7-year follow up of intra-operative radiotherapy for early breast cancer in a developing country

Scarce radiation resources and an often poor, rural population make single fraction, definitive intra-operative radiation (IORT) ideal for developing countries. From 2002 to 2005 IORT in breast conservation was administered utilizing existing infrastructure in an extremely resource-restricted environment. After tumor excision an applicator was introduced into the tumor bed. An existing Ir (192) after loader delivered a single fraction (21?Gy). Of thirty nine patients treated with 84 months follow-up, one patient suffered local, four regional and three systemic relapse. One patient died of disease, 2 of unrelated causes for a local control rate of 95% and a disease-specific survival of 95%. Cosmetic outcome was perceived excellent. IORT using existing after loaders and a low cost applicator greatly reduced health care resources. This extends breast conservation to indigent patients who cannot adhere to lengthy EBRT protocols.     

Analysis of failure after curative irradiation of extrahepatic bile duct carcinoma.

Thirty-four patients with subtotally resected or unresectable carcinoma of the extrahepatic bile ducts received radiation therapy; a minimum of 45 Gy (external beam) to the tumor and regional lymph nodes +/- 5-fluorouracil (5-FU). Seventeen patients received an external beam boost of 5 to 15 Gy to the tumor, and a specialized boost was used in the remaining 17 patients (iridium-192 transcatheter seeds in 10 and intraoperative radiation therapy [IORT] with electrons in seven). The median time to death in all 34 patients was 12 months (range, 4 to 98-months). The only patients who survived longer than 18 months were those either with gross total or subtotal resection before external irradiation (2 of 6) or who received specialized boosts (192Ir, 3 of 10; IORT, 3 of 7). Local failure was documented in 9 of 17 patients who received external beam irradiation alone +/- 5-FU, 3 of 10 patients who received an 192Ir boost, and 2 of 6 patients who received an IORT boost with curative intent.     

High dose rate (HDR) brachytherapy with conformal radiation therapy for localized prostate cancer

OBJECTIVES: To evaluate the outcome of high dose rate (HDR) brachytherapy with iridium 192 (Ir(192)) and 3D conformal external beam radiotherapy in patients with localized prostate cancer. METHODS: A total of 442 patients with localized prostate cancer underwent combined radiotherapy with interstitial brachytherapy with Ir(192) and 3D conformal external beam radiotherapy between December 1992 and March 2001. Patients underwent laparoscopic pelvic lymph node dissection to exclude patients with lymphatic involvement. Iridium 192 was delivered twice with a one-week interval in afterloading technique. 247 patients (56%) had clinical T3 disease and 128 patients (29%) had an initial PSA of more than 20 ng/ml. Progression was defined as biochemical failure according to ASTRO criteria. Patients were divided according to pretreatment variables that independently affected prostate-specific antigen (PSA) relapse-free survival in three risk groups. Low risk was defined as cT1c-cT2 and G1-G2 and PSA<10 ng/ml (n=94). Intermediate risk included patients with cT1c-cT2 and G1-G2 and PSA between 10 and 20 ng/ml (n=53). High risk group patients were cT3 or G3 or PSA>20 ng/ml (n=295). RESULTS: Median follow-up was 5 years. Late grade 3-4 complications according to RTOG/EORTC criteria occurred in 50 patients (11%).The initial PSA value decreased from median 11.8 ng/ml to 0.98 ng/ml 12 months after treatment, to 0.3 ng/ml after 60 months and to 0.1 ng/ml 10 years after therapy. 53% of the patients (n=235) reached a PSA nadir of 0.5 ng/ml. 66 patients (15%) had a local recurrence, 54 (12%) developed systemic disease and 12 (3%) had both local and systemic failure. The progression free survival rate was 65% at 5-year follow-up. Five-year progression free survival was 81% in the low risk group, 65% in the intermediate risk group and 59% in the high risk group. Five-year overall survival was 87% and 5-year disease specific survival 94%. Initial PSA value, risk group and age were significantly related to progression free survival. CONCLUSIONS: Combined HDR brachytherapy with Iridium 192 is an alternative treatment option for patients with localized prostate cancer. Initial PSA value, risk group, and age are important prognostic factors for progression free survival.     

Breast conservation therapy with tumor bed irradiation alone in a selected group of patients with stage I breast cancer

Abstract: Radiotherapy after breast-conserving surgery increases local control. We tested the feasibility of limited surgery with tumor bed irradiation only with ¹⁹²Ir in a selected group of patients with stage I breast cancer. Twenty-five breasts in 24 women more than 60 years old with low- or intermediate-grade stage I tumors were treated with placement of interstitial catheters at the time of lumpectomy and axillary node dissection. This procedure was followed by after-loading with low-dose ¹⁹²Ir to deliver 20–25 Gy to the tumor bed over 24–48 hours. There were neither local recurrences in the breast nor distant recurrences at a median follow-up of 47 months (range 25–90 months). Cosmetic appearance ranged from very good to excellent. There were no long-term complications. It is feasible to treat a select group of patients with tumor bed irradiation, using relatively low doses of interstitial irradiation, with excellent local control and no significant morbidity.     

Interstitial brachytherapy for malignant gliomas using the Brown-Roberts-Wells (BRW) stereotactic system

Eleven patients harboring recurrent or deep-seated malignant gliomas were treated by interstitial brachytherapy with 192Ir seed assembly, between June 1987 and September 1989. Implantations for the afterloaded catheter were performed using the Brown-Roberts-Wells (BRW) CT guided stereotactic system. The number of seeds and the distribution of the implants were chosen in such a way that the minimum tumor dose of 30-50Gy could be delivered to the surface or 1cm beyond the rim of the contrast enhancement. The radioactive sources were held in the afterloaded catheters that were removed after the desired dose had been delivered. Response to therapy was measured by serial CT scans and clinical examination. Tumor regressions were seen by CT scans made 2 or 3 months after implantation. One tumor showed complete regression (CR), four showed partial response (PR), one showed minor response (MR) and 5 showed no change (NC). Overall response rate was 54%. Six patients died 3 to 18 months following implantation, and five are still alive 7 to 27 months after implantation. No complications such as infection or hemorrhage were observed during the treatment. A patient harboring large (6.5cm in diameter) recurrent glioblastoma in the rt. parietal robe required a craniotomy due to the mass growing for one and half month after implantation, and radiation necrosis of the entire tumor mass was documented. The technique of stereotactic interstitial implantation was clinically well tolerated and easily reproducible and our preliminary results seemed encouraging. Technical improvement to achieve an adequate isodose distribution to cover the tumor volume might lead to improved survival rates.     

High dose rate brachytherapy of localized prostate cancer

OBJECTIVE: We evaluated the safety and efficacy of high dose rate (HDR) brachytherapy using Iridium-192 (Ir 192) and 3D conformal external beam radiotherapy in patients with localized prostate cancer. METHODS: A total of 444 patients with localized prostate cancer underwent combined radiotherapy with interstitial Ir 192 and 3D conformal external beam radiotherapy between December 1992 and March 2001. The 230 patients, treated between December 1992 and December 1997 were analyzed. All patients underwent laparoscopic pelvic lymph node dissection to exclude patients with lymphatic involvement. Ir 192 was delivered twice with a 1-week interval in HDR remote control technique. The interstitial dose from December 1992 to December 1993 was 10Gy, after December 1993 the dose was reduced to 9Gy per treatment session. The interstitial application was followed by external beam radiation of 45Gy for cT1-cT2 and 50.4Gy for cT3 tumor (40Gy from December 1992 to December 1993). Progression was defined as biochemical failure according to ASTRO criteria, e.g. three consecutive PSA rises following the PSA nadir. RESULTS: The median PSA value decreased from 12.8 to 0.93ng/ml 12 months after treatment. Median PSA value was 0.47 after 24 months, 0.30ng/ml after 36 months and 0.18ng/ml after 60 months. 68% of the biopsies were negative 24 months after therapy. Progression-free rate was 100% for cT1 tumors, 75% for cT2 and 60% for stage-cT3 on 5-year follow-up. Five-year overall survival was 93%, 5-year disease-specific survival was 98%. Initial PSA value <10ng/ml, low stage and low grade were significantly related to 5-year progression-free survival. CONCLUSIONS: Combined HDR brachytherapy with Ir 192 is an alternative treatment option especially for patients with cT3 prostate cancer. Initial PSA value, stage and grade, are important prognostic factors.     

Treatment of prostatic carcinoma by pelvic lymphadenectomy, temporary iridium-192 implant, and external irradiation

Forty patients with clinically localized adenocarcinoma of the prostate have been treated by a combination of pelvic lymphadenectomy, temporary Iridium-192 implantation, and external irradiation with follow-up of one to five years. 192Ir implant delivers a minimum tumor dose of 3,000 rad to A2 and B1 lesions and 3,500 to B2 and C lesions. Two weeks later patients receive 4,000 rad of external irradiation to the prostate over four to five weeks. Patients with pelvic nodal metastases receive 5,000 rad to the pelvis with a midline block at 4,000 rad. All patients have had a complete local response as judged by clinical criteria. Prostate needle biopsies have been performed on 16 patients one year or less after treatment, with 15 biopsies benign. The technique appears to offer excellent local control of prostatic adenocarcinoma with acceptably low morbidity.     

Hypofractionation with simultaneous integrated boost after breast-conserving surgery: Long term results of two phase-II trials

PurposeTo analyze long-term results of two multicenter prospective single-arm trials (ARO-2010-01 and ARO-2013-04) investigating adjuvant hypofractionated radiotherapy (HF) with simultaneous integrated boost (SIB) after breast-conserving surgery (BCS).MethodsEligible patients had histopathologically confirmed unifocal breast cancer planned for whole breast irradiation plus boost radiotherapy to the tumor bed. In both studies, a total dose of 40 Gy was applied to the whole breast and of 48 Gy to the tumor bed in 16 fractions of 2.5 and 3.0 Gy. Radiotherapy could be given either as three-dimensional conformal radiotherapy (3D-CRT) or as intensity-modulated radiotherapy (IMRT). The primary study objectives were feasibility and security within an observation period of six months. The current investigation focuses on long-term efficacy and toxicities.ResultsBetween 2011 and 2014, both trials enrolled 300 patients in total. Data from 274 of these patients could be used for the current analysis. The median follow-up time was 60 months and the 5-year disease-free survival 92.1%. Three patients suffered a local recurrence (after 36–72 months) while a regional recurrence occurred in one patient (after 17 months). The 5-year local control rate in the breast was 99.6%. 63.5% of all patients did not report any late radiation-related toxicity, 28.5% reported grade 1 and 7.3% grade 2 toxicities. The highest late toxicity was grade 3 in 2 women (0.7%, telangiectasia and lymphedema of the breast).ConclusionOur analysis demonstrates favorable efficacy and low rates of long-term side effects of HF with SIB after BCS. Randomized controlled phase III trials are ongoing.     

Long-term outcomes after breast conservation therapy for early stage breast cancer in a community setting

We, as a large community practice, retrospectively reviewed our experience in treating early stage breast cancer to determine rates of breast-conserving therapy (BCT), disease outcomes after such treatment, and risk factors for local recurrence. A hospital tumor registry was used to identify breast cancer cases diagnosed between 1987 and 2003. Rates of BCT and radiotherapy were examined using primary treatment data. For subsequent disease outcomes analyses, cases were limited to only those treated between 1987 and 1994 to allow for adequate follow-up. For the subset of 521 T1-2N0 patients treated with BCT, we calculated crude rates of first failure at 8 years, with outcomes classified as local failure (LF), distant or regional node failure (DNF), dead without failure (DWF), or alive without failure (AWF). Polychotomous logistic regression was done to assess the influence of age at diagnosis, tumor grade, total radiation dose to the tumor bed, and use of systemic therapy. From 1987 to 2003, rates of BCT went from 69% to 89% and the rate of radiation after breast-conserving surgery was 90%. For the subset of 521 T1-2N0 patients treated with BCT who had at least 8 years of follow-up, median age was 58 years, 15% had grade 1 tumors, 83% had T1 tumors, 4.6% had positive margins, 83% got a total radiation dose >or=60 Gy to the tumor bed, and 51% had systemic therapy. At 8 years, 7% of patients had LF, 8% DNF, 10% were DWF, and 75% were AWF. Patient age (p = 0.076), tumor grade (p = 0.056), use of systemic therapy (p = 0.077), and radiation dose (p = 0.127) had borderline significant effects on the risk of LF versus AWF. The majority of patients in this community were treated with BCT and most received radiotherapy. Local control was excellent and comparable to that seen in large academic centers.     

Skin-sparing mastectomy and immediate breast reconstruction: incidence of recurrence in patients with invasive breast cancer

The aim of this study was to investigate whether skin-sparing mastectomy (SSM), which is gaining increasing importance and gives well-accepted cosmetic results, provides adequate treatment of the patients' oncologic disease. From 1995 to 2003, 60 patients diagnosed with invasive breast cancer were treated with SSM and complete axillary dissection. All patients underwent immediate breast reconstruction after primary surgery. Patients were treated either with a latissimus dorsi flap or with a transversus rectus abdominis myocutaneous flap. Depending on the intraoperative analysis of frozen sections, 14 patients were treated with preservation of the nipple-areola complex. During a median follow-up of 52 months (4-92 months), four local recurrences (6.6%) occurred. One patient was also found to have contralateral breast carcinoma. Three patients developed distant metastases, and two patients died of their disease a mean of 18 months after primary therapy. Factors associated with local recurrence were tumor size, poor tumor differentiation, and positive node involvement. SSM followed by immediate breast reconstruction is an alternative to modified radical mastectomy in a subset of patients with invasive breast cancer. The risk of local recurrence is low and is associated with such factors as tumor stage, poor tumor differentiation, and node-positive disease. This procedure does not increase the risk of distant metastases, which is comparable to that after other surgical approaches.     

Tumor Bed Boost Omission After Negative Re-Excision in Breast-Conservation Treatment

Background We evaluated the necessity of a tumor bed boost after whole-breast radiotherapy for early-stage breast cancer after breast-conserving surgery and negative re-excision. Methods Of patients treated at the Virginia Commonwealth and Tufts Universities with breast-conservation therapy for early-stage breast cancer between 1983 and 1999, 205 required re-excision of the tumor cavity to obtain clear margins and were found to be without residual disease. Adjuvant conventionally fractionated whole-breast radiotherapy was given to a total dose of 50 Gy in 25 fractions. The tumor bed boost was omitted. Results The median follow-up was 98 months (range, 6–229 months). The tumor histological diagnosis was primarily infiltrating ductal carcinoma (183 cases; 89%). Nodal involvement was documented in 49 cases (24%). There were four documented recurrences at the tumor bed site. Five in-breast recurrences were documented to be in a location removed from the tumor bed. The overall Kaplan-Meier 15-year in-breast control rate was 92.4%, and the freedom from true recurrence rate was 97.6%. Conclusions The findings support the concept that postlumpectomy radiotherapy can be tailored according to the degree of surgical resection. There is an easily identifiable subgroup of patients who can avoid a tumor bed boost, thus resulting in a reduced treatment time and improved cosmesis, while maintaining local control rates that approach 100%. The data suggest that in patients who undergo a negative re-excision, treatment with whole-breast radiotherapy to 50 Gy is a sufficient dose to maximally reduce the risk of local recurrence.     

胸大肌包裹假体置入一期乳房重建在保留皮肤的乳癌根治术中的应用

目的：探讨保留皮肤的乳腺癌改良根治术一期胸大肌包裹假体置入乳房重建的可行性。方法：对28例0、I、II期乳腺癌患者行保留皮肤的乳腺癌改良根治术后,同期于胸大肌后方置入硅胶假体重建乳房,并根据冰冻切片检查结果决定是否保留乳头乳晕复合体。结果：28例早期乳腺癌患者均保留了乳头乳晕复合体,术后随访2～18个月,外观良好,双侧乳房对称,优良率达96.5%。所有病例均无局部复发或远处转移,无明显术后并发症。结论：保留皮肤的乳腺癌改良根治术后用硅胶假体行一期乳房重建,能达到满意的乳房美容效果,是治疗早期乳腺癌安全可行的方法。     

Five-year results: the initial clinical trial of MammoSite balloon brachytherapy for partial breast irradiation in early-stage breast cancer

OBJECTIVE: Patients with early-stage invasive ductal breast cancer were prospectively evaluated using MammoSite RTS balloon brachytherapy (RTS Cytyc Corp, Marlborough, MA) as the sole modality for delivering accelerated partial breast irradiation to the lumpectomy bed with breast-conserving surgery. This report presents the 5-year results of the treated patients. METHODS: From May 2000 to October 2001, 70 patients were enrolled in this prospective study. Forty-three patients completed accelerated partial breast irradiation with MammoSite brachytherapy following lumpectomy and axillary staging. Thirty-six patients have been followed for a median of 5.5 years (mean 65.2 months). Criteria for entry into the study were unifocal invasive ductal carcinoma, tumor size < or = 2 cm, age > or = 45 years, absence of extensive intraductal component, cavity size > or = 3 cm in 1 dimension, node-negative, and final margins negative per National Surgical Adjuvant Breast and Bowel Project definition. A minimum balloon-to-skin surface distance of 5 mm was required. A dose of 34 Gy was delivered in 10 fractions over 5 days prescribed to 1 cm from the applicator surface using iridium-192 high-dose-rate brachytherapy. Data on infection, seromas, cosmetic outcome, and toxicities were collected at 3 and 6 months and at yearly intervals. Local recurrences, both true recurrences in the lumpectomy bed and failures outside the initially treated target volume (elsewhere failures), were recorded. Contralateral breast failure rates were noted. RESULTS: The catheter was not implanted in 16 of the 70 enrolled patients due to cavity size not amenable to balloon placement (n = 10), ineligible by criteria (n = 4), and skin spacing (n = 2). Fifty-four patients were implanted and 43 were successfully treated with MammoSite balloon brachytherapy. Reasons for catheter explantation in 11 patients were poor cavity conformance in 7, inadequate skin spacing in 2, positive node in 1 and age less than 45 years in 1. Of the 43 patients who completed treatment, the infection rate was 9.3%. Seroma formation occurred in 32.6% of patients, of which 12% were symptomatic requiring aspiration. Asymptomatic fat necrosis was identified in 4 of the 43 patients, noted from time of catheter removal at 11, 14, 42, and 63 months. Good-excellent cosmetic outcomes were achieved in 83.3% of the 36 patients with more than 5 years of follow-up. Cosmetic outcomes were improved, with increased skin spacing having statistical significance at skin spacing > or = 7 mm. The only serious adverse events were 2 infections: mastitis and abscess. Seven of the 43 treated patients have been discontinued from follow-up. None had a local recurrence recorded at last visit. Reasons for exit from the study were death from metastatic disease (n = 3), lost to follow-up (n = 2), and placed in hospice for other medical conditions (n = 2). No local recurrences (either at the tumor bed or elsewhere in the breast) or regional recurrences have occurred in the 36 patients who have been followed for a median of 5.5 years. No contralateral cancers have developed. CONCLUSIONS: MammoSite balloon brachytherapy as a sole modality for delivering radiation to the tumor bed has been successful in achieving excellent local control in this initial clinical study of patients with early-stage invasive ductal breast cancer. This has been achieved with minimal toxicities and good-excellent cosmetic outcomes in 83.3%. Accelerated partial breast irradiation using the MammoSite balloon in a carefully selected group of patients has demonstrated 5-year local recurrence results comparable to those achieved with conventional whole breast radiation therapy and interstitial catheter brachytherapy as reported at 5-year data points in studies of these treatment modalities. Poor cavity conformance and inadequate skin distance were the main factors limiting use of the MammoSite device. Extended follow-up will be required to determine the long-term efficacy of this treatment modality.     

Long-term follow-up of a modified Anton-Hartrampf nipple reconstruction

This study was performed to determine the degree of shrinkage over time in nipple projection after reconstruction. Nipple-areolar reconstruction was performed using the modified Anton-Hartrampf technique, and pigmentation was achieved with tattooing. This study looked at 28 consecutive patients with nipple reconstruction performed at The Milton S. Hershey Medical Center of the Penn State Geisinger Health Systems between September 1989 and November 1993. Two patients were lost to follow-up and 3 patients died of breast cancer. Thus, 23 patients and a total of 32 nipples were investigated. Initial measurements of nipple projection were taken 2 weeks postoperatively. Patients were followed an average of 38.7 months (range, 11-66 months). Ten patients (18 nipples) had tissue expansion and implantation for breast mound reconstruction. Thirteen patients (14 nipples) had autologous breast mound reconstruction. The mean decrease in projection of the tissue expansion and implantation group was 76.7+/-9.7%. The mean decrease in projection of the autologous reconstruction group was 64.3+/-12.1%. The mean decrease in projection for the entire group was 71.3+/-21.9%. Comparison between the two groups using a two-sample t-test showed p = 0.0047. The authors concluded that there is a significant reduction in nipple projection over time using the modified Anton-Hartrampf technique regardless of the type of breast mound reconstruction. In addition, their results also indicated that nipple projection on the breast mound reconstructed with an autologous musculocutaneous flap technique achieved a better long-term outcome. This study is potentially helpful in planning the initial size of the reconstructed nipple papule to match the opposite normal nipple. Additional studies need to be performed on other types of nipple-areolar reconstruction.     

保留乳头乳晕复合体乳腺癌根治即刻胸大肌包裹假体植入乳房重建

目的 探讨保留乳头乳晕复合体(NAC)的乳腺癌改良根治术即刻胸大肌包裹假体植入乳房重建的可行性.方法 对28例0、I、II期乳腺癌行保留皮肤的乳腺癌改良根治术后,即刻于胸大肌后方植入硅胶假体重建乳房,并根据冰冻切片结果决定是否保留NAC.结果 28例早期乳腺癌均保留了NAC,术后随访2～18个月(中位随访期:15个月),外观良好,双侧乳房对称,优良率达96.5%;均无局部复发或远处转移,无明显术后并发症.结论 保留NAC的乳腺癌改良根治术后用硅胶假体行即刻乳房重建,能达到满意的乳房美容效果,是治疗早期乳腺癌安全可行的方法.     

保留乳头乳晕的改良根治术联合假体即刻置入术治疗早期乳腺癌的临床研究

目的观察保留乳头乳晕的改良根治术联合假体即刻置入术治疗早期乳腺癌的临床价值。 方法回顾性分析93例乳腺癌患者的临床资料,根据患者手术方案不同分为假体置入组(采取改良根治术联合假体置入术,n＝48)与传统手术组(行传统改良根治术,n＝45)。应用统计学软件SPSS19.0处理数据,两组年龄、肿瘤直径、体重指数采用( ±s)表示,行独立样本t检验;TNM分期、乳房外观优良率、术后心理状况及生活质量、并发症总发生率采取χ²检验,P<0.05为差异有统计学意义。 结果假体置入组与传统手术组并发症总发生率分别为25.0%与20.0%(P>0.05)。假体置入组术后3个月的乳房外观优良率为93.8%,显著高于传统手术组77.8%(P<0.05)。假体置入组术后6个月的焦虑、抑郁、恐惧、人际敏感、自我形象紊乱发生率分别为25%、16.7%、31.3%、20.8%、14.6%,显著低于传统手术组的46.7%、35.6%、53.3%、40%、33.3%(P<0.05)。两组2年无瘤生存率、随访期间复发率、转移率、死亡率均无统计学意义(P>0.05)。 结论保留乳头乳晕的改良根治术联合假体置入术治疗早期乳腺癌可满足患者乳房重建的需求,不影响根治效果且提高了患者乳房外形美观度,患者术后心理与生活质量得到改善,值得推广。     

Management of phyllodes breast tumors

Phyllodes tumors are a rare distinctive fibroepithelial tumors of the breast and their management continues to be questioned. The aim of our study was to examine the treatment and outcome of 165 patients with phyllodes tumors and to review the options for surgical management. This is a retrospective study of 165 patients who presented to the Institut Curie between January 1994 and November 2008 for benign, borderline or malignant phyllodes tumors. The median follow-up was 12.65 months [range 0-149.8]. The median age at diagnosis was 44 years [range 17-79]. One hundred and sixty patients (97%) had breast-conserving treatment, of whom 3 patients (1.8%) had oncoplastic breast surgery. Younger women had a significantly higher chance of having a benign phyllodes tumor (p = 0.0001) or a tumor of small size (p < 0.0001). Histologic examination showed 114 benign (69%), 37 borderline (22%) and 14 malignant tumors (9%). The median tumor size was 30 mm [range 5-150]. The tumor margins were considered incomplete (< 10 mm) in 46 out of 165 cases (28%) with 52% revision surgery. Only the tumor grade was a significant risk factor for incomplete tumor margins (p = 0.005). Fifteen patients developed local recurrence (10%) and two, metastases. In univariate analysis, the histologic grade (p = 0.008), and tumor size (p = 0.02) were significative risk factors for local recurrence with an accentuated risk for "borderline" tumors and tumors of large size.).Similar results were obtained using multivariate analysis (p = 0.07). The mainstay of treatment for phyllodes tumors remains excision with a safe surgical margin, taking advantage breast conserving surgery where amenable. For borderline or malignant phyllodes tumors or in cases of local tumor recurrence, mastectomy, and immediate breast reconstruction may become the preferred option. Genetic analysis will potentially supplement classical histologic examination in order to improve our management of these tumors. The role of adjuvant treatments is unproven and must be considered on a case-by-case basis.     

Palliative Therapiemöglichkeiten beim Ösophaguskarzinom

Considering the limited chances of radically curing esophageal carcinoma, most of these patients are candidates for palliative therapy. Priority should be given to rapid relief of dysphagia. Endoscopic implantation of esophageal prostheses is immediately effective in 90% of patients, whereas the onset of relief is slower with any alternative method. Long-term complications necessitate an endoscopic reintervention in 30% of the prosthesis carriers. Endoscopic prosthesis implantation is also the first-choice treatment for esophagotracheal fistulae. Self-expanding stents need only minimized preceding bougienage, which has lower complication rates than conventional plastic prostheses. Endoscopic laser radiation is better tolerated by patients than prosthesis implantation but is effective only in very short stenoses. Endoluminal brachytherapy with (192)iridium can be justified in patients with a survival expectancy of more than 6 months, the onset of its effect being slower but longer lasting. Palliative chemotherapy and radiochemotherapy are indicated when metastatic dissemination dominates the symptoms.     

Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem?

BACKGROUND: We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment. STUDY DESIGN: We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n=55), treatment of breast cancer (n=41), or both (n=27) at four large centers. RESULTS: Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other's cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients. CONCLUSIONS: The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.     

INTRA-OPERATIVE IMPLANT BRACHYTHERAPY IN THE MANAGEMENT OF SOFT-TISSUE SARCOMAS

Background : The management of localized soft-tissue sarcomas remains complex. This is a retrospective review of a single institution experience with manual afterloaded brachytherapy following intra-operative implantation of the tumour bed during surgery. Methods : Twelve patients over a 3-year period had resection for localized soft-tissue sarcomas and desmoids with insertion of intra-operative brachytherapy implants combined with resection for localized soft-tissue sarcomas. Manual afterloading of the implant with iridium wires was performed postoperatively in all patients. The low dose rate brachytherapy dose varied from 13 to 20 Gy. Supplementary external beam radiation was administered pre-operatively or postoperatively to bring the total dose of adjuvant irradiation to 60–65 Gy. Results : After a median follow-up period of 29 months, the 3-year local disease-free survival rate was 63%. The 3-year actuarial survival rate was 83%. There were no failures within the high-dose region of the implant, although two patients had locoregional failures adjacent to the tumour bed at the edge of the radiation field. Three patients developed distant metastases. Side effects were noted in five patients. Wound breakdown and delayed wound healing occurred in two patients. One patient required an amputation as a result of chronic non-healing and wound pain. Pathological fractures occurred in two patients. Those patients who did not develop wound breakdown had good cosmetic and functional outcomes. Conclusion : Intra-operative implantation of the tumour bed in combination with tumour resection for soft-tissue sarcomas results in a high degree of local control with acceptable complications. This modality offers the patient a high chance of avoiding a more radical surgical procedure such as limb amputation.