The 10-Year Local Recurrence and Partial Breast Radiotherapy for Early Breast Cancer Tmarted by Conservative Surgery

To study the local recurrence and the role of whole breast radiotherapy for early breast cancer treated by conservative surgery. METHODS From April 1990 to December 2000, 49 patients with early primary breast cancer were treated by conservative surgery in our hospital. The cases were comprised of Stage 0, 1; Stage Ⅰ, 31; and Stage Ⅱa, 17. Forty cases underwent quadrantectomy plus axillary lymph node dissection, and the other 9 cases had lumpectomy alone. Irradiation, which was received by 39 patients, was administered by using low tangential half fields with 6 MV X-ray to decrease the pulmonary irradiative volume. The dose to the whole breast was 45 Gy/22 ～23f/4.5W, then a 15 Gy boost dose was delivered to the tumor bed by an electron beam. The other patients underwent an irradiated regional field according to postoperative pathology. RESULTS All patients were followed-up for 10 years or more. The 10- year local recurrence rates, distant metastasis rates and survival rates were 6.1%, 4.1% and 98.0% respectively. All of the 3 patients who had a local recurrence had infiltrative carcinomas and negative lymph nodes. The 10-year local recurrence rate was higher （2.6% vs. 20.0%） with nonpostoperative whole breast radootherapy, but the statistical difference was not marked because of the low number of cases. All of the recurrent lesions localized within 3 cm of the primary lesion. CONCLUSION Original recurrence of the tumor was the main type of local recurrence. Radiotherapy after conservative surgery is very essential. After conservative surgery it is feasible that irradiation can be delivered alone to the neighboring region of the tumor bed. Partial breast radiotherapy can substitute for whole breast radiotherapy.     

Experience with intraoperative radiotherapy for breast cancer: the Geneva University Hospital's experience

Background Breast conserving surgery along with adjuvant radiotherapy is effective in terms of local control and survival for earlystage breast cancer (1).External beam radiotherapy (EBRT) following breast conserving surgery has been shown to improve survival by preventing local recurrence,in the Early Breast Cancer Trialists' Collaborative Group meta-analysis (2).Standard radiotherapy typically requires numerous fractions over a 3-5 week period and is performed weeks or months after surgery or chemotherapy.Partial breast irradiation (PBI) techniques,including intraoperative radiotherapy (IORT),have been investigated in the last decades (3,4).     

44例隐匿性乳腺癌临床分析

目的 分析隐匿性乳腺癌的诊断、治疗及预后情况,总结其诊断和治疗经验.方法 回顾性分析44例隐匿性乳腺癌患者的临床资料,44例隐匿性乳腺癌患者中,16例行乳腺癌根治术,19例行乳腺癌改良根治术,1例行保留乳腺的腋下淋巴结清扫,8例仅行腋下肿物切除.结果 在接受乳腺癌根治术的35例患者中,有4例(11.4%)在术后病理切片中发现原发灶,原发灶的最大直径为0.6～2.5 cm,其中3例为浸润性导管癌,1例为黏液腺癌;另有3例可在标本中见不典型增生.全组有38例患者获得随访,随访时间为12～132个月.32例行手术治疗且获得随访的患者中,2例死亡,3例术后局部复发并带瘤生存;未接受进一步手术治疗患者中,有2例分别于确诊后16和41个月后因浸润性导管癌行乳腺根治术;其余患者均无病生存.结论 对以腋下淋巴结肿大为惟一临床表现、经肿物活检确认为转移性腺癌的女性患者,应高度怀疑隐匿性乳腺癌的可能性.隐匿性乳腺癌的治疗方式可采用腋窝淋巴结清扫后全乳放疗或乳腺癌根治术.

Abstract：

Objective To summarize the experience of diagnosis and treatment of occult breast cancer in 44 cases. Methods Clinicopathological data of 44 cases of occult breast cancer initially presenting axillary mass alone treated in our department during Jan 1997 to Dec 2008 were retrospectively analyzed. Results The 44 patients with occult breast cancer accounted for 0.42% of all breast cancer patients admitted to our hospital and institute in the same period. The surgery included radical mastectomy in 16 cases, modified radical mastectomy in 19 cases, axillary clearance in 1 case, and simple axillary node excision in 8 cases. Follow-up, ranging from 12-132 months, was available in 38 cases. Among 32 cases who underwent mastectomy or axillary clearance, 2 cases died of distant metastases and 3 cases were still alive with local recurrence at the time of analysis. In two out of six cases who refused further surgical treatment received mastectomy 16 months and 41 months after the primary diagnosis of occult breast cancer, respectively. Others were alive without evidence of recurrence or metastases at the time of analysis. Conclusions Occult breast cancer should be taken into consideration in cases presenting with axillary metastasis of unknown primary origin. The treatment of occult breast cancer should include modified radical mastectomy/radical mastectomy or breast conserving surgery combined with breast irradiation.     

加速部分乳腺照射的研究进展

加速部分乳腺照射(accelerated partial breast irradiation,APBI)作为早期乳腺癌保乳术后的治疗手段,相较于全乳照射(whole breast irradiation,WBI)具有时间短、费用低等优势,成为近年来该领域的研究热点之一.目前已经确立的受Ⅰ级证据支持的APBI技术主要是...     

Accelerated partial breast irradiation:advances and controversies

The management of localized breast cancer has changed dramatically over the past three to four decades. Breast-conserving therapy, which involved lumpectomy followed by adjuvant irradiation, is now widely considered the standard of care in women with early-stage breast cancer. Accelerated partial breast irradiation (APBI), which involves focal irradiation of the lumpectomy cavity over a short period of time, has developed over the past two decades as an alternative to whole breast irradiation (WBI). Multiple APBI modalities have been developed including brachytherapy, external beam irradiation, and intraoperative irradiation. These new techniques have provided early-stage breast can-cer patients with shorter treatment duration and more focused irradiation, delivering very high biological doses to the region at a high risk of failures over a much shorter treatment course as compared with conventional radiotherapy. However, the advantages of APBI over conventional radiotherapy are controversial, including a higher risk of compli-cations reported in retrospective literature and shorter follow-up duration in the intraoperative APBI trials. Neverthe-less, APBI presents a valuable alternative to WBI for a selected population of women with early-stage breast cancer.     

早期乳腺癌保乳术后加速部分乳腺照射的研究进展

早期乳腺癌保乳术后行全乳腺照射（whole breast irradiation,WBI）已成为乳腺癌的标准治疗模式之一，具有与根治术相似的效果。对于早期乳腺癌患者，加速部分乳腺照射（accelerated partial breast irradiation,APBI）作为全乳腺照射的替代治疗是临床研究热点，其特点是短时间内单纯对瘤床进行局部照射。本文将APBI的照射技术、剂量分割模式和人群选择作一综述。     

影像引导保乳术后部分乳腺外照射靶区的确定

随着对保乳治疗后乳房内肿瘤复发模式认识的统一,部分乳腺照射(partial breast irradiation,PBI)受到广泛关注,而且近几年来的相关研究迅速开展.而通过三维适形放疗(three dimensional conformalradiotherapy,3D-CRT)和调强放疗(intensity-modulated radiotherapy,IMRT)技术实施的部分乳腺外照射(external-beam partial breast irradiation,EB-PBI),则是PBI的主要实现方式之一.     

腋窝淋巴结超声造影预测乳腺癌新辅助化疗的疗效

Objective To explore the predictive value of response to neoadjuvant chemotherapy(NAC)in local advanced breast cancer with contrast-enhanced ultrasound(CEUS)of axillary lymph node.Methods CEUS of metastatic axillary lymph nodes in 58 patients stacng Ⅱ-Ⅲ breast cancer was performed before and after NAC treatment. The enhancement patterns and parameters of time-intensity curve were assessed and compared with the pathology.Results The clinic response evaluation were drug-effective in 35 cases and no change in 23 ones.There Were no significant differences in enhancement patterns between no-change and drugeffective groups.Lymph node cortex arriving time was longer in drug-effective cases than that in no-change ones after NAC,whereas it showed no significant differences before NAC.Statistical significant difierence in enhancement duration(ED)was found between the two groups before NAC,which decreased markedly in drug-effective case8 after NAC.Histopatholngic response could be predicted with a sensitivity of 77% and a specificity of 90% by standardized ED below 275 seconds after NAC.No significant difference was found in time to peak(TP),peak intensity(PI)between the two groups.Conclusion The perfusion pattern of axillary lymph node CEUS after NAC Was insufficient to predict curative effect.But the lymph node cortex arriving time and enhancement duration may be of value in the prediction of clinical response to chemotherapy.     

腋窝淋巴结超声造影预测乳腺癌新辅助化疗的疗效

Objective To explore the predictive value of response to neoadjuvant chemotherapy(NAC)in local advanced breast cancer with contrast-enhanced ultrasound(CEUS)of axillary lymph node.Methods CEUS of metastatic axillary lymph nodes in 58 patients stacng Ⅱ-Ⅲ breast cancer was performed before and after NAC treatment. The enhancement patterns and parameters of time-intensity curve were assessed and compared with the pathology.Results The clinic response evaluation were drug-effective in 35 cases and no change in 23 ones.There Were no significant differences in enhancement patterns between no-change and drugeffective groups.Lymph node cortex arriving time was longer in drug-effective cases than that in no-change ones after NAC,whereas it showed no significant differences before NAC.Statistical significant difierence in enhancement duration(ED)was found between the two groups before NAC,which decreased markedly in drug-effective case8 after NAC.Histopatholngic response could be predicted with a sensitivity of 77% and a specificity of 90% by standardized ED below 275 seconds after NAC.No significant difference was found in time to peak(TP),peak intensity(PI)between the two groups.Conclusion The perfusion pattern of axillary lymph node CEUS after NAC Was insufficient to predict curative effect.But the lymph node cortex arriving time and enhancement duration may be of value in the prediction of clinical response to chemotherapy.     

Palliative Endoscopic Therapy of Esophageal Cancer

Patients with locally unresectable esophageal cancer or distant metastasis are usually treated with definite radiotherapy or radiochemotherapy. Dysphagia of these patients should further be treated by endoscopic therapy in order to maintain swallowing and oral food intake as long as possible. The same situation is present in patients with local recurrence of esophageal cancer after surgery or radiochemotherapy.     

Altered fractionation: rationale and justification for whole and partial breast hypofractionated radiotherapy

Over the last 2 decades, we have seen major advances in the application of radiotherapy after breast-conserving surgery. Two important contributions are the use of whole-breast hypofractionation and accelerated partial-breast irradiation. Three large randomized trials comparing whole-breast hypofractionation versus conventional fractionation for early breast cancer have shown similar rates of local recurrence and morbidity. As a result, whole-breast hypofractionation is now an option for selected patients after breast-conserving surgery. The delivery of accelerated partial-breast irradiation (APBI) has been studied using techniques of multicatheter interstitial brachytherapy, balloon-based brachytherapy, external-beam radiotherapy, and intraoperative radiotherapy. Multiple single and multi-institutional data have been published indicating good long-term results with APBI (in highly selected, low-risk patients) in terms of tumor control and toxicity. However, the long-term results of large, phase III trials comparing APBI with whole-breast irradiation are still pending.     

A randomised study of whole-breast vs tumour-bed irradiation after local excision and axillary dissection for early breast cancer

AimsWhole-breast radiotherapy (WBRT) after conservative surgery for early breast cancer is a routine standard of care. Despite this, a number of uncertainties in management still exist. Over recent years, a number of new technologies have allowed the development of partial-breast irradiation, with the intention of improving the risk–benefit relationship of routine breast radiotherapy. We report the results of a trial comparing partial- with WBRT, with prolonged follow-up.Materials and methodsBetween 1986 and 1990, 174 women were randomised to receive conventional whole-breast radiotherapy (WBRT) (40 Gy in 15 fractions), with a tumour-bed boost or partial-breast irradiation by a variety of techniques. Recruitment was problematic, and the trial closed prematurely well before meeting its recruitment target.ResultsA trend was observed towards higher local recurrence and a higher locoregional recurrence rate after irradiation of the tumour bed alone. Distant recurrence and survival were the same.ConclusionsConclusions are limited in view of the failure to complete accrual of the target of 400 participants, and in the context of the techniques of partial-breast radiotherapy used during this study, which would not compare with those in current use. Tumour-bed irradiation alone cannot currently be recommended as routine treatment outside the context of clinical trial.     

Radiation therapy for breast cancer

Over the past five decades, radiotherapy (RT) has become an integral part in the combined modality management of breast cancer. Although its significant effect on local control has been long demonstrated, only recently has adjuvant RT been shown to have a significant effect on breast cancer mortality and overall survival. This article summarizes the adjuvant role of RT after mastectomy and lumpectomy, as well as the rationale and techniques for partial-breast irradiation.     

Clinical experience using hypofractionated radiation schedules in breast cancer

Hypofractionation is attractive for whole- or partial-breast irradiation because it permits treatment to be given with fewer fractions in a shorter period of time and at less cost. A number of cohort studies suggest that hypofractionation may be given to the whole breast safely and with good local control. Recent randomized trials have confirmed that hypofractioned whole-breast irradiation is equivalent to more conventional whole-breast irradiation with respect to local recurrence and cosmetic outcome. Recently, there has been a renewed interest in hypofractionation for the delivery of partial-breast irradiation using a number of techniques including high-dose rate brachytherapy, 3-dimensional conformal radiation using external-beam techniques, and intraoperative therapy. Early cohort studies report good local control and acceptable morbidity. Randomized trials are now underway to compare this approach to conventional whole-breast irradiation.     

Concepts and techniques of intraoperative radiotherapy (IORT) for breast cancer.

The standard treatment for early breast cancer comprises wide local excision, sentinel lymph node biopsy or axillary lymph node dissection, adjuvant medical treatment and radiotherapy to the whole breast. Many studies suggest that local control plays a crucial role in overall survival. The local recurrence rate is estimated to be 1% per year and varies between 4 and 7% after 5 years and up to 10 to 20% in the long-term follow up. On the basis of low local recurrence rates the concept of whole breast irradiation comes up for discussion, and partial breast irradiation (PBI) is increasingly under consideration. Intraoperative radiotherapy (IORT) is referred to as the delivery of a single high dose of irradiation directly to the tumor bed (confined target) during surgery. PBI (limited field radiation therapy, accelerated partial breast irradiation APBI) is the irradiation exclusively confined to a breast volume, the tumor surrounding tissue (tumor bed) either during surgery or after surgery without whole breast irradiation. Various methods and techniques for IORT or PBI are under investigation. The advantage of a very short radiation time or the integration of the complete radiation treatment into the surgical procedure convinces at a first glance. The promising short-term results of those studies must not fail to mention that local recurrence rates could probably increase and furthermore give rise to distant metastases and a reduction in overall survival. The combination of IORT in boost modality and whole breast irradiation has the ability to reduce local recurrence rates. The EBCTCG overview approves that differences in local treatment that substantially affect local recurrence rates would avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality.     

Concepts and techniques of intraoperative radiotherapy (IORT) for breast cancer

The standard treatment for early breast cancer comprises wide local excision, sentinel lymph node biopsy or axillary lymph node dissection, adjuvant medical treatment and radiotherapy to the whole breast. Many studies suggest that local control plays a crucial role in overall survival. The local recurrence rate is estimated to be 1% per year and varies between 4 and 7% after 5 years and up to 10 to 20% in the long-term follow up. On the basis of low local recurrence rates the concept of whole breast irradiation comes up for discussion, and partial breast irradiation (PBI) is increasingly under consideration. Intraoperative radiotherapy (IORT) is referred to as the delivery of a single high dose of irradiation directly to the tumor bed (confined target) during surgery. PBI (limited field radiation therapy, accelerated partial breast irradiation APBI) is the irradiation exclusively confined to a breast volume, the tumor surrounding tissue (tumor bed) either during surgery or after surgery without whole breast irradiation. Various methods and techniques for IORT or PBI are under investigation. The advantage of a very short radiation time or the integration of the complete radiation treatment into the surgical procedure convinces at a first glance. The promising short-term results of those studies must not fail to mention that local recurrence rates could probably increase and furthermore give rise to distant metastases and a reduction in overall survival. The combination of IORT in boost modality and whole breast irradiation has the ability to reduce local recurrence rates. The EBCTCG overview approves that differences in local treatment that substantially affect local recurrence rates would avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality. This article is based on an invited lecture delivered at the 15th Annual Meeting of the Japanese Breast Cancer Society, held in Yokohama June 29-30, 2007.     

早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的临床分析

目的：观察早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的短期疗效与不良反应。方法64例早期乳腺癌患者保乳术后行两野切线全乳照射,全乳腺照射40．5 Gy／15 f,单次剂量2．7 Gy／f,同步瘤床推量至48 Gy／15 f,单次剂量3．2 Gy／f,总疗程3周,观察分析患者局部复发情况、美容效果及不良反应。结果中位随访时间17月,随访率为100％,无局部复发情况发生。3例患者表现乳腺中度胀痛;Ⅰ、Ⅱ、Ⅲ级急性皮肤反应发生率分别为17．2％、4．7％、1．6％;Ⅰ级血小板下降发生率与Ⅰ～Ⅱ级中性粒细胞减少发生率分别为1．6％、4．7％;放疗完成后4、7月美容优良率分别为90．6％、87．5％。结论早期乳腺癌保乳术后全乳放疗同步瘤床加量的短期疗效与以往常规放疗方式相似,缩短放疗时间,不会增加皮肤不良反应及降低美容效果。     

Lessons of studies of breast-conserving therapy with and without whole-breast irradiation for patient selection for partial-breast irradiation

Partial-breast irradiation is a promising approach for treating patients with early-stage invasive breast cancer. There are still few studies of partial-breast irradiation that address critical issues, such as criteria for patient selection. However, an enormous body of experience has been accumulated regarding the results in patients treated with "conventional" breast-conserving therapy using whole-breast irradiation and for patients treated with conservative surgery without radiotherapy of any kind. This article will therefore review portions of this existing experience that may aid the development of partial-breast irradiation and give perspective on the overall role that partial-breast irradiation may ultimately play in our therapeutic armamentarium.     

Short-course radiotherapy for the whole breast after breast conserving surgery

Short-course radiotherapy for the whole breast after breast conserving surgery is an alternative to conventional fractionation schedules for radiotherapy. This method shortens the treatment period by increasing the daily fraction dose from 2 to 2.5 Gy or more, and is already being used in Canada and parts of Europe as a more convenient treatment for breast cancer patients than conventional long-term radiotherapy. An important randomized trial in Canada found that there were no statistical differences in efficacy or adverse effects between conventional radiotherapy and short-course radiotherapy. However, that trial included only breast cancer patients with the most favorable prognoses and excluded patients who had carcinoma involving the inked margin of excision. In that trial, additional boost irradiation to the lumpectomy site was not used, and only 11% of patients were treated with systemic chemotherapy. It is also possible that irradiation using large fraction doses cause more severe late toxicities in normal breast tissue than conventional fraction irradiation. Therefore, while short-course radiotherapy may also prove more convenient, further clinical studies should be performed to confirm the feasibility of the new method for Japanese women, before being put into general clinical use in Japan. The present paper is a review of short-course radiotherapy for the whole breast after breast conserving surgery.     

Image-guided breast brachytherapy: an alternative to whole-breast radiotherapy

Lumpectomy and whole-breast radiotherapy (ie, breast-conservation treatment) are accepted as viable alternatives to mastectomy in locoregional management of breast cancer. These techniques are used to keep morbidity to a minimum, optimise cosmesis, and maintain treatment outcomes. Pathological and clinical data suggest that most recurrences of cancer in the ipsilateral breast are in the vicinity of the index lesion, and that remote recurrences are uncommon, whether or not whole-breast radiotherapy is delivered. These data lend support to the idea of partial-breast radiotherapy. Such a restricted treatment volume allows safe delivery of an accelerated hypofractionated regimen over a shortened course of 1 week. This technique differs from that of standard whole-breast tangential external-beam radiotherapy and necessitates investigation of accelerated partial-breast irradiation (APBI). Several techniques of APBI are being investigated; however, most experience, and the most favourable early outcomes, has been obtained with image-guided breast brachytherapy. This review highlights the rationale and outcomes of brachytherapy techniques.