has been identified in multiple databases from US, Europe and Asia. We have been studying these data to determine if this can lead to new ideas on how to prevent relapse in breast cancer. Using computer simulation and access to a very high quality database from Milan for patients treated with mastectomy only, we proposed that relapses within 3 years of surgery are stimulated somehow by the surgical procedure. During the week post surgery, metastatic development is enhanced 100 fold according to the simulation. Most relapses in breast cancer are in this early category. Retrospective data from a Brussels anesthesiology group suggested a plausible mechanism. Use of ketorolac, a common NSAID analgesic used in surgery was associated with far superior disease-free survival in the first 5 years after surgery. The expected prominent early relapse events in months 9-18 are reduced 5-fold. Transient systemic inflammation accompanying surgery (identified by IL-6 in serum) could facilitate angiogenesis of dormant micrometastases, proliferation of dormant single cells, and seeding of circulating cancer stem cells resulting in early relapse and could have been effectively blocked by the perioperative anti-inflammatory agent. If this observation holds up to further scrutiny, it could mean that the simple use of this safe, inexpensive and effective anti-inflammatory agent at surgery might eliminate early relapses. Similar bimodal patterns have been identified in other cancers suggesting a general effect. Based on the writings of Galen and Celsus, metastatic development after breast tumors were removed was known to them 2000 years ago.
This effect has been demonstrated recently in a mouse model by Krall et al Science Translational Medicine and reviewed in NEJM by Komaroff. In a series of experiments in 273 mice, aggressive mouse breast cancer cells were implanted in various locations. Initially, the tumor cells grew but then became dormant. This dormancy occurred only in mice with intact immunity, which suggests that the immune system can contain certain dormant metastases. Surgery of any type (including resection of a primary tumor) led to aggressive growth of metastases in 60% of animals, compared with 10% of control animals that did not undergo surgery. Surgical procedures caused systemic inflammatory responses. Activated monocytes from the marrow traveled to the sites of the dormant metastases and became tumor associated macrophages. These macrophages suppressed the immune system near the tumor, awakening the metastases from their dormancy. Treating the animals with NSAIDs before and immediately following surgery greatly attenuated growth of these metastases.
Since this effect has by now been shown in two Belgian retrospective studies as well as a mouse model we suggest this be tested in one or more clinical trials. We also note that the bleeding potential from using NSAIDs before surgery can apparently be reduced with the use of Tranexamic Acid – currently being tested in a clinical trial for mastectomy.
Citation Format: Retsky MW, Baum M, Vaidya JS, Rogers RA, Hrushesky WJ, Demicheli R, Forget P. Early relapses in breast cancer can be prevented by a perioperative NSAID, which would be a solution to a 2000 year old problem [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-01.
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Affiliation(s)
- MW Retsky
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
| | - M Baum
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
| | - JS Vaidya
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
| | - RA Rogers
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
| | - WJ Hrushesky
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
| | - R Demicheli
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
| | - P Forget
- Harvard TH Chan School of Public Health, Boston, MA; University College London (Emeritus), London, United Kingdom; University College London, London, United Kingdom; University of Southern Carolina (Retired), Columbia, SC; University of Milan, Milan, Italy; University Hospital Brussels, Brussels, Belgium
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Winters Z, Horsnell J, Elvers K, Maxwell AJ, Jones LJ, Shaaban AM, Schmid P, Williams NR, Beswick A, Greenwood R, Ingram JC, Saunders C, Vaidya JS, Esserman L, Jatoi I, Brunt AM. A systematic review of the impact of breast conserving surgery on cancer outcomes of multiple ipsilateral breast cancers (MIBC)–the case for a randomised trial. Eur J Surg Oncol 2018. [DOI: 10.1016/j.ejso.2018.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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23
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Winters ZE, Horsnell J, Elvers KT, Maxwell AJ, Jones LJ, Shaaban AM, Schmid P, Williams NR, Beswick A, Greenwood R, Ingram JC, Saunders C, Vaidya JS, Esserman L, Jatoi I, Brunt AM. Systematic review of the impact of breast-conserving surgery on cancer outcomes of multiple ipsilateral breast cancers. BJS Open 2018; 2:162-174. [PMID: 30079385 PMCID: PMC6069349 DOI: 10.1002/bjs5.53] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/11/2018] [Indexed: 01/16/2023] Open
Abstract
Background The clinical effectiveness of treating ipsilateral multifocal (MF) and multicentric (MC) breast cancers using breast‐conserving surgery (BCS) compared with the standard of mastectomy is uncertain. Inconsistencies relate to definitions, incidence, staging and intertumoral heterogeneity. The primary aim of this systematic review was to compare clinical outcomes after BCS versus mastectomy for MF and MC cancers, collectively defined as multiple ipsilateral breast cancers (MIBC). Methods Comprehensive electronic searches were undertaken to identify complete papers published in English between May 1988 and July 2015, primarily comparing clinical outcomes of BCS and mastectomy for MIBC. All study designs were included, and studies were appraised critically using the Newcastle–Ottawa Scale. The characteristics and results of identified studies were summarized. Results Twenty‐four retrospective studies were included in the review: 17 comparative studies and seven case series. They included 3537 women with MIBC undergoing BCS; breast cancers were defined as MF in 2677 women, MC in 292, and reported as MIBC in 568. Six studies evaluated MIBC treated by BCS or mastectomy, with locoregional recurrence (LRR) rates of 2–23 per cent after BCS at median follow‐up of 59·5 (i.q.r. 56–81) months. BCS and mastectomy showed apparently equivalent rates of LRR (risk ratio 0·94, 95 per cent c.i. 0·65 to 1·36). Thirteen studies compared BCS in women with MIBC versus those with unifocal cancers, reporting LRR rates of 2–40 per cent after BCS at a median follow‐up of 64 (i.q.r. 57–73) months. One high‐quality study reported 10‐year actuarial LRR rates of 5·5 per cent for BCS in 300 women versus 6·5 per cent for mastectomy among 887 women. Conclusion The available studies were mainly of moderate quality, historical and underpowered, with limited follow‐up and biased case selection favouring BCS rather than mastectomy for low‐risk patients. The evidence was inconclusive, weakening support for the St Gallen consensus and supporting a future randomized trial.
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Affiliation(s)
- Z E Winters
- Patient-Reported and Clinical Outcomes Research Group Surgical and Interventional Trials Unit (SITU) London UK
| | - J Horsnell
- Department of Breast Surgery Royal Surrey County Hospital NHS Foundation Trust Guildford UK
| | - K T Elvers
- Patient-Centred and Clinical Outcomes Research Group University of Bristol, Southmead Hospital Bristol UK
| | - A J Maxwell
- Nightingale Centre Wythenshawe Hospital Manchester UK
| | | | - A M Shaaban
- Department of Histopathology Queen Elizabeth Hospital Birmingham and University of Birmingham Birmingham UK
| | - P Schmid
- Centre for Experimental Cancer Medicine, Barts Cancer Institute Queen Mary University of London London UK
| | - N R Williams
- SITU, Division of Surgery and Interventional Science, Faculty of Medical Sciences University College London London UK
| | - A Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School University of Bristol, Southmead Hospital Bristol UK
| | - R Greenwood
- Research Design Service South West University Hospitals Bristol NHS Foundation Trust Bristol UK
| | - J C Ingram
- Research Design Service South West University Hospitals Bristol NHS Foundation Trust Bristol UK
| | - C Saunders
- Division of Surgery, Harry Perkins Institute of Medical Research, Fiona Stanley Hospital University of Western Australia Murdoch Western Australia Australia
| | - J S Vaidya
- SITU, Division of Surgery and Interventional Science, Faculty of Medical Sciences University College London London UK
| | - L Esserman
- University of California San Francisco Carol Franc Buck Breast Care Centre San Francisco California USA
| | - I Jatoi
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery University of Texas Health Science Centre San Antonio Texas USA
| | - A M Brunt
- Cancer Centre University Hospitals of North Midlands and Keele University Stoke-on-Trent UK
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Corica T, Nowak AK, Saunders CM, Bulsara MK, Taylor M, Williams NR, Keshtgar M, Joseph DJ, Vaidya JS. Cosmetic outcome as rated by patients, doctors, nurses and BCCT.core software assessed over 5 years in a subset of patients in the TARGIT-A Trial. Radiat Oncol 2018; 13:68. [PMID: 29653541 PMCID: PMC5899392 DOI: 10.1186/s13014-018-0998-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/13/2018] [Indexed: 11/24/2022] Open
Abstract
Background The purpose of this research was to assess agreement between four rating systems of cosmetic outcome measured in a subset of patients with early breast cancer participating in the randomised TARGIT-A trial. TARGIT-A compared risk-adapted single-dose intra-operative radiotherapy (TARGIT-IORT) to whole breast external beam radiotherapy (EBRT). Methods Patients, their Radiation Oncologist and Research Nurse completed a subjective cosmetic assessment questionnaire before radiotherapy and annually thereafter for five years. Objective data previously calculated by the validated BCCT.core software which utilizes digital photographs to score symmetry, colour and scar was also used. Agreement was assessed by the Kappa statistic and longitudinal changes were assessed by generalized estimating equations. Results Overall, an Excellent-Good (EG) cosmetic result was scored more often than a Fair-Poor (FP) result for both treatment groups across all time points, with patients who received TARGIT-IORT scoring EG more often than those who received EBRT however this was statistically significant at Year 5 only. There was modest agreement between the four rating systems with the highest Kappa score being moderate agreement which was between nurse and doctor scores at Year 1 with Kappa = 0.46 (p < 0.001), 95% CI (0.24, 0.68). Conclusion Despite similar overall findings between treatment groups and rating systems, the inter-rater agreement was only modest. This suggests that the four rating systems utilized may not necessarily be used interchangeably and it is arguable that for an outcome such as cosmetic appearance, the patient’s point of view is the most important. Trial Registration TARGIT-A ISRCTN34086741, Registered 21 July 2004, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13014-018-0998-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tammy Corica
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia. .,Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.
| | - Anna K Nowak
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia
| | | | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, 19 Mouat Street, Fremantle, WA, 6160, Australia
| | - Mandy Taylor
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Norman R Williams
- Surgical & Interventional Trials Unit, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, London, NW1 2FD, UK
| | - Mohammed Keshtgar
- Royal Free London Foundation NHS Trust, Division of Surgical Sciences, The Breast Unit, Pond Street, Hampstead, London, NW3 2QG, UK
| | - David J Joseph
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.,Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Jayant S Vaidya
- Division of Surgery & Interventional Science, University College London, London W1W 7TS, UK; Whittington Hospital, Royal Free Hospital and University College Hospital, University College London, London, NW1 2FD, UK
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Vaidya JS, Wenz F, Tobias JS. Trial supports targeted radiotherapy for early breast cancer but protocol still requires 3 weeks of daily therapy. BMJ Evid Based Med 2018; 23:38-39. [PMID: 29367327 DOI: 10.1136/ebmed-2017-110849] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/04/2022]
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London
| | - Frederik Wenz
- Department of Radiation Oncology, University of Heidelberg, Mannheim, Germany
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London, London, UK
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK
- Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
| | | | | | - Emma C Alexander
- GKT School of Medical Education, King's College London, London, UK
| | - Thomas Richards
- Department of Clinical Oncology, University College London Hospital, London, UK
| | | | - Bhawna Sirohi
- Department of Medical Oncology, Barts Health NHS Trust, London, UK
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospital, London, UK
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London W1W 7EJ, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London W1W 7EJ, UK
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Vaidya JS, Tobias JS. Targeted Intraoperative Radiotherapy Tumour Bed Boost during Breast-Conserving Surgery after Neoadjuvant Chemotherapy. Breast Care (Basel) 2017; 12:314-316. [PMID: 29234251 DOI: 10.1159/000479726] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
| | - Jeffrey S Tobias
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
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Vaidya A, Vaidya P, Both B, Brew-Graves C, Bulsara M, Vaidya JS. Health economics of targeted intraoperative radiotherapy (TARGIT-IORT) for early breast cancer: a cost-effectiveness analysis in the United Kingdom. BMJ Open 2017; 7:e014944. [PMID: 28819067 PMCID: PMC5724101 DOI: 10.1136/bmjopen-2016-014944] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 04/20/2017] [Accepted: 05/09/2017] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE The clinical effectiveness of targeted intraoperative radiotherapy (TARGIT-IORT) has been confirmed in the randomised TARGIT-A (targeted intraoperative radiotherapy-alone) trial to be similar to a several weeks' course of whole-breast external-beam radiation therapy (EBRT) in patients with early breast cancer. This study aims to determine the cost-effectiveness of TARGIT-IORT to inform policy decisions about its wider implementation. SETTING TARGIT-A randomised clinical trial (ISRCTN34086741) which compared TARGIT with traditional EBRT and found similar breast cancer control, particularly when TARGIT was given simultaneously with lumpectomy. METHODS Cost-utility analysis using decision analytic modelling by a Markov model. A cost-effectiveness Markov model was developed using TreeAge Pro V.2015. The decision analytic model compared two strategies of radiotherapy for breast cancer in a hypothetical cohort of patients with early breast cancer based on the published health state transition probability data from the TARGIT-A trial. Analysis was performed for UK setting and National Health Service (NHS) healthcare payer's perspective using NHS cost data and treatment outcomes were simulated for both strategies for a time horizon of 10 years. Model health state utilities were drawn from the published literature. Future costs and effects were discounted at the rate of 3.5%. To address uncertainty, one-way and probabilistic sensitivity analyses were performed. MAIN OUTCOME MEASURES Quality-adjusted life-years (QALYs). RESULTS In the base case analysis, TARGIT-IORT was a highly cost-effective strategy yielding health gain at a lower cost than its comparator EBRT. Discounted TARGIT-IORT and EBRT costs for the time horizon of 10 years were £12 455 and £13 280, respectively. TARGIT-IORT gained 0.18 incremental QALY as the discounted QALYs gained by TARGIT-IORT were 8.15 and by EBRT were 7.97 showing TARGIT-IORT as a dominant strategy over EBRT. Model outputs were robust to one-way and probabilistic sensitivity analyses. CONCLUSIONS TARGIT-IORT is a dominant strategy over EBRT, being less costly and producing higher QALY gain. TRIAL REGISTRATION NUMBER ISRCTN34086741; post results.
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Affiliation(s)
- Anil Vaidya
- School of Public Health, University of Alberta, Edmonton, Canada
- O-ZONE 2.0 Inc. HEOR Consultancy, Edmonton, Canada
| | - Param Vaidya
- O-ZONE 2.0 Inc. HEOR Consultancy, Edmonton, Canada
| | - Brigitte Both
- Carl-Zeiss Meditec AG, Oberkochen, Germany
- Witten/Herdecke University, Herdecke, Germany
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Max Bulsara
- Institute for Health Research, University of Notre Dame, Fremantle, Australia
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK
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Kolberg HC, Loevey G, Akpolat-Basci L, Stephanou M, Fasching PA, Untch M, Bulsara M, Vaidya JS, Liedtke C. Targeted intraoperative radiotherapy tumor bed boost during breast conserving surgery after neoadjuvant chemotherapy in hormone receptor positive HER2 negative breast cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e12090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12090 Background: Targeted intraoperative radiotherapy (TARGIT – IORT) as a tumor bed boost during breast conserving surgery is an established option for women with early breast cancer. In a previous study our group could show a beneficial effect of TARGIT-IORT on overall survival after neoadjuvant chemotherapy compared to an external boost in an unselected cohort. In this study we present an analysis of the hormone receptor positive HER2 negative subgroup. Methods: In this non-randomized cohort study involving 46 hormone receptor positive HER2 negative patients after NACT we compared outcomes of 21 patients who received a tumour bed boost with IORT (TARGIT-IORT) during lumpectomy versus 25 patients treated in the previous 13 months with external (EBRT) boost. All patients received whole breast radiotherapy. Disease free survival (DFS) and overall survival (OS) were compared. Results: There were no statistical differences between the two groups regarding tumor size, grading, nodal status and pCR rates. Median follow up was 49 months. Whereas DFS was not significantly different between the groups the 5-year Kaplan-Meier estimate of OS was significantly better by 21% with IORT: TARGIT-IORT 0 events 100%, EBRT 5 events 79%, log rank p = 0.028. Conclusions: Although our results have to be interpreted with caution due to a possible selection bias and the small numbers, we could show that the improved OS as previously demonstrated in our dataset for TARGIT-IORT during lumpectomy after neoadjuvant chemotherapy as a tumor bed boost compared to an external beam radiotherapy boost is driven by the hormone receptor positive HER2 negative subgroup. These data give further support to the inclusion of such patients in the TARGIT-B (Boost) randomised trial that is testing whether IORT boost is superior to EBRT boost and to the analysis of subgroups based on tumor biology in this trial.
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Affiliation(s)
| | | | - Leyla Akpolat-Basci
- Marienhospital Bottrop, Klinik für Gynäkologie und Geburtshilfe, Bottrop, Germany
| | - Miltiades Stephanou
- Marienhospital Bottrop, Klinik für Gynäkologie und Geburtshilfe, Bottrop, Germany
| | | | | | - Max Bulsara
- University of Notre Dame, Fremantle, Australia
| | | | - Cornelia Liedtke
- University of Schleswig-Holstein Campus Luebeck, Lübeck, Germany
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Kolberg HC, Loevey G, Akpolat-Basci L, Stephanou M, Fasching PA, Untch M, Bulsara M, Vaidya JS, Liedtke C. Targeted Intraoperative Radiotherapy Tumour Bed Boost During Breast Conserving Surgery after Neoadjuvant Chemotherapy in HER2 Positive and Triple Negative Breast Cancer. Rev Recent Clin Trials 2017; 12:93-100. [PMID: 28155607 DOI: 10.2174/1574887112666170201142458] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/27/2016] [Accepted: 01/11/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Targeted intraoperative radiotherapy (TARGIT - IORT) as a tumour bed boost after breast conserving surgery is well established for women with early breast cancer. A previous study from our group shows a beneficial effect of TARGIT-IORT on overall survival (OS) but not disease-free survival (DFS) after neoadjuvant chemotherapy compared to an external boost suggesting a potential non-inferiority of TARGIT-IORT. In this study, we present results regarding the high-risk subset of patients (i.e. with triple negative (TN) and HER2 positive tumours) from this cohort. METHOD In this non-randomized cohort study involving patients with HER2 positive (n= 28) and triple negative (n=42) tumours after NACT we compared outcomes of 40 patients with tumour bed boost applied with TARGIT IORT during lumpectomy versus 30 patients treated in the previous 13 months with external (EBRT) boost. All patients received whole breast radiotherapy. Rates of DFS and OS were compared. RESULTS Median follow up was 49 months. In comparison of TARGIT-IORT vs. EBRT 5-year Kaplan- Meier estimates of OS showed no significant difference among patients with HER2 positive tumours (100% vs. 91.7%, log rank p = 0.22). The same was seen for DFS (83.3% vs. 77.0%, log rank p=0.38). The results for TN cases were similar (OS : 87.5% vs. 74.1%, log rank p=0.488; DFS 87.5% vs. 60%, log rank p=0.22). CONCLUSION Although survival estimates trended towards favouring TARGIT-IORT, no significant differences could be observed and the significantly positive result for OS favoring TARGIT-IORT in the whole cohort of 116 patients could not be reproduced in this subset analysis of patients with TN and HER2 positive tumours. This may be contributable to the limited number of patients but may also indicate that effects seen in the whole cohort were mainly driven by ER and/or PR positive and HER2 negative tumours. Most importantly, non-inferiority of TARGIT-IORT as an intraoperative boost could be reproduced in these high-risk patients.
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Affiliation(s)
- Hans-Christian Kolberg
- Department of Gynecology and Obstetrics, Marienhospital Bottrop gGmbH, Josef-Albers-Str. 70, 46236 Bottrop, Germany
| | | | | | | | | | - Michael Untch
- Helios Klinikum Berlin-Buch, Schwanebecker Chaussee 50, 13125 Berlin, Germany
| | - Max Bulsara
- University of Notre Dame, 32 Mouat St, Fremantle WA 6959, Australia
| | - Jayant S Vaidya
- University College London, 235 Euston Rd, Fitzrovia, London NW1 2BU, United Kingdom
| | - Cornelia Liedtke
- University Hospital Schleswig- Holstein/ Campus Luebeck, Ratzeburger Alle 160, 23538 Luebeck, Germany
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Kolberg HC, Loevey G, Akpolat-Basci L, Stephanou M, Fasching PA, Untch M, Liedtke C, Bulsara M, Vaidya JS. Targeted intraoperative radiotherapy tumour bed boost during breast-conserving surgery after neoadjuvant chemotherapy. Strahlenther Onkol 2016; 193:62-69. [PMID: 27858093 DOI: 10.1007/s00066-016-1072-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 10/19/2016] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The use of targeted intraoperative radiotherapy (TARGIT-IORT) as a tumour bed boost during breast-conserving surgery (BCS) for breast cancer has been reported since 1998. We present its use in patients undergoing breast conservation following neoadjuvant therapy (NACT). METHOD In this retrospective study involving 116 patients after NACT we compared outcomes of 61 patients who received a tumour bed boost with IORT during lumpectomy versus 55 patients treated in the previous 13 months with external (EBRT) boost. All patients received whole breast radiotherapy. Local recurrence-free survival (LRFS), disease-free survival (DFS), distant disease-free survival (DDFS), breast cancer mortality (BCM), non-breast cancer mortality (NBCM) and overall mortality (OS) were compared. RESULTS Median follow up was 49 months. The differences in LRFS, DFS and BCM were not statistically significant. The 5‑year Kaplan-Meier estimate of OS was significantly better by 15% with IORT: IORT 2 events (96.7%, 95%CI 87.5-99.2), EBRT 9 events (81.7%, 95%CI 67.6-90.1), hazard ratio (HR) 0.19 (0.04-0.87), log rank p = 0.016, mainly due to a reduction of 10.1% in NBCM: IORT 100%, EBRT 89.9% (77.3-95.7), HR (not calculable), log rank p = 0.015. The DDFS was as follows: IORT 3 events (95.1%, 85.5-98.4), EBRT 12 events (69.0%, 49.1-82.4), HR 0.23 (0.06-0.80), log rank p = 0.012. CONCLUSION IORT during lumpectomy after neoadjuvant chemotherapy as a tumour bed boost appears to give results that are not worse than external beam radiotherapy boost. These data give further support to the inclusion of such patients in the TARGIT-B (boost) randomised trial that is testing whether IORT boost is superior to EBRT boost.
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Affiliation(s)
- Hans-Christian Kolberg
- Department of Gynecology and Obstetrics, Marienhospital Bottrop gGmbH, Josef-Albers-Str. 70, 46236, Bottrop, Germany.
| | | | - Leyla Akpolat-Basci
- Department of Gynecology and Obstetrics, Marienhospital Bottrop gGmbH, Josef-Albers-Str. 70, 46236, Bottrop, Germany
| | - Miltiades Stephanou
- Department of Gynecology and Obstetrics, Marienhospital Bottrop gGmbH, Josef-Albers-Str. 70, 46236, Bottrop, Germany
| | | | | | - Cornelia Liedtke
- University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Max Bulsara
- University of Notre Dame, Fremantle, Australia.,University College, London, UK
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Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Saunders C, Brew-Graves C, Potyka I, Morris S, Vaidya HJ, Williams NR, Baum M. An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial). Health Technol Assess 2016; 20:1-188. [PMID: 27689969 DOI: 10.3310/hta20730] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Based on our laboratory work and clinical trials we hypothesised that radiotherapy after lumpectomy for breast cancer could be restricted to the tumour bed. In collaboration with the industry we developed a new radiotherapy device and a new surgical operation for delivering single-dose radiation to the tumour bed - the tissues at highest risk of local recurrence. We named it TARGeted Intraoperative radioTherapy (TARGIT). From 1998 we confirmed its feasibility and safety in pilot studies. OBJECTIVE To compare TARGIT within a risk-adapted approach with whole-breast external beam radiotherapy (EBRT) over several weeks. DESIGN The TARGeted Intraoperative radioTherapy Alone (TARGIT-A) trial was a pragmatic, prospective, international, multicentre, non-inferiority, non-blinded, randomised (1 : 1 ratio) clinical trial. Originally, randomisation occurred before initial lumpectomy (prepathology) and, if allocated TARGIT, the patient received it during the lumpectomy. Subsequently, the postpathology stratum was added in which randomisation occurred after initial lumpectomy, allowing potentially easier logistics and a more stringent case selection, but which needed a reoperation to reopen the wound to give TARGIT as a delayed procedure. The risk-adapted approach meant that, in the experimental arm, if pre-specified unsuspected adverse factors were found postoperatively after receiving TARGIT, EBRT was recommended. Pragmatically, this reflected how TARGIT would be practised in the real world. SETTING Thirty-three centres in 11 countries. PARTICIPANTS Women who were aged ≥ 45 years with unifocal invasive ductal carcinoma preferably ≤ 3.5 cm in size. INTERVENTIONS TARGIT within a risk-adapted approach and whole-breast EBRT. MAIN OUTCOME MEASURES The primary outcome measure was absolute difference in local recurrence, with a non-inferiority margin of 2.5%. Secondary outcome measures included toxicity and breast cancer-specific and non-breast-cancer mortality. RESULTS In total, 3451 patients were recruited between March 2000 and June 2012. The following values are 5-year Kaplan-Meier rates for TARGIT compared with EBRT. There was no statistically significant difference in local recurrence between TARGIT and EBRT. TARGIT was non-inferior to EBRT overall [TARGIT 3.3%, 95% confidence interval (CI) 2.1% to 5.1% vs. EBRT 1.3%, 95% CI 0.7% to 2.5%; p = 0.04; Pnon-inferiority = 0.00000012] and in the prepathology stratum (n = 2298) when TARGIT was given concurrently with lumpectomy (TARGIT 2.1%, 95% CI 1.1% to 4.2% vs. EBRT 1.1%, 95% CI 0.5% to 2.5%; p = 0.31; Pnon-inferiority = 0.0000000013). With delayed TARGIT postpathology (n = 1153), the between-group difference was larger than 2.5% and non-inferiority was not established for this stratum (TARGIT 5.4%, 95% CI 3.0% to 9.7% vs. EBRT 1.7%, 95% CI 0.6% to 4.9%; p = 0.069; Pnon-inferiority = 0.06640]. The local recurrence-free survival was 93.9% (95% CI 90.9% to 95.9%) when TARGIT was given with lumpectomy compared with 92.5% (95% CI 89.7% to 94.6%) for EBRT (p = 0.35). In a planned subgroup analysis, progesterone receptor (PgR) status was found to be the only predictor of outcome: hormone-responsive patients (PgR positive) had similar 5-year local recurrence with TARGIT during lumpectomy (1.4%, 95% CI 0.5% to 3.9%) as with EBRT (1.2%, 95% CI 0.5% to 2.9%; p = 0.77). Grade 3 or 4 radiotherapy toxicity was significantly reduced with TARGIT. Overall, breast cancer mortality was much the same between groups (TARGIT 2.6%, 95% CI 1.5% to 4.3% vs. EBRT 1.9%, 95% CI 1.1% to 3.2%; p = 0.56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1.4%, 95% CI 0.8% to 2.5% vs. 3.5%, 95% CI 2.3% to 5.2%; p = 0.0086), attributable to fewer deaths from cardiovascular causes and other cancers, leading to a trend in reduced overall mortality in the TARGIT arm (3.9%, 95% CI 2.7% to 5.8% vs. 5.3%, 95% CI 3.9% to 7.3%; p = 0.099]. Health economic analyses suggest that TARGIT was statistically significantly less costly than EBRT, produced similar quality-adjusted life-years, had a positive incremental net monetary benefit that was borderline statistically significantly different from zero and had a probability of > 90% of being cost-effective. There appears to be little uncertainty in the point estimates, based on deterministic and probabilistic sensitivity analyses. If TARGIT were given instead of EBRT in suitable patients, it might potentially reduce costs to the health-care providers in the UK by £8-9.1 million each year. This does not include environmental, patient and societal costs. LIMITATIONS The number of local recurrences is small but the number of events for local recurrence-free survival is not as small (TARGIT 57 vs. EBRT 59); occurrence of so few events (< 3.5%) also implies that both treatments are effective and any difference is unlikely to be large. Not all 3451 patients were followed up for 5 years; however, more than the number of patients required to answer the main trial question (n = 585) were followed up for > 5 years. CONCLUSIONS For patients with breast cancer (women who are aged ≥ 45 years with hormone-sensitive invasive ductal carcinoma that is up to 3.5 cm in size), TARGIT concurrent with lumpectomy within a risk-adapted approach is as effective as, safer than and less expensive than postoperative EBRT. FUTURE WORK The analyses will be repeated with longer follow-up. Although this may not change the primary result, the larger number of events may confirm the effect on overall mortality and allow more detailed subgroup analyses. The TARGeted Intraoperative radioTherapy Boost (TARGIT-B) trial is testing whether or not a tumour bed boost given intraoperatively (TARGIT) boost is superior to a tumour bed boost given as part of postoperative EBRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN34086741 and ClinicalTrials.gov NCT00983684. FUNDING University College London Hospitals (UCLH)/University College London (UCL) Comprehensive Biomedical Research Centre, UCLH Charities, Ninewells Cancer Campaign, National Health and Medical Research Council and German Federal Ministry of Education and Research (BMBF). From September 2009 this project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, University of Western Australia, Perth, WA, Australia
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Stephen Morris
- Health Economics Group, Department of Biomedical Engineering, University College London, London, UK
| | | | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
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Kolberg HC, Loevey G, Akpolat-Basci L, Stephanou M, Fasching PA, Untch M, Liedtke C, Bulsara M, Vaidya JS. Targeted intraoperative radiotherapy tumour bed boost during breast conserving surgery after neoadjuvant chemotherapy. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Leyla Akpolat-Basci
- Marienhospital Bottrop, Klinik für Gynäkologie und Geburtshilfe, Bottrop, Germany
| | - Miltiades Stephanou
- Marienhospital Bottrop, Klinik für Gynäkologie und Geburtshilfe, Bottrop, Germany
| | | | | | - Cornelia Liedtke
- University of Schleswig-Holstein Campus Luebeck, Luebeck, Germany
| | - Max Bulsara
- University of Notre Dame, Fremantle, Australia
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Vaidya JS, Bulsara M, Wenz F, Coombs N, Singer J, Ebbs S, Massarut S, Saunders C, Douek M, Williams NR, Joseph D, Tobias JS, Baum M. Reduced Mortality With Partial-Breast Irradiation for Early Breast Cancer: A Meta-Analysis of Randomized Trials. Int J Radiat Oncol Biol Phys 2016; 96:259-265. [PMID: 27478165 DOI: 10.1016/j.ijrobp.2016.05.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/18/2016] [Accepted: 05/05/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE With earlier detection and more effective treatment, mortality from breast cancer continues to fall and it has become increasingly important to reduce the toxicity of treatments. Partial-breast radiation therapy, which focuses radiation to the tumor bed, may achieve this aim. We analyzed mortality differences in randomized trials of partial-breast irradiation (PBI). METHODS AND MATERIALS We included data from published randomized trials of PBI (alone or as part of a risk-adapted approach) versus whole-breast irradiation (WBI) for invasive breast cancer suitable for breast-conserving therapy. We identified trials using PubMed and Google searches with the terms "partial breast irradiation" OR "intraoperative radiotherapy" OR "IMRT" OR ("accelerated" AND "radiation") AND "randomised/randomized," as well as through discussion with colleagues in the field. We calculated the proportion of patients who had events in each randomized arm at 5 years' follow-up and created a forest plot using Stata, version 14.1. RESULTS We identified 9 randomized trials of PBI versus WBI in invasive breast cancer; 5-year outcomes were available for non-breast cancer mortality in 5 trials (n=4489) and for breast cancer mortality in 4 trials (n=4231). The overall mortality was 4.9%. There was no detectable heterogeneity between the trials for any of the outcomes. There was no difference in the proportion of patients dying of breast cancer (difference, 0.000% [95% confidence interval (CI), -0.7 to +0.7]; P=.999). Non-breast cancer mortality with PBI was lower than with WBI (difference, 1.1% [95% CI, -2.1% to -0.2%]; P=.023). Total mortality with PBI was also lower than with WBI (difference, 1.3% [95% CI, -2.5% to 0.0%]; P=.05). CONCLUSIONS Use of PBI instead of WBI in selected patients results in a lower 5-year non-breast cancer and overall mortality, amounting to a 25% reduction in relative terms. This information should be included when breast-conserving therapy is proposed to a patient.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Health, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Nathan Coombs
- Department of Surgery, Great Western Hospital, Swindon, UK
| | - Julian Singer
- Department of Clinical Oncology, The Princess Alexandra Hospital, Harlow, UK
| | | | - Samuele Massarut
- National Cancer Institute, Centro di Riferimento Oncologico, Aviano, Italy
| | | | - Michael Douek
- Department of Surgery, Kings College London, London, UK
| | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - David Joseph
- Departments of Radiation Oncology, and Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
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Coombs NJ, Coombs JM, Vaidya UJ, Singer J, Bulsara M, Tobias JS, Wenz F, Joseph DJ, Brown DA, Rainsbury R, Davidson T, Adamson DJA, Massarut S, Morgan D, Potyka I, Corica T, Falzon M, Williams N, Baum M, Vaidya JS. Environmental and social benefits of the targeted intraoperative radiotherapy for breast cancer: data from UK TARGIT-A trial centres and two UK NHS hospitals offering TARGIT IORT. BMJ Open 2016; 6:e010703. [PMID: 27160842 PMCID: PMC4890331 DOI: 10.1136/bmjopen-2015-010703] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To quantify the journeys and CO2 emissions if women with breast cancer are treated with risk-adapted single-dose targeted intraoperative radiotherapy (TARGIT) rather than several weeks' course of external beam whole breast radiotherapy (EBRT) treatment. SETTING (1) TARGIT-A randomised clinical trial (ISRCTN34086741) which compared TARGIT with traditional EBRT and found similar breast cancer control, particularly when TARGIT was given simultaneously with lumpectomy, (2) 2 additional UK centres offering TARGIT. PARTICIPANTS 485 UK patients (249 TARGIT, 236 EBRT) in the prepathology stratum of TARGIT-A trial (where randomisation occurred before lumpectomy and TARGIT was delivered simultaneously with lumpectomy) for whom geographical data were available and 22 patients treated with TARGIT after completion of the TARGIT-A trial in 2 additional UK breast centres. OUTCOME MEASURES The shortest total journey distance, time and CO2 emissions from home to hospital to receive all the fractions of radiotherapy. METHODS Distances, time and CO2 emissions were calculated using Google Maps and assuming a fuel efficiency of 40 mpg. The groups were compared using the Student t test with unequal variance and the non-parametric Wilcoxon rank-sum (Mann-Whitney) test. RESULTS TARGIT patients travelled significantly fewer miles: TARGIT 21 681, mean 87.1 (SE 19.1) versus EBRT 92 591, mean 392.3 (SE 30.2); had lower CO2 emissions 24.7 kg (SE 5.4) vs 111 kg (SE 8.6) and spent less time travelling: 3 h (SE 0.53) vs 14 h (SE 0.76), all p<0.0001. Patients treated with TARGIT in 2 hospitals in semirural locations were spared much longer journeys (753 miles, 30 h, 215 kg CO2 per patient). CONCLUSIONS The use of TARGIT intraoperative radiotherapy for eligible patients with breast cancer significantly reduces their journeys for treatment and has environmental benefits. If widely available, 5 million miles (8 000 000 km) of travel, 170 000 woman-hours and 1200 tonnes of CO2 (a forest of 100 hectares) will be saved annually in the UK. TRIAL REGISTRATION NUMBER ISRCTN34086741; Post-results.
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Affiliation(s)
| | | | - Uma J Vaidya
- Nonsuch High School for Girls, UK
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
| | - Julian Singer
- Department of Radiotherapy, Princess Alexandra Hospital, Harlow, UK
| | - Max Bulsara
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
- University of Notre Dame, Fremantle, Western Australia, Australia
| | - Jeffrey S Tobias
- Department of Radiation Oncology(JST), University College London, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University of Heidelberg, Germany
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | | | | | | | | | | | - David Morgan
- Sherwood Forest Hospitals NHS Foundation Trust, Nottinghamshire, UK
| | - Ingrid Potyka
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
| | - Tammy Corica
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Mary Falzon
- Department of Pathology, University College London, London, UK
| | - Norman Williams
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
| | - Jayant S Vaidya
- Surgical and Interventional Trials Unit of the Division of Surgery and Interventional Science, University College London, London, UK
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, Charles Bell House, London, London W1W 7EJ, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jeffrey S Tobias
- Department of Clinical Oncology, Univeristy College London Hospitals, London, UK
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, Charles Bell House, London, London W1W 7EJ, UK
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Pathmarajah P, Shah K, Taghipour K, Ramachandra S, Thorat MA, Chaudhry Z, Patkar V, Peters F, Connor T, Spurrell E, Tobias JS, Vaidya JS. Letrozole-induced necrotising leukocytoclastic small vessel vasculitis: First report of a case in the UK. Int J Surg Case Rep 2015; 16:77-80. [PMID: 26432999 PMCID: PMC4643446 DOI: 10.1016/j.ijscr.2015.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 09/17/2015] [Indexed: 11/30/2022] Open
Abstract
Letrozole is a commonly used drug in breast cancer treatment. Letrozole induced cutaneous leukocytoclastic small vessel vasculitis: first UK case. There was extensive superficial skin necrosis; needed local and systemic steroids. Interestingly, the cancer shrank without treatment during the 3-4 month episode. Breast teams should be aware of this rare side effect.
Introduction Letrozole, an aromatase inhibitor, is a commonly used neo-adjuvant drug to treat hormone-sensitive breast cancer. There have been a few cases of aromatase inhibitor induced vasculitis but the first case of letrozole-induced vasculitis was reported from Switzerland in 2014 (Digklia et al.) [1]. Presentation of case We report the case of a 72-year-old woman with a small breast cancer. She was started on pre-operative letrozole (2.5 mg/d) whilst awaiting surgery. Ten days later she presented with burning pain and purpuric skin lesions which progressed to extensive ischaemic superficial necrosis of the lower limb skin, resolving over 3–4 months after local and systemic steroids. Histologically, it showed leucocytoclasis with evidence of eosinophilia consistent with a diagnosis of cutaneous leukocytoclastic small vessel vasculitis. Discussion The initial clinical presentation was severe burning pain around the ankles and a spreading violaceous rash. Letrozole was stopped. Wide local excision (lumpectomy) and sentinel node biopsy were postponed because of the accompanying pneumonitis and gastrointestinal upset, and were carried out 3.5 months later. Fortunately, the tumour size did not increase, but appeared to reduce, and axillary lymph nodes remained negative, i.e., this patient’s cancer outcome does not seem to have been jeopardized. Conclusion Leukocytoclastic vasculitis is a hypersensitivity reaction that is usually self-resolving, though our case needed systemic steroid treatment. Letrozole is a commonly used drug in clinical practice and prescribers should be aware of this rare side effect, which in our case delayed treatment without any apparent harm and possibly reduced tumour size.
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Affiliation(s)
| | - Karishma Shah
- University College London Medical School, Gower St, London WC1E6BT, United Kingdom
| | - Kathy Taghipour
- Department of Dermatology, The Whittington Hospital, London N195NF, United Kingdom
| | - Su Ramachandra
- Department of Histopathology, The Whittington Hospital, London N195NF, United Kingdom
| | - Mangesh A Thorat
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom; Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, EC1M 6BQ, United Kingdom
| | - Ziaullah Chaudhry
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom
| | - Vivek Patkar
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom
| | - Francesca Peters
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom
| | - Thomas Connor
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom
| | - Emma Spurrell
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom
| | - Jeffrey S Tobias
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom
| | - Jayant S Vaidya
- The Breast Unit, The Whittington Hospital, London N195NF, United Kingdom; Division of Surgery and Interventional Science, University College London, 132 Hampstead Road, London NW1 2PS, United Kingdom.
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Vaidya JS, Bulsara M, Wenz F, Joseph D, Saunders C, Massarut S, Flyger H, Eiermann W, Alvarado M, Esserman L, Falzon M, Brew-Graves C, Potyka I, Tobias JS, Baum M. In Regard to Hepel and Wazer. Int J Radiat Oncol Biol Phys 2015; 92:953-954. [PMID: 26194663 DOI: 10.1016/j.ijrobp.2015.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Jayant S Vaidya
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, Whittington Health, London, UK; Department of Surgery, Whittington Health, London, UK
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Surgery, University of Western Australia, Perth, WA, Australia
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologia, Aviano, Italy
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, California
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, California
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, Whittington Health, London, UK
| | - Chris Brew-Graves
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, Whittington Health, London, UK
| | - Michael Baum
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
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Wenz F, Sedlmayer F, Herskind C, Welzel G, Sperk E, Neumaier C, Gauter-Fleckenstein B, Vaidya JS, Sütterlin M. Accelerated Partial Breast Irradiation in Clinical Practice. Breast Care (Basel) 2015; 10:247-52. [PMID: 26600760 DOI: 10.1159/000437194] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Accelerated partial breast irradiation (APBI) has been under clinical investigation for more than 15 years. There are several technical approaches that are clinically established, e.g. brachytherapy, intraoperative radiotherapy (IORT), or external-beam radiotherapy. The understanding of the underlying biology, optimal technical procedures, patient selection criteria, and imaging changes during follow-up has increased enormously. After completion of several phase III trials using brachytherapy or IORT, APBI is currently increasingly used either in phase IV studies, registries, or in selected patients outside of clinical studies. Consensus statements about suitable patients are available from several international and national societies like ASTRO, ESTRO, and DEGRO. One may expect that 15-25% of patients undergoing breast-conserving surgery may qualify for APBI, i.e. patients with small invasive ductal breast cancer without clinical lymph node involvement.
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Affiliation(s)
- Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Felix Sedlmayer
- Department of Radiotherapy and Radiation Oncology, LHK Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Carsten Herskind
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Neumaier
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Benjamin Gauter-Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, United Kingdom
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Vaidya JS, Bulsara M, Wenz F, Joseph D, Saunders C, Massarut S, Flyger H, Eiermann W, Alvarado M, Esserman L, Falzon M, Brew-Graves C, Potyka I, Tobias JS, Baum M. Pride, Prejudice, or Science: Attitudes Towards the Results of the TARGIT-A Trial of Targeted Intraoperative Radiation Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2015; 92:491-7. [PMID: 26068479 PMCID: PMC4464618 DOI: 10.1016/j.ijrobp.2015.03.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 03/04/2015] [Accepted: 03/19/2015] [Indexed: 11/04/2022]
Affiliation(s)
- Jayant S Vaidya
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Health, London, UK.
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Surgery, University of Western Australia, Perth, WA, Australia
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologia, Aviano, Italy
| | - Henrik Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, California
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, California
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - Chris Brew-Graves
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - Michael Baum
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
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Morgan DAL, Vaidya JS. Perspectives in breast cancer treatment: APBI and breast-conserving surgery. In regard to Moran et al and Smith et al. Int J Radiat Oncol Biol Phys 2014; 90:967. [PMID: 25585788 DOI: 10.1016/j.ijrobp.2014.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
Affiliation(s)
- David A L Morgan
- Sherwood Forest Hospitals NHS Foundation Trust, Nottinghamshire, United Kingdom
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Affiliation(s)
- Jayant S Vaidya
- University College London, Division of Surgery and Interventional Science, London W1W 7EJ, UK.
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia; Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Michael Baum
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia; Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
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Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Keshtgar M, Flyger HL, Massarut S, Alvarado M, Saunders C, Eiermann W, Metaxas M, Sperk E, Sütterlin M, Brown D, Esserman L, Roncadin M, Thompson A, Dewar JA, Holtveg HMR, Pigorsch S, Falzon M, Harris E, Matthews A, Brew-Graves C, Potyka I, Corica T, Williams NR, Baum M. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet 2014; 383:603-13. [PMID: 24224997 DOI: 10.1016/s0140-6736(13)61950-9] [Citation(s) in RCA: 581] [Impact Index Per Article: 58.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The TARGIT-A trial compared risk-adapted radiotherapy using single-dose targeted intraoperative radiotherapy (TARGIT) versus fractionated external beam radiotherapy (EBRT) for breast cancer. We report 5-year results for local recurrence and the first analysis of overall survival. METHODS TARGIT-A was a randomised, non-inferiority trial. Women aged 45 years and older with invasive ductal carcinoma were enrolled and randomly assigned in a 1:1 ratio to receive TARGIT or whole-breast EBRT, with blocks stratified by centre and by timing of delivery of targeted intraoperative radiotherapy: randomisation occurred either before lumpectomy (prepathology stratum, TARGIT concurrent with lumpectomy) or after lumpectomy (postpathology stratum, TARGIT given subsequently by reopening the wound). Patients in the TARGIT group received supplemental EBRT (excluding a boost) if unforeseen adverse features were detected on final pathology, thus radiotherapy was risk-adapted. The primary outcome was absolute difference in local recurrence in the conserved breast, with a prespecified non-inferiority margin of 2·5% at 5 years; prespecified analyses included outcomes as per timing of randomisation in relation to lumpectomy. Secondary outcomes included complications and mortality. This study is registered with ClinicalTrials.gov, number NCT00983684. FINDINGS Patients were enrolled at 33 centres in 11 countries, between March 24, 2000, and June 25, 2012. 1721 patients were randomised to TARGIT and 1730 to EBRT. Supplemental EBRT after TARGIT was necessary in 15·2% [239 of 1571] of patients who received TARGIT (21·6% prepathology, 3·6% postpathology). 3451 patients had a median follow-up of 2 years and 5 months (IQR 12-52 months), 2020 of 4 years, and 1222 of 5 years. The 5-year risk for local recurrence in the conserved breast was 3·3% (95% CI 2·1-5·1) for TARGIT versus 1·3% (0·7-2·5) for EBRT (p=0·042). TARGIT concurrently with lumpectomy (prepathology, n=2298) had much the same results as EBRT: 2·1% (1·1-4·2) versus 1·1% (0·5-2·5; p=0·31). With delayed TARGIT (postpathology, n=1153) the between-group difference was larger than 2·5% (TARGIT 5·4% [3·0-9·7] vs EBRT 1·7% [0·6-4·9]; p=0·069). Overall, breast cancer mortality was much the same between groups (2·6% [1·5-4·3] for TARGIT vs 1·9% [1·1-3·2] for EBRT; p=0·56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1·4% [0·8-2·5] vs 3·5% [2·3-5·2]; p=0·0086), attributable to fewer deaths from cardiovascular causes and other cancers. Overall mortality was 3·9% (2·7-5·8) for TARGIT versus 5·3% (3·9-7·3) for EBRT (p=0·099). Wound-related complications were much the same between groups but grade 3 or 4 skin complications were significantly reduced with TARGIT (four of 1720 vs 13 of 1731, p=0·029). INTERPRETATION TARGIT concurrent with lumpectomy within a risk-adapted approach should be considered as an option for eligible patients with breast cancer carefully selected as per the TARGIT-A trial protocol, as an alternative to postoperative EBRT. FUNDING University College London Hospitals (UCLH)/UCL Comprehensive Biomedical Research Centre, UCLH Charities, National Institute for Health Research Health Technology Assessment programme, Ninewells Cancer Campaign, National Health and Medical Research Council, and German Federal Ministry of Education and Research.
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MESH Headings
- Aged
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Humans
- Intraoperative Care/methods
- Intraoperative Care/mortality
- Kaplan-Meier Estimate
- Mastectomy, Segmental/methods
- Mastectomy, Segmental/mortality
- Middle Aged
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/prevention & control
- Radiotherapy/methods
- Radiotherapy/mortality
- Treatment Outcome
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Affiliation(s)
- Jayant S Vaidya
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK; Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Hopsital, London, UK.
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Mohammed Keshtgar
- Department of Surgery, Royal Free Hospital, London, UK; Department of Surgery, Whittington Hopsital, London, UK
| | - Henrik L Flyger
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Samuele Massarut
- Department of Surgery, Centro di Riferimento Oncologia, Aviano, Italy
| | - Michael Alvarado
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Christobel Saunders
- Department of Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Surgery, University of Western Australia, Perth, WA, Australia
| | - Wolfgang Eiermann
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Marinos Metaxas
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Marc Sütterlin
- Department of Gynecology and Obstetrics, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Douglas Brown
- Department of Surgery, Ninewells Hospital, Dundee, UK
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Mario Roncadin
- Department of Radiation Oncology, Centro di Riferimento Oncologia, Aviano, Italy
| | | | - John A Dewar
- Department of Radiation Oncology, Ninewells Hospital, Dundee, UK
| | - Helle M R Holtveg
- Department of Breast Surgery, University of Copenhagen, Copenhagen, Denmark
| | - Steffi Pigorsch
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany
| | - Mary Falzon
- Department of Pathology, University College London Hospitals, London, UK
| | - Eleanor Harris
- Department of Radiation Oncology, East Carolina University Brody School of Medicine, Greenville, NC, USA
| | - April Matthews
- Psychosocial Oncology Clinical Studies Group, National Cancer Research Institute, London, UK; Independent Cancer Patients' Voice, London, UK
| | - Chris Brew-Graves
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Tammy Corica
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Norman R Williams
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Clinical Trials Group, Division of Surgery and Interventional Science, University College London, London, UK
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Wenz FK, Vaidya JS, Bulsara M, Suetterlin M, Sperk E, Ataseven B, Pigorsch S, Feyer PC, Blohmer JU, Kaufmann M, Roedel C, Friese K, Belka C, Solomayer E, Fleckenstein J, Park-Simon TW, Bremer M, Joseph DJ, Tobias JS, Baum M. TARGIT-A trial: Updated results for local recurrence and survival for the German centers. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.1121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1121 Background: In 2010, we reported data on local control and early toxicity for the TARGIT-A trial of intraoperative radiotherapy after lumpectomy for early breast cancer. The updated results and first analysis of survival of the whole cohort (n = 3,451) were presented at San Antonio Breast Cancer Symposium in December 2012. We analysed the German cohort of patients, which was supposed to be more homogeneous (prepathology IORT only, homogeneous treatment in EBRT arm) and lower risk (older, smaller tumors, larger margin) than the international cohort of patients due to legal restrictions for radiotherapy studies in Germany. Methods: TARGIT-A was a randomised trial in patients >=50 years with invasive ductal carcinoma (<= 2cm) undergoing breast conserving surgery comparing standard fractionated whole breast EBRT (56 Gy) with single dose TARGIT (20 Gy) immediately after tumor excision / at the time of the primary operation. The experimental arm mandated additional EBRT (46 Gy, excluding a boost, n = 126) if adverse features were detected on final pathology (EIC, N+, margin < 1 cm) making this a “risk-adapted policy”. Median follow-up was 2 years and 5 months. Results: 734 patients recruited from 7 centres in Germany. Patient’s ages were <=50y 3%, 51-60y 33%, 61-70y 51%, >70y 12%. Tumour sizes were 0-1cm 35%, 1.1-2cm 55% and >2cm 11%. Grade I 29%, II 59%, III 12% and nodes negative 81%, 1-3 nodes 16%, >3 nodes 3%. At 5-years, the absolute number of events in TARGIT vs. EBRT were as follows: Primary outcome: IBR 4 vs. 1, Exploratory outcome: All recurrences (breast +axilla+contralateral+distant recurrence) 11 vs. 7, Secondary outcome: All deaths 6 vs. 12, Breast Cancer deaths 3 vs. 5, Non-Breast Cancer deaths 3 vs. 7. Conclusions: Patients in the TARGIT-A trial have excellent 5 year outcomes (local control > 97%, overall survival >= 94%) in both arms of the trial. Clinical trial information: protocol 99PRT/47.
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Affiliation(s)
- Frederik K. Wenz
- Department of Radiation Oncology, Mannheim Medical Center, University of Heidelberg, Mannheim, Germany
| | | | - Max Bulsara
- University of Notre Dame, Fremantle, Australia
| | | | - Elena Sperk
- Department of Radiation Oncology, Mannheim Medical Center, University of Heidelberg, Mannheim, Germany
| | - Beyhan Ataseven
- Department of Gynecology, Rotkreuzkliniken Munich, Munich, Germany
| | - Steffi Pigorsch
- Deptartment of Radiation Oncology, Technical University Munich, Munich, Germany
| | - Petra C. Feyer
- Clinic of Radiooncology and Nuclear Medicine, Vivantes Klinikum Neukölln, Berlin, Germany
| | | | | | | | - Klaus Friese
- Department of Gynecology and Obstetrics, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, Ludwig Maximilians University Munich, Munich, Germany
| | - Erich Solomayer
- Department of Obstetrics and Gynecology, University Medical Center, Homburg/Saar, Germany
| | | | | | | | | | | | - Michael Baum
- University College London, London, United Kingdom
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Retsky M, Demicheli R, Hrushesky WJM, Forget P, De Kock M, Gukas I, Rogers RA, Baum M, Sukhatme V, Vaidya JS. Reduction of breast cancer relapses with perioperative non-steroidal anti-inflammatory drugs: new findings and a review. Curr Med Chem 2013; 20:4163-76. [PMID: 23992307 PMCID: PMC3831877 DOI: 10.2174/09298673113209990250] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 03/26/2013] [Accepted: 03/31/2013] [Indexed: 12/21/2022]
Abstract
To explain a bimodal pattern of hazard of relapse among early stage breast cancer patients identified in multiple databases, we proposed that late relapses result from steady stochastic progressions from single dormant malignant cells to avascular micrometastases and then on to growing deposits. However in order to explain early relapses, we had to postulate that something happens at about the time of surgery to provoke sudden exits from dormant phases to active growth and then to detection. Most relapses in breast cancer are in the early category. Recent data from Forget et al. suggest an unexpected mechanism. They retrospectively studied results from 327 consecutive breast cancer patients comparing various perioperative analgesics and anesthetics in one Belgian hospital and one surgeon. Patients were treated with mastectomy and conventional adjuvant therapy. Relapse hazard updated Sept 2011 are presented. A common Non-Steroidal Anti-Inflammatory Drug (NSAID) analgesic used in surgery produced far superior disease-free survival in the first 5 years after surgery. The expected prominent early relapse events in months 9-18 are reduced 5-fold. If this observation holds up to further scrutiny, it could mean that the simple use of this safe, inexpensive and effective anti-inflammatory agent at surgery might eliminate early relapses. Transient systemic inflammation accompanying surgery could facilitate angiogenesis of dormant micrometastases, proliferation of dormant single cells, and seeding of circulating cancer stem cells (perhaps in part released from bone marrow) resulting in early relapse and could have been effectively blocked by the perioperative anti-inflammatory agent.
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Affiliation(s)
- Michael Retsky
- Harvard School of Public Health, BLDG I, Rm 1311, 665 Huntington, Ave, Boston, MA 02115, USA.
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47
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Vaidya JS. Should healthy populations be screened for breast cancer? A consultant surgeon's perspective. Qual Prim Care 2013; 21:189-192. [PMID: 23968270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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48
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Retsky M, Rogers R, Demicheli R, Hrushesky WJ, Gukas I, Vaidya JS, Baum M, Forget P, Dekock M, Pachmann K. NSAID analgesic ketorolac used perioperatively may suppress early breast cancer relapse: particular relevance to triple negative subgroup. Breast Cancer Res Treat 2012; 134:881-8. [PMID: 22622810 DOI: 10.1007/s10549-012-2094-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 05/06/2012] [Indexed: 12/13/2022]
Abstract
To explain a bimodal relapse hazard among early stage breast cancer patients treated by mastectomy we postulated that relapses within 4 years of surgery resulted from something that happened at about the time of surgery to provoke sudden exits from dormant phases to active growth. Relapses at 10 months appeared to be surgery-induced angiogenesis of dormant avascular micrometastases. Another relapse mode with peak about 30 months corresponded to sudden growth from a single cell. Late relapses were not synchronized to surgery. This hypothesis could explain a wide variety of breast cancer observations. We have been looking for new data that might provide more insight concerning the various relapse modes. Retrospective data reported in June 2010 study of 327 consecutive patients compared various perioperative analgesics and anesthetics in one Belgian hospital and one surgeon. Patients were treated with mastectomy and conventional adjuvant therapy. Follow-up was average 27.3 months with range 13-44 months. Updated hazard as of September 2011 for this series is now presented. NSAID ketorolac, a common analgesic used in surgery, is associated with far superior disease-free survival in the first few years after surgery. The expected prominent early relapse events are all but absent. In the 9-18 month period, there is fivefold reduction in relapses. If this observation holds up to further scrutiny, it could mean that the simple use of this safe and effective anti-inflammatory agent at surgery might eliminate most early relapses. Transient systemic inflammation accompanying surgery could be part of the metastatic tumor seeding process and could have been effectively blocked by perioperative anti-inflammatory agents. In addition, antiangiogenic properties of NSAIDs could also play a role. Triple negative breast cancer may be the ideal group with which to test perioperative ketorolac to prevent early relapses.
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Affiliation(s)
- Michael Retsky
- Harvard School of Public Health, BLDG I, Rm 1311, 665 Huntington, Ave, Boston, MA 02115, USA.
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Vaidya JS, Baum M, Wenz F, Bulsara M, Tobias J, Alvarodo M, Saunders C, Williams N, Joseph D. P3-13-07: The TARGIT-A Trial Update Confirms No Increase in Local Recurrence. Cancer Res 2011. [DOI: 10.1158/0008-5472.sabcs11-p3-13-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: In June 2010, we published the results of the TARGIT-A trial (1) that compared “one-size fits” all radiotherapy (whole breast radiotherapy-EBRT group) with risk -adjusted radiotherapy (TARGIT- group: single dose TARGeted Intraoperative radioTherapy with additional whole breast radiotherapy if adverse prognostic factors were found). These results showed that the risk of local recurrence in the TARGIT group was non-inferior to that of the EBRT group (the difference between the two arms was 0.25% at 4 years). We now report the results analyzed after further follow up of the total trial cohort without unblinding.
Method: As often repeated, unplanned analysis comparing two groups in a randomized trial can result in an increased alpha-spent as well as carry the risk of a false positive result, we have remained blinded to the further recurrences in the trial according to allocated treatment, since the original publication in the Lancet. Instead we proposed and performed a blinded analysis of the local recurrence rate for the whole cohort. We plotted the Kaplan Meier plots and compared the estimated 4-year recurrences.
Results: Amongst the 2232 patients randomized, there were 13 recurrences at the time of Lancet publication and since then, we have had 8 additional recurrences. The number of patients who have completed at least 4 years of follow up has increased from 420 to 717. We found that the 4-year Kaplan Meier estimate of local recurrence was 1.08% (95% CI 0.59 −1.96) at the time of the Lancet publication and it is 1.09% (95% CI 0.65 - 1.85) now.
Conclusion: We found that the overall 4-year recurrence rates of the TARGIT-A trial have remained stable with a longer follow up and therefore; it is statistically implausible, that one particular arm has a significantly higher local recurrence.
References
1. Vaidya JS, Joseph DJ, Tobias JS, Bulsara M, Wenz F, Saunders C, Alvarado M, Flyger HL, Massarut S, Eiermann W, Keshtgar M, Dewar J, Kraus-Tiefenbacher U, Sutterlin M, Esserman L, Holtveg HM, Roncadin M, Pigorsch S, Metaxas M, Falzon M, Matthews A, Corica T, Williams NR, Baum M. Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial. Lancet 2010;376(9735):91–102.
Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-13-07.
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Affiliation(s)
- JS Vaidya
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - M Baum
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - F Wenz
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - M Bulsara
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - J Tobias
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - M Alvarodo
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - C Saunders
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - N Williams
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
| | - D Joseph
- 1University College London, London, United Kingdom; University of Heidelberg, Mannheim, United Kingdom; University of Notre Dame, Fremantle, United Kingdom; University College Hospital and Whittington Hospital, London, United Kingdom; School of Surgery, University of Western Australia, London (All), United Kingdom; University of San Francisco, London (All), United Kingdom; Sir Charles Gairdener Hospital, London (All), United Kingdom
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Vaidya JS, Baldassarre G, Thorat MA, Massarut S. Role of glucocorticoids in breast cancer. Curr Pharm Des 2011; 16:3593-600. [PMID: 20977423 DOI: 10.2174/138161210793797906] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 09/24/2010] [Indexed: 11/22/2022]
Abstract
Glucocorticoids play an essential role in embryonic development and tissue homeostasis and possess important anti-inflammatory and immunosuppressive properties. Due to their very wide spectrum of activity, Glucocorticoids are one of the most commonly used drugs-used in the treatment of asthma, arthritis, autoimmune diseases and shock/SIRS. glucocorticoids are a main component of treatment regimens in hematological malignancies due to their pro-apoptotic properties and are also used as co-treatment several other cancers and chemotherapy regimens including those in breast cancer treatment. In breast cancer, however, glucocorticoids may have diverse effects and could inhibit chemosensitivity. Additionally, glucocorticoids through their receptor may interact with ER in a feedback loop regulating each other's activities. The normal variation of glucocorticoid levels with time of the day, menstrual cycle or year could have a interesting chronobiological interaction with the well recorded variation in breast cancer proliferation and metastatic potential. Glucocorticoids could play a very complex role in breast cancer epidemiology, biology and treatment; this review aims to present a comprehensive discussion as well as speculate future directions for research.
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Affiliation(s)
- Jayant S Vaidya
- Research Department of Surgery, University College London, UK.
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