Tumor Bed Control with Balloon-Based Accelerated Partial Breast Irradiation: Incidence of True Recurrences Versus Elsewhere Failures in the American Society of Breast Surgery MammoSite? Registry Trial

Background

Randomized trials demonstrate that lumpectomy plus whole-breast irradiation (WBI) yields survival equivalent to mastectomy. Studies that use WBI, however, typically report higher tumor bed recurrence rates than elsewhere failures (EF) (historically considered new primary lesions). The rate of true recurrence (TR) versus EF was queried for a large patient cohort treated with accelerated partial breast irradiation (APBI).

Methods

A total of 1,449 cases of early-stage breast cancer were treated on the American Society of Breast Surgeons MammoSite^? Registry Trial with lumpectomy plus balloon-based APBI (34?Gy, 10 BID fractions). A total of 1,255 cases (87?%) had invasive breast cancer, and 194 patients (13?%) had ductal carcinoma in situ. Rates of TR versus EF were calculated and compared to historical WBI controls.

Results

Median follow-up was 60 (range 0?C109) months. Fifty patients (3.5?%) developed an ipsilateral breast tumor recurrence (IBTR). The 5-year actuarial rate of IBTR was 3.6?% (invasive breast cancer 3.6?%, ductal carcinoma in situ 3.4?%). Fourteen IBTR (1.1?%) were TR, while 36 (2.6?%) were EF. Estrogen receptor?Cnegative status was associated with IBTR for invasive malignancies as well as for EF only (p?p?=?0.067) and extensive intraductal component (p?=?0.087). No pathologic factors were explicitly associated with TR.

Conclusions

IBTR after balloon-based APBI is low and similar to rates reported for WBI. In this data set, APBI had fewer tumor bed recurrences (presumably initial cancer recurrences) than EF (presumably new primary lesions). This suggests that balloon-based APBI has a tumor bed control rate that is at least equal to (and potentially higher than) WBI.     

Locoregional Recurrence Following Accelerated Partial Breast Irradiation for Early-Stage Invasive Breast Cancer: Significance of Estrogen Receptor Status and Other Pathological Variables

Background

Understanding risk factors for locoregional recurrence (LRR) after accelerated partial breast irradiation (APBI) can help to guide patient selection for treatment with APBI. Published findings to date have not been consistent. More data are needed as these risk factors continue to be defined.

Methods

A total of 277 women with early-stage invasive breast cancer underwent lumpectomy and were treated adjuvantly at our institution with APBI using high-dose rate brachytherapy. APBI was delivered using multicatheter interstitial brachytherapy (91 %) or single-entry catheter brachytherapy (9 %) to a dose of 32–34 Gy in 8–10 twice daily fractions. Failure patterns and risk factors for recurrence were analyzed.

Results

With a median follow-up of 61 months, the 5-year locoregional control rate was 94.4 %. Negative estrogen receptor (ER) status was strongly associated with LRR on multivariate analysis (p < 0.005). Lobular histology, the presence of an extensive intraductal component, and lymphovascular invasion also were significant but to a lesser degree than ER-negative status. Patients with multiple risk factors were at highest risk for LRR. Age was not significantly associated with increased risk for LRR.

Conclusions

The presence of specific pathological features, particularly ER negative status, was associated with increased risk of LRR in this cohort of women treated with APBI. Further investigation is warranted to determine whether patients with adverse pathological risk factors are at higher risk of LRR after APBI than after conventional whole breast irradiation (WBI), as these same features also may place women at risk for LRR after WBI.     

Timing of Infectious Complications Following Breast-Conserving Therapy with Catheter-Based Accelerated Partial Breast Irradiation

Background

Accelerated partial breast irradiation (APBI) has been used as an alternative to whole-breast irradiation as part of breast-conserving therapy. Indications and outcomes are topics of ongoing investigation. Previous publications have focused on early postoperative infections and reported low rates of delayed infection. We investigated the pattern of infection after catheter-based APBI at our institution.

Methods

Patients who underwent single-entry catheter-based APBI were identified from an institutional prospective registry including data regarding comorbidities and outcomes. Time of infection was calculated from the date of definitive catheter insertion and classified as early (≤30 days) or delayed.

Results

A total of 91 breast cancer patients were treated with APBI and enrolled in the registry from 2009 to 2011. The median follow-up was 484 days. Breast infection occurred in 13 (14.3 %), with 3 (3.3 %) occurring within 30 days of catheter placement and 10 (11.0 %) in a delayed fashion. Four patients required hospital admission, five underwent percutaneous aspiration, and one underwent incision and drainage. Eight were treated as outpatients with oral antibiotics alone.

Conclusions

Consistent with other reports, we found an overall infection rate of 14.3 % with single-entry catheter-based APBI. There were substantially fewer infections in the early postoperative period than reported elsewhere, but there were more delayed infections. The intensive follow-up in our study likely identified late infections that may not have otherwise been recognized. Vigilance for infectious complications must continue beyond the immediate treatment period in patients undergoing catheter-based APBI. These infections can range in severity but typically can be managed in an outpatient setting.     

Cost Comparison of Radiation Treatment Options After Lumpectomy for Breast Cancer

Background

Radiation therapy (RT) after lumpectomy for breast cancer can be delivered with several different regimens. We evaluated a cost-minimization strategy to select among RT options.

Methods

An institutional review board (IRB)-approved retrospective review identified a sample of 100 women who underwent lumpectomy for invasive or in situ breast cancer during 2009. Post lumpectomy RT options included: no radiation in women ≥70 years [T1N0, estrogen receptor (ER)+] per Cancer and Leukemia Group B (CALGB) 9343 (no-RT), accelerated external-beam partial-breast irradiation (APBI), and Canadian fractionation (C-RT), as alternatives to standard whole-breast radiation therapy (WBRT). Eligibility for RT regimens was based on published criteria. RT costs were estimated using the 2011 US Medicare Physician Fee Schedule and average Current Procedural Terminology (CPT) codes billed per regimen at our institution. Costs were modeled in a 1,000-patient theoretical cohort.

Results

Median patient age was 56.5 years (range 32–93 years). Tumor histology included invasive ductal cancer (78 %), ductal carcinoma in situ (DCIS) (15 %), invasive lobular cancer (6 %), and mixed histology (1 %). Median tumor size was 1 cm (range 0.2–5 cm). Estimated per-patient cost of radiation was US$5,341.81 for APBI, US$9,121.98 for C-RT, and US$13,358.37 for WBRT. When patients received the least expensive radiation regimen for which they were eligible, 14 % received no-RT, 44 % received APBI, 7 % received C-RT, and 35 % defaulted to WBRT. Using a cost-minimization strategy, estimated RT costs were US$7.67 million, versus US$13.36 million had all patients received WBRT, representing cost savings of US$5.69 million per 1,000 patients treated.

Conclusions

A cost-minimization strategy results in a 43 % reduction in estimated radiation costs among women undergoing breast conservation.     

Accelerated Partial-Breast Irradiation Versus Whole-Breast Irradiation for Early-Stage Breast Cancer Patients Undergoing Breast Conservation, 2003–2010: A Report from the National Cancer Data Base

Background

Previous studies have demonstrated an increase in the utilization of accelerated partial-breast irradiation via brachytherapy (APBI-b), but larger, more contemporary studies examining overall APBI use are lacking.

Methods

A total of 575,438 nonneoadjuvant American Joint Committee on Cancer stage 0 to II breast conservation patients were selected from the National Cancer Data Base from 2003 to 2010 who underwent either whole-breast irradiation or APBI.

Results

Overall, 59,396 patients (10.3 %) underwent APBI. The use of APBI for the entire cohort increased from 3.4 % in 2003 to 12.8 % (p < 0.001) in 2008 and then decreased to 12.4 % in 2010. Three-dimensional conformal radiation increased from 0.8 to 2.2 %, intensity-modulated radiotherapy increased from 0.7 to 1.3 %, and brachytherapy (APBI-b) increased from 2.0 to 8.9 %. The most significant factors associated with APBI use were patient age and facility location. Patients 80–89 years old were 3.8 times more likely to undergo APBI compared to patients 30–39 years old (odds ratio [OR] 3.77, 95 % confidence interval [CI] 3.45–4.10, p < 0.001). Patients living in the West census region were 2.0 times more likely to undergo APBI compared to patients living in the Northeast (OR 2.0, 95 % CI 1.93–2.15, p < 0.001). Using the American Society of Radiation Oncology (ASTRO) guidelines, among patients with noninvasive cancer who received APBI, 95.6 % were categorized as “cautionary” and 4.4 % as “unsuitable.” Of the invasive patients, 43.8 % were categorized as “suitable,” 47.0 % as “cautionary,” and 9.2 % as “unsuitable.”

Conclusions

The utilization of APBI has stabilized at approximately 12 % starting in 2008. The majority of APBI is delivered using APBI-b, with patient age being the most significant factor associated with APBI use.     

Twenty-Year Outcomes after Breast-Conserving Surgery and Definitive Radiotherapy for Mammographically Detected Ductal Carcinoma In Situ

Background

Management of mammographically detected ductal carcinoma in situ (DCIS) at a single institution was reviewed to determine long-term clinical outcomes after treatment with breast-conserving therapy (BCT).

Methods

Data from all patient-cases with DCIS who received BCT between 1980 and 1993 were reviewed. Patient demographics and pathologic factors were analyzed for their effect on outcomes, including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included breast-conserving surgery followed by external-beam radiotherapy to the whole breast, with 86?% of patients receiving a lumpectomy cavity boost. The median dose to the whole breast was 50 Gy and 60.4?Gy to the lumpectomy cavity.

Results

A total of 129 cases were evaluated; the median follow-up was 19.3?years. Twenty-one patients developed an ipsilateral breast tumor recurrence (IBTR), 76.2?% of which were invasive (n?=?16). Fourteen recurrences (66?%) were within the same breast quadrant (true recurrence), while an additional 7 cases developed an IBTR elsewhere in the breast. True recurrences were more prevalent in women <45?years of age (20?%/24?% vs. 5.1?%/8?%) at 10 and 20?years (p?=?0.02). The 5-, 10-, 15-, and 20-year actuarial rates of IBTR for this cohort were 8.7, 10.4, 12.1, and 16.3?% (IBTR), while overall survival at 5, 10, and 20 years was 97.6, 96.8, and 96.8?%, respectively.

Conclusions

Mammographically detected DCIS remains a clinically distinct subset of noninvasive breast cancer. With 20?year follow-up, local control and overall survival are excellent after BCT.     

Update on DCIS Outcomes from the American Society of Breast Surgeons Accelerated Partial Breast Irradiation Registry Trial

Background

Since the initial reports on use of MammoSite accelerated partial breast irradiation (APBI) for treatment of ductal carcinoma in situ (DCIS), additional follow-up data were collected. We hypothesized that APBI delivered via MammoSite would continue to be well tolerated, associated with a good cosmetic outcome, and carry a low risk for recurrence in patients with DCIS.

Materials and Methods

From 2002–2004, 194 patients with DCIS were enrolled in a registry trial to assess the MammoSite. Follow-up data were available for all 194 patients. Median follow-up was 54.4 months; 63 patients had at least 5 years of follow-up. Data obtained included patient-, tumor-, and treatment-related factors, and recurrence incidence.

Results

Of the 194 patients, 87 (45%) had the MammoSite placed at lumpectomy; 107 patients (55%) had the device placed postlumpectomy. In the first year of follow-up, 16 patients developed a breast infection, though the method of device placement was not associated with infection risk. Also, 46 patients developed a seroma that was associated with applicator placement at the time of lumpectomy (P = 0.001). For patients with at least 5 years of follow-up, 92% had favorable cosmetic results. There were 6 patients (3.1%) who had an ipsilateral breast recurrence, with 1 (0.5%) experiencing recurrence in the breast and axilla, for a 5-year actuarial local recurrence rate of 3.39%.

Conclusions

During an extended follow-up period, APBI delivered via MammoSite continued to be well tolerated for patients with DCIS. Use of this device may make lumpectomy possible for patients who would otherwise choose mastectomy because of barriers associated with standard radiation therapy.     

Efficacy of accelerated partial breast irradiation as a neoadjuvant treatment for patients with breast cancer: a pilot study

BACKGROUND: Breast conserving treatment (BCT) consists of breast-conserving operation and followed by whole-breast irradiation (WBI). Accelerated partial breast irradiation (APBI) is being considered as a possible alternative to WBI. Neoadjuvant APBI might provide more benefit than postsurgical APBI because tumor downstaging will enhance the likelihood of BCT. METHODS: APBI was delivered as 50 Gy in 5 fractions over 5 days before operation for patients with breast cancer of 3 to 4 cm in diameter. Patients with tumors 3 cm or less were deemed to be candidates for breast-conserving operation. RESULTS: Between September 1998 and August 1999, 12 women were enrolled. The mean tumor diameter and volume were reduced from 3.4 to 1.8 cm (reduction rate: 47%) and from 8.1 to 2.2 cm3 (reduction rate: 71%), respectively. The mean pathologic tumor size was 1.5 cm, and a complete pathologic response was found in 1 patient (8%). All patients were eligible for breast-conserving operation. No ipsilateral breast recurrences have been observed to date. CONCLUSIONS: This is the first report of neoadjuvant APBI for relatively large breast cancers. Although the number of participants was small, these results would encourage the development of clinical trials exploring the efficacy of neoadjuvant APBI.     

Treatment Efficacy with Accelerated Partial Breast Irradiation (APBI): Final Analysis of the American Society of Breast Surgeons MammoSite® Breast Brachytherapy Registry Trial

Background

The purpose of this study was to examine data on treatment efficacy, cosmesis and toxicities for the final analysis of the American Society of Breast Surgeons MammoSite^® breast brachytherapy registry trial.

Methods

A total of 1,449 cases of early-stage breast cancer underwent breast conserving therapy. The single-lumen MammoSite^® device was used to deliver accelerated partial breast irradiation (APBI) (34 Gy in 3.4 Gy fractions). Of these, 1,255 cases (87 %) had invasive breast cancer (IBC) and 194 cases had DCIS. Median follow-up was 63.1 months with 45 % of all patients having follow-up of 6 years or longer.

Results

There were 41 cases (2.8 %) that developed an ipsilateral breast tumor recurrence (IBTR) for a 5-year actuarial rate of 3.8 % (3.7 % for IBC and 4.1 % for DCIS). Tumor size (odds ratio [OR] = 1.1, p = 0.03) and estrogen receptor negativity (OR = 3.0, p = 0.0009) were associated with IBTR, while a trend was noted for positive margins (OR = 2.0, p = 0.06) and cautionary/unsuitable status compared with suitable status (OR = 1.8, p = 0.07). The percentage of patients with excellent/good cosmetic results at 60, 72, and 84 months was 91.3, 90.5, and 90.6 %, respectively. The overall rates of fat necrosis and infections remained low at 2.5 and 9.6 % with few late toxicity events beyond 2 years. The overall symptomatic seroma rate was 13.4 and 0.6 % beyond 2 years.

Conclusions

The final analysis of treatment efficacy, cosmesis, and toxicity from the American Society of Breast Surgeons MammoSite^® breast brachytherapy registry trial confirms previously noted excellent results and compares favorably with other forms of APBI with similar follow-up and to outcomes seen in selected patients treated with whole breast irradiation.     

Accelerated partial breast irradiation after conservative surgery for breast cancer

OBJECTIVE: To critically review the theoretical and actual risks and benefits of accelerated partial breast irradiation (APBI) after breast-conserving surgery. SUMMARY BACKGROUND DATA: Because of rapid evolution of radiation therapy techniques related to brachytherapy and three-dimensional conformal radiation therapy, APBI has very recently come to the forefront as a potential local treatment option for women with breast cancer. This review aims to give an overview of the biologic rationale for APBI techniques, and benefits and limitations of APBI techniques. METHODS: The authors reviewed the currently available published world medical literature on breast-conserving surgery with and without postoperative irradiation; all studies involving partial breast irradiation, including brachytherapy, for breast cancer; and currently accruing and planned APBI trials. The focus of this review was the early results of treatment in terms of toxicity, complications, cosmesis, and local control. RESULTS: On average, approximately 3% of patients treated with breast-conserving surgery will have an in-breast local recurrence away from the original lumpectomy site with or without postoperative standard whole-breast irradiation. The results of phase I-II studies involving approximately 500 patients treated with APBI after breast-conserving surgery have been published. Although many of the studies have limited long-term follow-up and potential selection bias, early results suggest that toxicity, cosmesis, and local control are comparable to outcomes seen after breast-conserving surgery followed by standard whole-breast irradiation. CONCLUSIONS: Recent advances in radiation delivery and published series of partial breast irradiation support large randomized trials comparing APBI with standard whole-breast irradiation after breast-conserving surgery.     

Changing Behavior in Clinical Practice in Response to the ACOSOG Z0011 Trial: A Survey of the American Society of Breast Surgeons

Background

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated no difference in overall survival or local?Cregional recurrence rates between patients planned for breast conservation therapy including whole breast irradiation (WBI) with one or two positive sentinel lymph nodes (SLNs) randomly selected to undergo axillary lymph node dissection (ALND) versus no further surgery. The current study was undertaken to evaluate the impact of Z0011 on surgical practice nationally.

Methods

A survey was sent by e-mail to 2,759 members of the American Society of Breast Surgeons (ASBrS). Questions assessed the respondents?? practice, familiarity with Z0011, and preferences for treating patients with one or two positive SLNs.

Results

Of those surveyed, 849 (30.8?%) responded. The majority (97?%) indicated familiarity with the data. Of those respondents, 468 (56.9?%) would not routinely perform ALND in patients planned to receive WBI, while 279 (36.0?%) would consider omission of completion ALND in patients planned to receive accelerated partial breast irradiation (APBI), and 218 (26.6?%) would consider omission of ALND in patients not planned to receive radiation. Academic and private practice surgeons were equally likely to incorporate Z0011 into practice.

Conclusions

ACOSOG Z0011 has changed surgical practice. ASBrS respondents have embraced Z0011 and have changed their practice, omitting ALND in patients with one or two positive SLNs who will undergo WBI. However, many also omit ALND in patients undergoing surgery without radiation or with APBI. As these clinical scenarios were not studied in Z0011, further evaluation is required prior to changing clinical practice.     

Factors Associated with Optimal Cosmetic Results at 36 Months in Patients Treated with Accelerated Partial Breast Irradiation (APBI) on the American Society of Breast Surgeons (ASBrS) MammoSite® Breast Brachytherapy Registry Trial

Purpose

To evaluate factors associated with optimal cosmetic results at 36 months for early-stage breast cancer patients enrolled on the American Society of Breast Surgeons (ASBrS) MammoSite^® Breast Brachytherapy registry trial.

Materials and Methods

1,440 patients (1,449 cases) with early-stage breast cancer undergoing breast-conserving therapy were treated with the MammoSite^® radiation therapy system (RTS) brachytherapy catheter to deliver adjuvant accelerated partial breast irradiation (APBI) (34 Gy in 3.4-Gy fractions). Cosmetic outcome was evaluated at each follow-up visit and dichotomized as excellent/good or fair/poor. Median follow-up for surviving patients was 43.0 months (range 0–73.0 months).

Results

The percentage of patients with good/excellent cosmetic results at 12, 24, 36, and 48 months were as follows: 94.5% (n = 950/1,005), 93.8% (n = 781/833), 93.1% (n = 683/734), and 90.4% (n = 520/575), respectively. Three-year absolute rates of good/excellent cosmesis were as follows: breast-related wound infection (BWI) (83.3%) versus no BWI (94%), <7 mm skin spacing (87.5%) versus ≥7 mm skin spacing (93.6%). Using multiple regression analysis, factors predictive of worse cosmetic outcome at 36 months included smaller skin spacing [odds ratio (OR) 1.06, confidence interval (CI) 1.01–1.12] and BWI (OR 0.33, CI 0.16–0.70). A predictive model developed showed that presence of a BWI, use of chemotherapy, and skin spacing had the most effect on cosmetic outcomes. However, in patients that did not develop a breast infection, skin spacing and use of chemotherapy had the most effect on cosmesis.

Conclusion

APBI delivered by MammoSite^® brachytherapy lead to good/excellent cosmesis in 93% of patients with 3-year follow-up. Breast wound infection, use of chemotherapy, and skin spacing were found to be the three most important predictors of cosmesis at 36 months in our cohort of patients.     

Omission of Axillary Dissection According to ACOSOG Z0011: Impact on Adjuvant Treatment Recommendations

Objective

A recent, randomized trial (ACOSOG Z0011) has demonstrated that omission of completion axillary lymph node dissection (ALND) in patients with one or two sentinel lymph node (SLN) metastases treated with breast conserving therapy (BCT) does not have a negative impact on survival. This study evaluates the impact of omitting ALND on adjuvant treatment recommendations.

Methods

Performing a search of our clinical database, we identified patients meeting the main inclusion and exclusion criteria of ACOSOG Z0011 treated at the University of Heidelberg Breast Center. We performed blinded mock interdisciplinary tumor boards based on patient and tumor characteristics as well as (1) SLN information or (2) final nodal status after ALND. Differences between treatment recommendations were noted and analyzed.

Results

A total of 132 patients were included; 80.3 % of these had one and 19.7 % had two metastatic sentinel nodes with a rate of micrometastases only of 19.7 %, and 39.7 % of patients had additional nonsentinel node metastases upon ALND. Overall, there was a change in adjuvant chemotherapy in 18.2 % of cases. Treatment recommendations based on ALND lead to a more aggressive therapy in 16.6 % of cases, all of them with additional metastatic nonsentinel nodes. Chemotherapy was not recommended in only two cases (1.5 %) based on ALND. Based on ALND, irradiation of the supraclavicular and infraclavicular nodes was added in 5.3 % of patients.

Conclusions

Completion ALND for patients with one or two metastatic sentinel nodes in pT1-2 cN0 PBC treated with BCT does have a relevant impact on adjuvant treatment. This should be considered in shared decision making.     

In support of the Choosing Wisely campaign: Perceived higher risk leads to unnecessary imaging in accelerated partial breast irradiation?

Accelerated partial breast irradiation (APBI) is an increasingly utilized modality for early stage breast cancer as part of breast conservation therapy (BCT). There remains concern regarding local recurrence, requiring more frequent post‐radiation surveillance imaging. The purpose of this study is to determine clinical significance of frequent surveillance in this perceived higher risk population. Patients treated at a community academic medical center from 2005 to 2013 with partial breast radiation were retrospectively identified. All patients were treated with lumpectomy followed by balloon based APBI. Diagnostic, clinical, radiographic, and outcomes data were collected. One hundred and sixty‐nine patients were identified. Median age at time of diagnosis was 63. Stage was 0, I, and II in 27%, 64%, and 9%, respectively. Most patients had pure invasive ductal cancer. Ninety‐two percent and 99% of patients had imaging performed by 6 and 12 months (± 3 months) respectively. Median interval between end of radiation and first image, and subsequent 3 images were 6, 6, 9, and 12 months, respectively. Median follow‐up was 49 months for all patients (range 7‐106). Six patients experienced local recurrence: 4 invasive, all clinically detected, and none within the first 2 years. One patient had mammographically detected recurrent ductal carcinoma in situ. No mammographic images within the first year lead to diagnosis of recurrent cancer. APBI via balloon base brachytherapy offered women excellent locoregional control rates. Frequent mammographic surveillance did not result in increased detection of early recurrent disease. The result of our study are in line with the Choosing Wisely campaign recommendations to perform no more than annual follow‐up for women who have completed radiation as part of BCT, with first imaging done at 6‐12 months. We recommend mammographic surveillance be performed no more frequently than annually, with first image after BCT to be done 12 months from completion of radiation.     

Accelerated partial breast irradiation using the MammoSite device: early technical experience and short-term clinical follow-up

The MammoSite brachytherapy system is a novel form of intracavitary accelerated partial breast irradiation (APBI) that allows treatment over a 5- to 7-day course after breast conserving surgery (BCS). Fifty-one patients with invasive breast carcinoma underwent BCS and APBI using the MammoSite device, with 30 (59%) patients having drain placement in the lumpectomy cavity. Main outcome measures included time to initiating APBI, cosmesis using the Harvard Scale, and local and distant tumor recurrence with short-term follow-up. Five (9.8%) devices were explanted because of unfavorable final pathological findings or infection. Mean time to the start of APBI in patients without drain placement was 7.2 days (range, 5-12 days) compared with 5.1 days (range, 3-8 days) in patients with drains (P = 0.003). Cosmetic results were excellent in 25 (54.3%) patients, good in 19 (41.3%) patients, and fair in 2 (4.4%) patients. With a mean follow-up of 16 months (range, 6-38 months), no ipsilateral breast recurrences developed in any of the 51 patients. Thirteen patients had at least a 2-year follow-up. Two patients developed brain metastases and died at 19 and 23 months, respectively. The favorable short-term outcomes support further studies comparing APBI with standard whole-breast irradiation in patients undergoing BCS.     

Lumpectomy Closure Technique Does Not Affect Dosimetry in Patients Undergoing External-Beam-Based Accelerated Partial Breast Irradiation

Background

During the breast lumpectomy procedure, surgeons traditionally elect to use either a superficial or full-thickness closure when sealing the wound depending on surgeon preference as well as desired outcomes. The purpose of this study was to examine dosimetric endpoints in patients with superficial versus full-thickness closures with accelerated partial breast irradiation (APBI).

Methods

Patients who underwent breast conservation surgery followed by 3D conformal external-beam APBI were identified (n = 45) and were separated according to the type of cavity closure performed: superficial and full thickness. Data gathered from the retrospective review of patient charts was analyzed according to criteria in the NSABP B-39 protocol in order to quantify the amount of radiation delivered to organs at risk. The patient seroma cavity was further given a cavity visualization score to assess the impact of wound closure on treatment planning.

Results

There was no significant difference in the mean CVS score for the 2 groups. There were no statistical differences in all dosimetric endpoints compared for the 2 types of closure, and both groups met NSABP B-39 guidelines for the ipsilateral breast, heart, and ipsilateral lung dosimetry.

Conclusions

We found no significant difference in dosimetric outcomes in either the superficial or deep closure treatment groups. Breast surgeons should not alter their preferred closure strategy in anticipation of 3D-CRT APBI.     

Irradiación parcial acelerada con multicatéteres en la cirugía conservadora por cáncer de mama

Introduction

Accelerated partial breast irradiation (APBI) with multicatheters after lumpectomy for breast cancer (BC) may be an alternative to whole breast irradiation in selected patients. The aim is to show our 5 year experience.

Method

Between June 2007 and June 2012, 87 BC patients have been evaluated for APBI. Inclusion criteria were: age over 40 years, unifocal tumour, infiltrating ductal or intraductal carcinoma, tumour size smaller than 3 cm and no lymph node involvement. Complications, cosmetic results and local and distant recurrences were evaluated.

Results

Treatment was completed in 48 patients and contraindicated in 39. The average age of treated patients was 59 years. Operating time was 123 min with 9 implanted catheters in each patient. No complications were observed during surgery or radiotherapy. Patients were discharged from hospital after 4 days. Tumour size was 11 mm. Of these, 35 were infiltrating ductal and 13 intraductal carcinomas. A total of 44 patients received adjuvant treatment. Mean follow-up was 22 months with no evidence of local or distant recurrence. The cosmetic outcome was good or excellent in 66% of cases.

Conclusions

APBI with multicatheter placed after lumpectomy for BC is feasible and safe but requires a strict selection of patients.     

Outcomes and Predictive Factors for Salvage Therapy After Local–Regional Recurrence Following Neoadjuvant Chemotherapy and Breast Conserving Therapy

Background

There are few data addressing local–regional recurrence (LRR) and salvage therapies in patients treated with neoadjuvant chemotherapy (NCT) compared to those treated with surgery first. We characterize the clinical course and predictive features of salvage treatment for LRR after breast conserving therapy (BCT) analyzed by initial treatment.

Methods

We identified 1,589 patients who underwent BCT; 1,141 (72 %) patients underwent initial surgery, and 448 (28 %) received NCT. Kaplan–Meier and Cox regression analyses were performed to analyze factors associated with overall survival (OS), local control (LC) of recurrence, and distant metastasis-free survival (DMFS) following LRR.

Results

56 patients had a LRR, for a crude recurrence rate of 3 %. For patients with potentially curable recurrence (excluding distant metastases within 3 months of LRR), the 5-year OS, LC, and DMFS rates were 52, 77, and 69 %. On multivariate analysis, initial pathologically negative node status and use of surgery for salvage were significant factors associated with higher OS. Additionally, older age was associated with higher LC rates after salvage. Estrogen receptor-positive disease and surgery for LRR were associated with reduced risk of distant metastases; regional recurrence and use of initial adjuvant chemotherapy were associated with increased risk of distant metastases. For each of these endpoints, the addition of NCT to the multivariate model did not approach significance.

Conclusions

LRR is an uncommon event after BCT and many patients with LRR remain curable (5-year OS >50 %). Our data indicate that NCT does not compromise salvage after LRR, providing further assurance that this strategy is safe for appropriately selected breast cancer patients.