Outcomes with intraoperative radiation therapy for early‐stage breast cancer

Adjuvant radiation therapy has been associated with improved local control following breast‐conserving surgery. Traditionally, treatment has been delivered with whole breast irradiation over 3‐6 weeks or partial breast irradiation over 1‐3 weeks. However, intraoperative radiation therapy (IORT) has emerged as a technique that delivers a single dose of radiotherapy at the time of surgery for early‐stage breast cancers. We report initial outcomes and acute toxicities with intraoperative radiation from a single institution. Patients with DCIS or Stage I‐II breast cancer who underwent lumpectomy and sentinel lymph node biopsy (nodal sampling excluded in some cases) were included. All patients in this analysis were treated with IORT as at the time of surgery, 20 Gy in 1 fraction with 50 kV x‐ray. Patients were treated at a single institution between 2011 and 2019. Follow‐up was per standard institutional protocol. Two hundred and one patients were included in the analysis, with a median follow‐up of 23 months (range: 0‐73 months). Median age was 71 years old. Overall, 4 (2.0%) patients had DCIS, 186 (92.5%) patients had Stage 1 disease, and 11 patients had (5.5%) Stage 2 disease. All patients were estrogen receptor‐positive, 175 (87.9%) progesterone receptor‐positive, and 1 (0.5%) HER2 amplified. The crude rate of local recurrence was 2.0% (n = 4) and distant metastasis rate was 0.5% (n = 1). The rate of arm lymphedema was 0.5% (n = 1) and chronic telangiectasia rate was 1.1% (n = 2). Intraoperative radiation therapy, in a cohort of low‐risk patients, demonstrated low rates of recurrence and reproducibility in a multi‐disciplinary setting. Further follow‐up, analysis of patient satisfaction and cosmesis, and comparison to whole breast irradiation and partial breast techniques is necessary in order to further validate these findings.     

A prospective single-institution study of intraoperative radiotherapy (IORT) for early-stage breast cancer

Intraoperative radiation therapy (IORT) is an option for breast-conserving therapy in early-stage breast cancer. IORT is given in one fraction at the time of surgery and eliminates the need for adjuvant external beam radiation therapy. However, previous trials indicate increased local failure rates compared with whole-breast irradiation, which engenders controversy around the appropriate use of IORT. We conducted a prospective study of patients diagnosed with early-stage breast cancer (T1-T2, N0-N1) at the University of Oklahoma Health Sciences Center (OUHSC) between 2013 and 2017 and treated with lumpectomy followed by intraoperative radiation therapy (IORT). Data collected included stage of disease, tumor location, histology, tumor markers, lymph node status, surgical margin size, recurrence, cosmetic outcomes, and length of follow-up. In-breast tumor recurrence rate (IBTR) in the 77 evaluable patients was 3.9% (3 patients). Margins were close (1 mm or less) in all three recurrent patients, and two were initially diagnosed with DCIS. Recurrence rates in our patients were comparable to prior reports. All recurrences were in patients with close margins indicating that this may represent a predictive feature for exclusion from IORT; additional studies are essential to determine the recurrence rates among patients treated with IORT and to identify potential predictors of IORT eligibility.     

Selection of neoadjuvant treatment based on the 21-GENE test results in luminal breast cancer

Neoadjuvant chemotherapy (NAC) is an optimal option in early breast cancer, but in ER-positive/HER2-negative (luminal) is still controversial, although a survival benefit has recently been observed when a histological response by Symmans’ method type 0 or I is achieved. The 21-gene Oncotype DX Breast Recurrence Score® assay (Oncotype DX®) is a validated test to assess the survival benefit of adjuvant chemotherapy in these patients but its role in the neoadjuvant setting is less established. We analyzed the results of the Oncotype DX® test in a cohort of 122 consecutive patients selected to receive NAC based on classical clinicopathological parameters and the correlation between the Oncotype DX® results and the pathological response assessed by Symmans’ method. Median age was 56.5 (range 31–84) years. Initial tumor size was T1 (<20 mm) in 46 patients (37.7%), 57 (46.7%) had a T2 tumor (20–50 mm), and 19 (15.6%) had a tumor size more than 50 mm. 59 (48.4%) had axillary node involvement. The median expression estrogen and progesteron receptors by immunohistochemistry was 280 and 120 respectively and median Ki67 index was 28%. The Recurrence Score (RS) results were <11 in 21 patients (17.2%) patients, RS 11 to 25 in 58 (47.5%), and RS > 25 in 43 (35.2%). Considering the Oncotype DX test results, neoadjuvant chemotherapy was administered to 60 patients (49%), 11 (9%) received adjuvant chemotherapy and 51 (42%) no chemotherapy. Testing with the assay has therefore led to 42% fewer chemotherapy treatments. Among 60 patients receiving NAC, pathologic response was achieved for 5 patients (8.3%) with RCB-0 and 15 RCB-1 (25%). We did not find any pathological response RCB-0 and RCB-I in the 20 patients who received NAC and had a Recurrence Score result <21 for the premenopausal group, or a RS result <25 for the postmenopausal group. For patients with highest Recurrence Score results (RS > 21 or 25 according to menopausal status) it was 12% (5/40) RCB-0 and 40% (16/40) RCB-I.ConclusionsThe Oncotype DX test could be a useful tool to select patients candidates for neoadjuvant chemotherapy in luminal breast cancer. Neoadjuvant chemotherapy could be avoided in 42% of patients. We found a correlation between Recurrence Score results and pathological response with 14% of RCB-0 and a total of 47% of significant pathological response type RCB-0 and RCB-I in patients with highest Recurrence Score results. Interestingly, patients with a Recurrence Score result inferior to 32 did not get any histological response type 0 and only 5% RCB-I.     

False‐negative rate of ultrasound‐guided fine‐needle aspiration cytology for identifying axillary lymph node metastasis in breast cancer patients

Axillary nodal status remains an important determinant of prognosis and of the therapeutic strategy in patients with a newly diagnosed breast cancer. The aim of this study was to assess the false‐negative rate of ultrasound (US)‐guided fine‐needle aspiration cytology (FNAC) in axillary node staging at breast cancer diagnosis. All patients with a newly diagnosed breast cancer who had an indeterminate or suspicious axillary node sampled with an FNAC between 2007 and 2014 were included in the study. FNAC results were compared to the final histopathological results of surgically removed axillary lymph nodes. Patient demographics, tumor, and nodal characteristics were analyzed. Diagnostic accuracy tests were performed using IBM SPSS, version 22. A total of 3515 patients with breast cancer were identified, 675 of whom had ultrasound‐guided FNAC of ipsilateral axillary lymph nodes (mean age: 55 years; Range: 26‐84). A benign (C2) result was observed in 52% (n = 351) and a malignant (C5) result in 35% (n = 238). C1 was obtained in 11% (n = 76), C3 in 0.6% (n = 4), and C4 in 0.9% (n = 6). Of the 238 patients with a malignant (C5) FNAC, 99.6% had confirmed axillary lymph node metastatic disease on histopathology. Of the 351 patients with benign FNAC (C2), 31% (n = 108) of patients had a positive lymph node on histology. The false‐negative rate of preoperative FNAC remains too high (31%) to omit definitive surgical staging of the axilla. The high diagnostic accuracy when a positive FNAC is obtained allows appropriate tailored decisions regarding definitive therapy.     

Breast conservation for male breast cancer: Case report of intraoperative radiation

Male breast cancer (MBC) comprises <1% of all breast cancers in the United States. MBC is typically treated with total mastectomy while the majority of female breast cancer is treated with breast conservation therapy combined with various forms of radiation. One method that has developed over the last two decades is the use of intraoperative radiation therapy (IORT) as a type of accelerated partial breast irradiation to direct the treatment field to the tumor bed. Since overall prognosis and systemic therapy recommendations for MBC are similar to breast cancer in women, we describe the first case of MBC treated with BCS and IORT. Our patient is a 62‐year‐old male who was found to have a right breast 1.6 cm palpable mass at the 10:00 position 1 cm radially from the nipple. Core biopsy demonstrated invasive ductal carcinoma, moderately differentiated, estrogen and progesterone receptor positive, and Her 2 Negative. The patient had a strong desire for breast conservation, and needed to minimize daily radiation treatments due to his work schedule. After discussion among our multidisciplinary tumor board, we felt this patient to be suitable for BCS and IORT given his age, favorable tumor subtype, size, and clinically early stage breast cancer. A right axillary sentinel lymph node biopsy and central lumpectomy was performed. The INTRABEAM device (Carl Zeiss Meditec, Oberkochen, Germany) was utilized for radiation delivery. The patient had negative margins on his final pathology. The postoperative course was uneventful and at the 6 month follow‐up visit there were no issues and he had an excellent cosmetic outcome. BCS and IORT is an option in appropriately selected male patients with favorable subtype early stage breast cancer.     

Effect of internal mammary vessels radiation dose on outcomes of free flap breast reconstruction

To assess the impact of internal mammary (IM) vessels radiation dose on autologous free‐flap based breast reconstruction outcomes. We retrospectively evaluated the medical records of breast cancer patients who underwent mastectomy and free‐flap breast reconstruction after postoperative radiation therapy (RT) to the breast/chest wall with (n = 9) or without (n = 11) electively including the IM lymph nodes. Twenty patients were included. Median age at diagnosis was 50 years (range, 33‐63). The median time interval between the start of RT and reconstructive surgery was 16 months (range, 6‐45). The maximal IM vessels dose was not associated with the risk of all complications (P = 0.44) or fat necrosis (P = 0.31). The mean IM vessels dose was not significant for the risk of all complications (P = 0.13) but was significant for fat necrosis (P = 0.04). A high mean IM vessels dose was related to the occurrence of fat necrosis.     

Are Mammographic Changes in the Tumor Bed More Pronounced After Intraoperative Radiotherapy for Breast Cancer? Subgroup Analysis from a Randomized Trial (TARGIT‐A)

Intraoperative radiotherapy (IORT) with low‐energy x‐rays is increasingly used in breast‐conserving therapy (BCT). Previous non‐randomized studies have observed mammographic changes in the tumor bed to be more pronounced after IORT. The purpose of this study was to reassess the postoperative changes in a randomized single‐center subgroup of patients from a multicenter trial (TARGIT‐A). In this subgroup (n = 48) 27 patients received BCT with IORT, 21 patients had BCT with standard whole‐breast radiotherapy serving as controls. Overall 258 postoperative mammograms (median follow‐up 4.3 years, range 3–8) were retrospectively evaluated by two radiologists in consensus focusing on changes in the tumor bed. Fat necroses showed to be significantly more frequent (56% versus 24%) and larger (8.7 versus 1.6 sq cm, median) after IORT than those in controls. Scar calcifications were also significantly more frequent after IORT (63% versus 19%). The high incidence of large fat necroses in our study confirms previous study findings. However, the overall higher incidence of calcifications in the tumor bed after IORT represents a new finding, requiring further attention.     

Increasing omission of radiation therapy and sentinel node biopsy in elderly patients with early stage,hormone‐positive breast cancer

Prospective evidence demonstrates that there is limited benefit of axillary staging with sentinel lymph node biopsy (SLNB) or radiation therapy (RT) in patients over age 70 with clinical stage I, hormone‐positive breast cancer. The clinical impact of this literature is unknown. Our hypothesis is that omission of SLNB and RT has increased over time in these patients, and patient and tumor characteristics can predict when omission strategies are used. A single‐center tumor registry was queried for all patients over age 70 with ER+, Her2/neu‐negative, clinical T1N0 invasive breast cancer from 2009 to 2017, who underwent breast conservation (n = 141). Date of treatment, age, tumor characteristics, use of SLNB, and use of RT were evaluated. The trend of treatment strategy over time was evaluated. Multivariable analysis was performed on the subgroup of patients after publication of the long‐term follow‐up CALGB 9343 data¹. Patients undergoing treatment with omission of RT and SLNB increased over the study period (P = .0006). Patients who did not receive RT were older (78.76 years ± 5.48 vs 73.37 ± 3.63, P < .01). There was no difference between tumor grade and size between uses of RT. Of patients who received SLNB (n = 84), only 3 (3.5%) had a positive LN. On multivariable analysis of patients who were treated after publication of the CALGB 9343 data (2014‐2017), only age was predictive of being treated with RT (OR, 0.77; 95% CI, 0.67‐0.88). Omission of both RT and SLNB are increasing in clinical practice in appropriately selected patients. The likelihood that patients are offered omission of these interventions increases with age. Low nodal positivity rates suggest that this strategy may be underutilized. Tumor grade and size were not predictive of omission of RT in this group of low‐risk patients. Long‐term data are needed as these approaches are increasingly adopted.     

Adjuvant treatment and survival in older women with triple negative breast cancer: A Surveillance,Epidemiology, and End Results analysis

Patients with triple negative breast cancer were identified using the Surveillance, Epidemiology, and End Results database. Competing risks analysis was used to assess the cumulative incidence of breast cancer‐specific mortality (BCSM). Multivariable Fine‐Gray regression was used to identify predictors of BCSM. Women age 70+ (n = 4221) were less likely to receive chemotherapy and radiation treatment (P < 0.0001) and had higher BCSM compared to younger women (P < 0.0001). There were no differences in BCSM in patients who received adjuvant treatment (P = 0.10). Stage II patients derived the greatest relative and absolute benefit from adjuvant treatment. Age was not a significant predictor of BCSM.     

The Relative Benefits of Tamoxifen in Older Women with T1 Early‐Stage Breast Cancer Treated with Breast‐Conserving Surgery and Radiation Therapy

Small, hormone receptor‐positive breast carcinomas in older women are associated with low local recurrence rates. The relative benefits of adjuvant hormonal therapy remain unclear in elderly women with small, node‐negative breast cancer after breast‐conserving surgery and adjuvant radiation therapy. From our institutional data base, 224 patients ≥65 years of age with T1N0M0 breast cancer treated with BCS+RT were identified. Of these, 102 patients (45.5%) received tamoxifen (TAM) and 122 patients (54.5%) did not (no‐TAM). The median follow‐up time was 62.6 months. The 10‐year local relapse‐free survival (LRFS) was 98% in both the TAM and no‐TAM cohorts (p = 0.58); the 10‐year DMFS was 83% TAM vs. 89% no‐TAM (p = 0.91). There was no difference in 10‐year contralateral breast relapse or overall survival (OS) between the two cohorts. In univariate and multivariate analysis, use of TAM was not associated with LRFS, distant metastases‐free survival (DMFS), OS, or a reduction in contralateral breast cancers when compared with the no‐TAM cohort. In this large cohort of T1N0 elderly breast cancer patients treated with CS+RT, the use of TAM did not appear to decrease ipsilateral breast relapse, contralateral breast relapse, distant metastasis, or OS.     

Intraoperative Radiotherapy of Early Breast Cancer Using Low‐Kilovoltage X‐Rays‐Reasons for Omission of Planned Intraoperative Irradiation

The purpose of this study is to investigate reasons for omission of a planned intraoperative radiotherapy (IORT) during breast‐conserving surgery (BCS). Between 2002 and 2009, in 297 women an IORT during BCS was planned. In 55 women this irradiation was finally not performed. We retrospectively analyzed pre‐, peri‐, and postoperative data of these 55 women. Main reasons for omission of an IORT were insufficient tumor–skin distance (n = 20, 35.1%), an oversized wound cavity (n = 14, 24.6%), and a combination of both (n = 8, 14%). Further reasons (n = 12, 21.1%) were temporal shortage, unplanned maintenance work of the Intrabeam^® device, unsuitable anatomicosurgical conditions, and ineligible histologic findings. Apart from suitable anatomic conditions, a precise preoperative ultrasonography as well as a strict interdisciplinary preoperative management is important for successful application of IORT.     

Racial Disparities in Hypofractionated Radiotherapy Breast Cancer Clinical Trials

There is a paucity of data regarding factors affecting enrollment onto radiation oncology clinical trials. The purpose of this study was to determine patients and tumor characteristics that influenced enrollment of breast cancer patients onto hypofractionated breast radiotherapy trials (HBRTs) at a single institution. In this retrospective cohort study, patients enrolled on HBRTs at the Rutgers Cancer Institute of New Jersey (n = 132) were compared with a cohort of breast cancer patients eligible for, but not enrolled onto HBRTs treated during the same time period (n = 132). Charts were retrospectively reviewed to determine patients' demographics, clinico‐pathologic factors, and treatment characteristics. Statistical analysis was performed to analyze variables affecting enrollment onto HBRTs between the two groups. Over a 42‐month time period, 132 patients treated on HBRTs received 2,475–4,995 cGy over 3 to 15 fractions. When compared with patients treated off trial, there was no statistically significant effect of age, family history, lymph node positivity, tumor grade, estrogen or Her‐2 receptor status, use of chemotherapy or hormones, use of brachytherapy, or the site of initial consultation on HBRT enrollment. Non‐White women were less likely to enroll in HBRT's when compared with White women (25.7% versus 40.1%, p = 0.0129), though this was found to be a nonsignificant trend when taking stage into consideration on multivariate analysis (OR for lower T‐stage: 0.281, p = 0.003, OR 1.839 for white race, p = 0.076). Consistent with previous studies, non‐White women were less likely to enroll in HBRTs than White women. However, disease stage accounted for these racial disparities. Further studies must be performed to determine if race is an independent factor determining radiation oncology clinical trial enrollment.     

Paclitaxel,Carboplatin, and Trastuzumab in a Neo‐adjuvant Regimen for HER2‐positive Breast Cancer

To evaluate a nonanthracycline‐containing regimen consisting of 24 weekly administrations of paclitaxel, carboplatin, and trastuzumab as neo‐adjuvant therapy for human epidermal growth factor receptor 2 (HER2)‐positive breast cancer. Patients with stage II or III breast cancer, including inflammatory disease, with HER2 overexpression (immunohistochemistry and/or fluorescent in situ hybridization) were treated with 24 weekly administrations of paclitaxel 70 mg/m², carboplatin AUC = 3 mg/mL/minute, and trastuzumab 2 mg/kg (loading dose 4 mg/kg). In cycles 7, 8, 15, 16, 23, and 24, only trastuzumab was given. The primary end point was pathologic complete response (pCR) in both breast and axilla. Of 61 evaluable patients, 61% had stage II disease and 75% were node‐positive. The median NRI (Neoadjuvant Response Index, a measure of the degree of downstaging by chemotherapy) of all patients was 0.86. Twenty‐seven (44%) had a NRI of 1.0, which corresponds to pCR in breast and lymph nodes. The most commonly reported grade 3/4 toxicities were neutropenia (72%) and thrombocytopenia (36%). Dose reduction was necessary in 51% of the patients. A weekly carboplatin–paclitaxel–trastuzumab neo‐adjuvant regimen is highly active in HER2‐positive breast cancer with an acceptable toxicity profile. A multicenter phase 2 trial has recently reached its accrual target and will serve as a basis for a subsequent randomized phase 3 study comparing this regimen to a similar regimen preceded by anthracyclines.     

Does Intraoperative Radiation Therapy Improve Local Tumor Control in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma? A Propensity Score Analysis

Background  Locoregional recurrence (LRR) is an important factor after pancreaticoduodenectomy (PD) for pancreatic cancer. Intraoperative radiation therapy (IORT) administered to the resection bed may improve local tumor control. Methods  We performed a retrospective analysis of patients who underwent PD at Thomas Jefferson University Hospital (TJUH) between 1995 and 2005 to identify patients who underwent resection with and without IORT. Data collected included age, gender, complications, margin status, stage, survival, and recurrence. Unadjusted analyses of the IORT and non-IORT groups were performed using Fisher’s chi-square method for discrete variables and Wilcoxon rank sum test for continuous variables. To account for biases in patient selection for IORT, a propensity score was calculated for each patient and adjusted statistical analyses were performed for survival and recurrence outcomes. Results  Between January 1995 and November 2005, 122 patients underwent PD for periampullary tumors, including 99 pancreatic cancers. Of this group, 37 patients were treated with IORT, and there was adequate follow-up information for a group of 46 patients who underwent PD without IORT. The IORT group contained a higher percentage of Stage IIB or higher tumors (65%) than in the non-IORT group (39.1%), though differences in stage did not reach significance (P = .16). There was a nonsignificant decrease in the rate of LRR in patients who had IORT (39% non-IORT vs. 23% IORT, P = .19). The median survival time of patients who received IORT was 19.2 months, which was not significantly different than patients managed without IORT, 21.0 months (P = .78). In the propensity analyses, IORT did not significantly influence survival or recurrence after PD. Conclusions  IORT can be safely added to management approaches for resectable pancreatic cancer, with acceptable morbidity and mortality. IORT did not improve locoregional control and did not alter survival for patients with resected pancreatic cancer. IORT is an optional component of adjuvant chemoradiation for pancreatic cancer. In the future, IORT may be combined with novel therapeutic agents in the setting of a clinical trial in order to attempt to improve outcomes for patients with pancreatic cancer. Presented as Poster Presentation at the American Hepatico-Pancreato-Biliary Association, April 2008, Ft. Lauderdale, FL.     

The efficacy and safety of hypofractionated radiotherapy with concurrent anti‐HER‐2 therapy following breast‐conserving therapy for breast cancer

The purpose of this study was to report rates and severities of radiation‐related toxicities and analyze disease‐control outcomes in patients who have received hypofractionated whole breast radiation (HF) with concurrent trastuzumab with or without pertuzumab. We conducted a retrospective cohort study including women with stage I‐III HER2‐positive breast cancer who received HF at the University of Pennsylvania between 1/2005 and 5/2018 with concurrent trastuzumab with or without pertuzumab. Fractionation was 266 cGy daily to a total dose of 4256 cGy with or without a sequential tumor bed boost. Eighty patients were included in the cohort with a median follow‐up time of 21.44 months. There was one grade 3 acute toxicity (fatigue) and no grade 3 late toxicities. 91% and 25% of patients experienced grade 1‐2 acute and late skin reactions, respectively. An excellent‐good cosmetic outcome was reported by 74% and 95% of patients and physicians, respectively. No patients experienced tumor recurrences, and the only death was due to a secondary cause. These results suggest that hypofractionated whole breast radiation administered concurrently with anti‐HER‐2 therapies is efficacious and has acceptable toxicity in early‐stage breast cancer patients treated with lumpectomy. Continued follow‐up is warranted to evaluate long‐term outcomes.     

Prediction of pathological margin status using preoperative contrast‐enhanced MRI in patients with early breast cancer who underwent skin‐sparing mastectomy

Skin‐sparing mastectomy (SSM) with immediate reconstruction is standard surgical treatment for early breast cancer with widespread ductal carcinoma in situ (DCIS). The local recurrence rate after SSM is up to 7.0%. We investigated prediction of the pathological margin using contrast‐enhanced MRI, and evaluated the cut‐off point to obtain the safety margin. We performed SSM with immediate reconstruction in 216 early breast cancer patients with widespread DCIS and/or invasive cancer from January 2014 to December 2015. Forty cases were retrospectively reviewed after excluding those with >15 mm between skin and tumor, determined by preoperative contrast‐enhanced MRI, or involving reconstructive surgery for local recurrence, immeasurable lesion by preoperative contrast‐enhanced MRI, or neoadjuvant chemotherapy. We defined a positive pathological margin as <1 mm from the cancer nest. We reviewed the distance between skin and tumor by MRI and pathological examination. To identify the cut‐off for predicting a positive pathological margin, we performed sensitivity analysis using an ROC curve. The margin‐positive rate by pathological examination was 27.5% (n = 11/40), with a moderate correlation of MRI margin and pathological margin (r = 0.44). The best cut‐off point for margin positivity was 5 mm of MRI margin, with sensitivity and specificity of 54% and 86%, respectively (P = 0.009). This is the first prediction of pathological margin by preoperative contrast‐enhanced MRI in early breast cancer patients with SSM. Care is required for SSM if the MRI margin is less than 5 mm due to pathological margin positivity.     

Clinical Features and Treatment Response of Solid Neuroendocrine Breast Carcinoma to Adjuvant Chemotherapy and Endocrine Therapy

Solid neuroendocrine breast carcinoma (solid NEBC) is a relatively uncommon malignant tumor of the breast. The purpose of our study was to explore the incidence and clinical features of this tumor, and to evaluate the efficacy of adjuvant chemotherapy and endocrine therapy for patients with solid NEBC. Of 7542 breast cancers registered during the period from March 2004 to April 2011, 22 patients (0.29%) who underwent surgery had tumors that were histologically confirmed as solid NEBC, and were enrolled in this study. The age range of these patients was 29–77 years (mean 52.5 years). Patients were staged according to the 7th edition of the pathologic tumor‐node‐metastasis (pTNM) staging system. Biopsies or resection specimens were reviewed and reclassified according to the World Health Organization (WHO) 2003 classification. We recorded clinical features including gender and age, chief complaint, and past medical history, tumor characteristics including size, location, preoperative diagnosis, and pathologic and immunohistochemical findings, the therapeutic schedule, and the follow‐up results. Solid NEBC is a rare and distinct category of malignant disease of the breast, with good prognosis, and in most early‐stage cases, is resectable. The role of adjuvant chemotherapy and endocrine therapy in solid NEBC may be limited and should be studied further.     

Effect of primary tumor resection on overall survival in patients with stage IV breast cancer

We aimed to evaluate the effect of primary tumor resection on overall survival in stage IV breast cancer patients. In total, 284 breast cancer patients presenting with breast cancer at stage IV at initial diagnosis, between 2001 and 2014, were enrolled in the study. Patients were divided into two groups based on surgical resection of the primary tumor. Overall survival (OS) between the two groups was analyzed. Patients in the surgery group (n = 92) had smaller tumors than those in the no‐surgery group (n = 192, T0‐1:17.7% vs 34.8%, P < 0.001). The surgery group more often had negative nodal status (5.7% vs 33.7%, P < 0.001). Multiple metastatic organ sites were more common in the no‐surgery group than in the surgery group (55.7% vs 15.2%, P < 0.001). The surgery group showed a better OS than the no‐surgery group (P = 0.01). Multivariate analysis showed that surgical resection of primary tumors tended to be associated with improved OS (HR = 0.67, P = 0.055). T stage, ER, HER2 and metastatic organ sites were independent prognostic factors for OS in multivariate analysis. Surgical resection of the primary tumor may be a treatment option for patients with stage IV disease and may not have a negative effect on overall survival.     

Impact of Surgery‐Radiation Interval on Locoregional Outcome in Patients Receiving Neo‐adjuvant Therapy and Mastectomy

Delays in the initiation of radiation are increasingly common for medically underserved patients. We evaluated the impact of delay in initiation of postmastectomy radiation (PMRT) in breast cancer patients treated with neo‐adjuvant therapy (NAT) in a cohort of medically underserved patients with multiple barriers to timely care. We retrospectively reviewed medical records of 248 consecutively treated patients. Clinical stage was 34.4% II, 65.6% III. The median interval from surgery to PMRT was 11.9 weeks; 22.2% started PMRT within 8 weeks of surgery, 52% within 12 weeks, and 67.3% within 16 weeks. The cumulative 5‐year incidence of locoregional recurrence (LRR) was 5.8% (95% CI: 3.2–9.7). There was no significant difference in locoregional outcome among patients starting PMRT within 8 weeks versus >8 weeks (p = 0.634), ≤12 versus >12 weeks (p = 0.332), or ≤16 versus >16 weeks (p = 0.549) after surgery. Although timely initiation of PMRT remains a priority, the locoregional control benefit of PMRT appears to be maintained up to at least 16 weeks, and in those without early locoregional recurrence, PMRT should be offered despite such a delay.     

Radioterapia intraoperatoria en cáncer de mama precoz: análisis observacional frente a radioterapia externa

IntroductionIn early breast cancer (EBC), a single dose of intraoperative radiotherapy (IORT) might be an option to standard whole breast radiotherapy (WBRT). However, there is no consensus about its use and clinical results.Aimto analyse the morbidity and oncological outcomes of IORT as monotherapy in EBC.MethodsA single centre observational analytic study was performed. A prospective IORT cohort (2015-17) and a retrospective WBRT cohort (2012-17) were selected following the same criteria: ≥ 45 y.o., invasive ductal carcinoma or variants, radiological tumour size ≤ 3 cm, positive oestrogenic receptors, negative HER2, cN0; exclusion criteria: lymphovascular invasion, multicentricity/multifocality, BRCA mutation and neoadjuvant therapy. Clinical, histological, surgical, oncological characteristics and complications were collected.ResultsA total of 425 cases were selected: 217 in IORT cohort and 208 in WBRT cohort. Average age in IORT and WBRT groups was 67±9.5 and 64.8 ± 9.9 y.o. respectively (p = 0.01). ASA 3 risk score patients were 17.7% in IORT and 24 cases in WBRT (p = 0.027). There were no differences in histological results or tumoral stage. Average follow up was 24.4 ± 8 months in IORT and 50.5 ± 18 months in WBRT (p < 0.001). No differences were detected in local recurrence, metastases or mortality. Complications that required reintervention or hospitalization were similar in both groups. A total of 3 and 14 cases developed early severe dermatitis in IORT and WBRT groups respectively (p = 0.01).ConclusionIORT as monotherapy in selected patients with EBC stands for an alternative option versus WBRT. It seems especially useful in advanced-age patients with severe comorbidities. IORT associates lesser early severe dermatitis.