Ⅱ期乳癌术后胸壁电子束弧形照射临床观察

目的分析应用电子束弧形照射技术对Ⅱ期乳癌根治术后放疗的临床效果。方法对87例接受了乳癌改良根治术后的Ⅱ期患者实施了术后放疗。靶区为患侧锁骨上、下淋巴引流区、腋窝、胸壁(包括手术疤痕),肿瘤位于内侧象限者,加以内乳区照射。内乳区、胸壁采用电子束弧形照射。结果全组病例5年存活率为79.5%,5年无瘤存活率为76.4%,腋窝淋巴结阳性率<20%组5年生存率为84.8%;>20%组为73.1%(P<0.001)。结论①实施根据胸廓外型和靶区深度调整并转换电子束能量的弧形照射,可以得到理想的靶区剂量分布,改善放疗效果,提高乳癌病人的局部肿瘤控制率,从而改善存活率及生存质量。②腋窝淋巴结阳性率>20%提示预后较差,对此组病例应予以积极的综合治疗。     

Locoregional irradiation for inflammatory breast cancer: effectiveness of dose escalation in decreasing recurrence

Purpose: To evaluate the effect of radiation dose escalation on locoregional control, overall survival, and long-term complication in patients with inflammatory breast cancer.

Patients and Methods: From September 1977 to December 1993, 115 patients with nonmetastatic inflammatory breast cancer were treated with curative intent at The University of Texas M. D. Anderson Cancer Center. The usual sequence of multimodal treatment consisted of induction FAC or FACVP chemotherapy, mastectomy (if the tumor was operable), further chemotherapy, and radiation therapy to the chest wall and draining lymphatics. Sixty-one patients treated from September 1977 to September 1985 received a maximal radiation dose of 60 Gy to the chest wall and 45–50 Gy to the regional lymph nodes, 22 treated once a day at 2 Gy per fraction, and 35 were treated b.i.d. (32 after mastectomy and all chemotherapy was completed, and 2 immediately after mastectomy; one patient had distant metastases discovered during b.i.d. irradiation, and treatment was stopped). Four additional patients received preoperative radiation with standard fractionation. Based on the analysis of the failure patterns of the patients, the dose was increased for the b.i.d. patients in the new series, with 51 Gy delivered to the chest wall and regional nodes, followed by a 15-Gy boost to the chest wall with electrons. From January 1986 to December 1993, 39 patients were treated b.i.d. to this higher dose after mastectomy and all the chemotherapy was completed; and 8 additional patients received preoperative irradiation with b.i.d. fractionation to 51 Gy. During this period, another 7 patients were treated using standard daily doses of 2 Gy per fraction to a total of 60 Gy, either because they had a complete response or minimal residual disease at mastectomy or because their work schedule did not permit the b.i.d. regimen. Comparison was made between the groups for locoregional control, disease-free and overall survival, and complication rates.

Results: The median follow-up time was 5.7 years (range, 1.8–17.6 years). For the entire patient group, the 5- and 10-year local control rates were 73.2% and 67.1%, respectively. The 5- and 10-year disease-free survival rates were 32.0% and 28.8%, respectively, and the overall survival rates for the entire group were 40.5% and 31.3%, respectively. To evaluate the effectiveness of dose escalation, a specific comparison of patients who received b.i.d. radiation after mastectomy and completion of adjuvant chemotherapy was performed. There were 32 patients treated b.i.d. to 60 Gy in the old series versus 39 patients treated b.i.d. to 66 Gy in the new series. There was an significant improvement in the rate of locoregional control for the b.i.d. patients for the old vs. new series, from 57.8% to 84.3% and from 57.8% to 77.0% (p = 0.028) at 5 and 10 years, respectively. Chemotherapy regimens did not change significantly during this time period.

Long-term complications of radiation, such as arm edema more than 3 cm (7 patients), rib fracture (10 patients), severe chest wall fibrosis (4 patients), and symptomatic pneumonitis (5 patients), were comparable in the two groups, indicating that the dose escalation did not result in increased morbidity. Significant differences in the rates of locoregional control (p = 0.03) and overall survival (p = 0.03), and a trend of better disease-free survival (p = 0.06) were also observed that favored the recently treated patients receiving the higher doses of irradiation.

Conclusion: Twice-daily postmastectomy radiation to a total of 66 Gy for patients with inflammatory breast cancer resulted in improved locoregional control, disease free survival, and overall survival, and was well tolerated.     

Radiotherapy following mastectomy: indication and contraindication of chest wall irradiation

Purpose: To determine in which cases radiotherapy of the chest wall following mastectomy is indicated, based on the local recurrent rate in patients with locally advanced breast cancer.

Methods and Materials: From 1984 until 1994, 105 patients who had four or more histopathologically confirmed axillary nodes metastases, or T3-4Nany, were subjected to mastectomy and were administered radiotherapy postoperatively using the hockey-stick field, which included the ipsilateral supraclavicular fossa and internal mammary nodes, except the chest wall. Median age was 51 years old (range, 23 to 82 years old). Eighty-five patients underwent radical mastectomy, 18 modified radical mastectomy, and 2 extended radical mastectomy. Fraction size was 2 Gy/day, the weekly fraction size was 10 Gy and the total dose ranged from 44 Gy to 54 Gy (median 50 Gy). Seventy-four patients were administered adjuvant chemotherapy, and 61 patients were administered hormone therapy.

Results: The 5-year disease-free survival rates of the whole study population were 66%. The 5-year chest wall recurrence rates were 10%. The 5-year chest wall recurrence rates of the patients who had no vascular invasion (n = 19) and the patients who had definite vascular invasion (n = 38) were 0% and 24%, respectively (p = 0.036). All the patients who presented chest wall recurrence had four or more axillary nodes metastases. Nine of the 10 patients who presented chest wall recurrence had definite vascular invasion, while there was no information about vascular invasion for the remaining patient. Factors such as age, pathological subtypes, tumor location, estrogen receptors, extent of resection, chemotherapy, and hormone therapy did not influence the development of chest wall recurrence.

Conclusion: Among patients with breast cancer who have four or more positive axillary nodes or T3-4Nany, those who have no vascular invasion or less than 4 axillary nodes metastases do not need to be subjected to chest wall irradiation after radical mastectomy.     

Thermoradiotherapy for locally recurrent breast cancer with skin involvement.

PURPOSE: This retrospective analysis investigated the effectiveness and side-effects of combined hyperthermia and radiation therapy in locally recurrent breast cancer after primary modified radical mastectomy. The aim of the thermoradiotherapy was to reduce the substantial risk of symptomatic chest wall disease. MATERIALS AND METHODS: Between May 1995-August 1998, 39 extensively pre-treated women with progressive locoregional chest wall tumours were treated with local radiofrequency hyperthermia, given twice a week immediately before radiotherapy. Sixty-two per cent of the patients had received previous radiotherapy, with a median dose of 50 Gy, 64% had received chemotherapy, 36% hormonal therapy, and 13% local therapy with miltefosin, respectively. Nine patients were treated for microscopic residual disease after local tumour excision (R1-resection) and 30 patients for gross macroscopic nodular recurrences. Twenty-seven patients had two adjacent hyperthermia fields at the ipsilateral chest wall to cover the whole irradiation area. Each field received a median of seven local hyperthermia sessions (range 2-12, average 5.6 sessions) just before radiation therapy, with a median dose of 60 Gy (range 30-68 Gy). The monitored maximum(average) and average(average) epicutaneous temperatures were 42.1 degrees C and 41.0 degrees C, respectively. Maximum(average) and average(average) intratumoural temperatures of 43.0 degrees C and 41.1 degrees C, respectively, were achieved in nine chest wall recurrences with intratumoural temperature probes. Concurrent hormonal therapy was administered in 48%, and concurrent chemotherapy in 10% of patients. RESULTS: Median overall survival time was 28 months (Kaplan Meier), with 71% and 54% of patients living 1 and 2 years after thermoradiotherapy. The median time to local failure has not been reached, local tumour control after 2 years being 53%. Actuarial 1 and 2 year local tumour controls for microscopic residual disease were 89%, and for macroscopic nodular recurrences 71% and 46%, respectively (p = 0.09). Actuarial 1 and 2 year local tumour controls after treatment with a total dose of less than 60 Gy were 51% and 38%, respectively, and, after a total dose greater than 60 Gy, 84% and 60% (p = 0.01), respectively. Actuarial 1 year local tumour control was 92% after complete tumour remission, versus 57% after partial remission (p = 0.002). Three of the 39 patients died of cancer en cuirasse, 13 patients due to distant metastases. Acute thermoradiotherapy related erythema, dry desquamation and moist desquamation were seen in 28.2%, 30.7%, and 30.7% of patients, respectively. Soft tissue necrosis occurred in two patients with previous post-operative delayed wound healing, and in one patient above a silicon implant. CONCLUSION: This study showed that, in extensively pre-treated patients with locally recurrent breast cancer, local tumour control after thermoradiotherapy depended on tumour resectability, response of macroscopic tumour to thermoradiotherapy, and total irradiation dose.     

Loco-regional recurrences after mastectomy in breast cancer: prognostic factors and implications for postoperative irradiation

Purpose: Potential risk factors including DNA flow cytometric-derived parameters predicting loco-regional recurrence (LRR) in early breast cancer were investigated.

Materials and methods: This study included 608 patients treated by modified radical mastectomy between 1982 and 1987. Recommendations regarding local treatment as well as adjuvant systemic therapy did not change during this period. Patients treated by adjuvant chemotherapy were randomized to receive additional medroxyprogesterone acetate (MPA) treatment. Only 59 (10%) patients received postoperative irradiation (XRT) to the chest wall and/or axillary lymph nodes; another 121 (20%) patients received XRT to the internal mammary nodes because of centromedially located tumours.

Results: Patients were followed for a median period of 7.5 years. The event-free survival at 10 years was 50%. The cumulative incidence rate of LRR at 10 years was 18% (n=93), either with (n=30) or without (n=63) concurrent distant metastases. The chest wall, regional lymph nodes or both were involved in 41 (44%), 38 (41%) and 12 (13%) patients, respectively. Multivariate analysis according to the Cox model revealed two factors associated with LRR, i.e. pT (P<0.05) and nodal status (P<0.05). In node-positive patients extracapsular tumour extension (ECE) and pT were independent risk factors. DNA ploidy and S-phase fraction did not yield additional information. Based on pT, nodal status and extracapsular extension of tumour growth a high risk (>10%) and low risk (<10%) group for LRR could be identified.

Conclusions: Results indicate that T-stage and nodal status, combined with ECE, may help to identify patients at risk for loco-regional recurrence, whereas DNA flow cytometry does not.     

Radiation therapy following mastectomy for axillary node-positive breast cancer: indication of chest wall irradiation

This retrospective study was conducted to determine the indication of chest wall irradiation following mastectomy in axillary node-positive breast cancer patients. Between 1982 and 1993, 103 women with axillary node-positive breast cancer received postoperative radiation therapy following mastectomy using the hockey-stick field, which included the ipsilateral supraclavicular fossa and internal mammary nodes, without the chest wall. Ages ranged from 33 to 73 years (median: 47). Thirty-five patients underwent modified radical mastectomy, 48 radical mastectomy, and 20 extended radical mastectomy. Twenty-two patients had 1-3 positive axillary nodes, and 81 had 4 or more positive axillary nodes. The total doses ranged from 42 to 64 Gy (median 54 Gy) with a daily fraction size of 2 Gy. Adjuvant chemotherapy was given to 75 patients, and hormone therapy was administered to 78 patients. The median follow-up time was 121 months (range, 68-191 months) for the 57 surviving patients. The actuarial overall survival rate and the chest wall control rate at 10 years for all patients were 55% and 85%, respectively. Of the 103 patients, 14 developed chest wall recurrence. In the analysis, status of vascular invasion alone had a significant impact on chest wall control. In patients with definite vascular invasion, 2 of 5 (40%) patients with 1 to 3 positive axillary nodes, and 10 of 31 (32%) with 4 or more positive axillary nodes developed chest wall recurrence. In contrast, no patients without definite vascular invasion developed chest wall recurrence. Factors such as age, menopausal status, pathology, tumor location, extent of resection, estrogen receptor status, total dose, chemotherapy, and hormone therapy did not influence the development of chest wall recurrence. Among node-positive breast cancer patients following mastectomy, those with definite vascular invasion should be delivered chest wall irradiation regardless of the number of positive axillary nodes. In contrast, those without definite vascular invasion need not be administered chest wall irradiation.     

Surgical resection of the primary tumor, chest wall control, and survival in women with metastatic breast cancer

BACKGROUND

Among women presenting with de novo stage IV breast cancer, 35% to 60% undergo local therapy, presumably to avoid uncontrolled chest wall disease. Several studies suggest that resection of the primary tumor may prolong survival, but chest wall outcome data are notably lacking. The authors reviewed chest wall status, time to first progression (TTFP), and overall survival (OS) in this group of women.

METHODS

Women presenting at the Lynn Sage Breast Center (1995‐2005) with an intact primary tumor and stage IV breast cancer or postoperative diagnosis of distant metastases were identified. Logistic regression and Cox proportional hazards models, adjusted for relevant covariates, were used to examine associations between surgical treatment and chest wall status, TTFP, and OS.

RESULTS

Of 111 eligible women, 47 (42%) underwent early resection of the primary tumor. Chest wall status was available for 103 women. Local control was maintained in 36 of 44 (82%) patients in the surgical group versus 20 of 59 (34%) patients without surgery (P = .001). TTFP was prolonged in the surgical group (adjusted hazards ratio [HR], 0.493; P = .015). The adjusted HR for OS in the surgical group was 0.798 (P = .520). Chest wall control was associated with improved OS regardless of whether surgical resection of the tumor was performed (HR, 0.415; P < .0002).

CONCLUSIONS

These data support the notion that improved local control may play a role in improving outcomes in women with stage IV breast cancer, and resection of in‐breast tumors can help to achieve this. A randomized trial is needed to rule out selection bias as an explanation for these findings. Cancer 2008. © 2008 American Cancer Society.     

Early-stage bilateral breast cancer treated with breast-conserving surgery and definitive irradiation: The university of pennsylvania experience

: To determine whether patients with early-stage bilateral breast cancer can be treated with definitive irradiation following breast-conserving surgery with acceptable survival, local control, complications, and cosmesis.

: During the period 1977–1992, 55 women with State 0, I, or II concurrent (n = 12) or sequential (n = 43) bilateral breast cancer were treated with definitive irradiation following breast-conserving surgery. The records of these 55 patients with 110 treated breasts were reviewed for tumor size, histology, pathologic axillary lymph node status, first and overall site(s) of failure, and adjuvant chemotherapy or hormonal therapy. Curves for survival, local control, and regional control were determined. Cosmetic outcome, complication rates, and matching technique were analyzed. The median total radiation dose delivered was 64 Gy *range 42–72) using tangential whole-breast irradiation followed by an electron or iridium implant boost. The tangential fields were matched with no overlap in 40 patients (73%); there was overlap on skin of up to 4 cm in 14 patients. (25%); and the matching technique was unknown in 1 patient (2%). The median follow-up for the 12 women with concurrent bilateral breast cancer was 4.0 years. The median follow-up for the other 43 women with sequential cancer was 9.3 and 4.9 years, respectively, after the first and second cancers.

: For the overall group of 55 patients, the 5- and 10-year overall survival rates were 96% and 94%, respectively, after treatment of the first cancer, and 96% and 92%, respectively, after treatment of the second cancer. The 5- and 10-year actuarial relapse-free survival rates were 90% and 75%, respectively, after treatment of the first cancer, and 83% and 72%, respectively, after treatment of the second cancer. For the 110 treated breast cancers, th 5- and 10-year actuarial local failure rates were 5% and 15%, respectively. Complication rates were: 28% breast edema, 8% arm edema, 4% pneumonitis, 3% cellulitis, 1% rib fracture, and 1% brachial plexopathy; no patients developed matchline fibrosis. For patients with a minimum of 3 years of relapse-free follow-up, the rate of excellent or good cosmetic outcome for 104 treated beasts was 85%.

: Definitive irradiation after breast-consercing surgery is technically feasible for selected patients with concurrent or sequential early-stage bilateral breast cancer. Survival, local control, complication rates, and cosmetic outcomes appear comparable to historical reports of breast conservation treatment for unilateral disease. Bilateral definitive breast irradiation after breast-conservation surgery should be considered an acceptable alternative treatment to bilatera; mastectomy for selected patients with concurrent or sequential early-stage bilateral breast cancer.     

Radiotherapy after high-dose chemotherapy and peripheral blood stem cell support in high-risk breast cancer

To assess the toxicity and efficacy of radiotherapy with respect to locoregional control after adjuvant high-dose chemotherapy for patients with breast cancer. At first, radiotherapy was withheld because of toxicity concerns, but it was introduced in 1995 because of reported high locoregional relapse rates.

Between 1992 and 1998, 40 patients with Stage II–III high-risk breast cancer received adjuvant high-dose chemotherapy consisting of thiotepa, mitoxantrone, and cyclophosphamide and peripheral blood stem cell support after four cycles of induction chemotherapy. The chest wall or breast, as well as the supraclavicular nodes, were irradiated with electrons and photons to a median dose of 50.4 Gy in 20 patients. Six additional patients received only supraclavicular irradiation to a median dose of 50.4 Gy. Acute toxicity was scored clinically. Pulmonary function tests were performed in 14 irradiated patients before high-dose chemotherapy and 1.1–4.4 years (median 1.6) after irradiation. The median follow-up time of living patients was 33 vs. 67 months in irradiated (n = 26) and nonirradiated (n = 14) patients, respectively.

G2 and G3 hematologic toxicity occurred in 1 patient each. No clinical pneumonitis or clinical impairment of lung function was observed. After 1–2 years, the lung function tests showed only minor changes in 4 patients. The 3-year locoregional control rate was 92% in the irradiated patients vs. 58% in the nonirradiated patients (p = 0.049, actuarial analysis).

In this series, adjuvant radiotherapy after adjuvant chemotherapy for breast cancer appeared well tolerated, with improved local regional control and without significant side effects. Longer follow-up and more patient accrual, as well as Phase III trials, are necessary for confirmation.     

The significance of local recurrence of carcinoma of the breast

One hundred twenty-one patients with local or regional recurrence of carcinoma of the breast without evidence of distant metastases were treated with megavoltage radiation therapy. All patients had radical or modified radical mastectomy as their initial treatment. The 10 year survival probability of this group of patients is 26 %, with a local control probability of 46 %. Within this group of patients with recurrent disease, factors found to be associated with a poorer prognosis include peripheral nodal recurrence, advanced initial disease stage and short disease free interval. Contrary to expectation, patients with recurrence within the mastectomy scar (as opposed to chest wall recurrence wide of the scar) or a history of previous radiotherapy had poorer local control rates (although not statistically significant), without effect upon overall survival. Comprehensive radiation therapy (peripheral lymphatic plus chest wall) enhanced the local control rate for the entire group and the survival probability for patients with isolated chest wall recurrence compared with limited radiation therapy fields. (Five year survival probability: chest wall irradiation only = 27%; chest wall and peripheral lymphatic = 54%). Patients given systemic therapy at the time of local recurrence showed no survival benefit. Aggressive, comprehensive radiation therapy is indicated for locally recurrent breast cancer. More effective systemic therapy is needed, especially for higher risk patients.     

T4期乳腺癌患者改良根治术后胸壁放疗加量的疗效及预后分析

目的分析T4期乳腺癌患者改良根治术后胸壁放疗加量的疗效。方法回顾分析2000-2016年收治的148例T4期、改良根治术后放疗的乳腺癌患者资料,胸壁放疗加量组57例,不加量组91例。放疗采用常规+胸壁电子线、三维适形+胸壁电子线、调强放疗+胸壁电子线照射,加量组EQD2>50Gy。全组患者均接受新辅助化疗。Kaplan-Meier法生存分析并Logrank检验差异,Cox模型多因素预后分析。结果中位随访时间67.2个月,5年胸壁复发(CWR)、局部区域复发(LRR)、无瘤生存(DFS)、总生存(OS)率分别为9.9%、16.2%、58.0%、71.4%。胸壁放疗加量和不加量的5年CWR、LRR、DFS、OS率分别为14%和7%、18%和15%、57%和58%、82%和65%(P>0.05)。多因素分析显示胸壁加量与否对预后无显著影响(P>0.05)。45例复发高危组患者中放疗加量组似乎有较高的OS率(P=0.058)、DFS率(P=0.084)和较低的LRR率(P=0.059)。结论T4期乳腺癌患者异质性较强,胸壁放疗加量对全组患者无明显获益。对于有脉管瘤栓阳性、pN2-N3、激素受体阴性中2~3个高危因素患者胸壁放疗加量有改善疗效趋势。     

Primary radiotherapy of breast cancer: treatment results in locally advanced breast cancer and in operable patients selected by positive axillary apex biopsy.

To evaluate the efficacy of radiotherapy without surgery, treatment results in patients treated for locally advanced breast cancer (n = 209) and those selected by positive axillary apex biopsy (n = 289) in the period between 1977 and 1985 have been analysed retrospectively. Treatment consisted of primary irradiation to the breast and regional lymph nodes followed by a boost to the primary breast tumour and palpable regional disease to a mean normalised total dose (NTD) of 64.7 Gy with a range of 33.4-93 Gy (2 Gy fractions, alpha/beta = 5 Gy). Adjuvant systemic treatment was given in 30% of the locally advanced and in 40% of the apex positive patients. Thirty percent of the apex positive patients had an excisional biopsy of the breast tumour. By multivariate analysis a prognostic index is constructed for locoregional control, overall survival and distant disease-free interval. Primary tumour size and clinical nodal status are independent prognostic factors for locoregional control. Based on the prognostic index for local control four different groups can be identified with 5 year local control rates varying from 47 to 86%. Patients treated with adjuvant chemotherapy and patients irradiated to a NTD of 60 Gy or more had significantly better local control. For overall survival primary tumour size, clinical nodal size and age are independent prognostic factors. Patients irradiated to a NTD above 60 Gy had significantly better results. Survival according to the prognostic index for survival varies between 20 and 50% at 5 years for the four groups subdivided according to the index for survival. Primary tumour size, clinical node size and age are independent prognostic factors for distant disease-free interval. Patients treated with adjuvant hormonal therapy had significantly better results. In the four groups subdivided according to the prognostic index for distant disease-free interval results vary from 17 to 30% at 5 years.     

Multi-institutional review of repeat irradiation of chest wall and breast for recurrent breast cancer

PURPOSE: To review the toxicity and clinical outcomes for patients who underwent repeat chest wall or breast irradiation (RT) after local recurrence. METHODS AND MATERIALS: Between 1993 and 2005, 81 patients underwent repeat RT of the breast or chest wall for locally recurrent breast cancer at eight institutions. The median dose of the first course of RT was 60 Gy and was 48 Gy for the second course. The median total radiation dose was 106 Gy (range, 74.4-137.5 Gy). At the second RT course, 20% received twice-daily RT, 54% were treated with concurrent hyperthermia, and 54% received concurrent chemotherapy. RESULTS: The median follow-up from the second RT course was 12 months (range, 1-144 months). Four patients developed late Grade 3 or 4 toxicity. However, 25 patients had follow-up >20 months, and no late Grade 3 or 4 toxicities were noted. No treatment-related deaths occurred. The development of Grade 3 or 4 late toxicity was not associated with any repeat RT variables. The overall complete response rate was 57%. No repeat RT parameters were associated with an improved complete response rate, although a trend was noted for an improved complete response with the addition of hyperthermia that was close to reaching statistical significance (67% vs. 39%, p = 0.08). The 1-year local disease-free survival rate for patients with gross disease was 53% compared with 100% for those without gross disease (p < 0.0001). CONCLUSIONS: The results of our study have shown that repeat RT of the chest wall for patients with locally recurrent breast cancer is feasible, because it is associated with acceptable acute and late morbidity and encouraging local response rates.     

Local control and outcome of patients irradiated for isolated chest wall recurrences of breast cancer

Between January 1970 and December 1978, 149 breast cancer patients with isolated chest wall recurrences developing after initial curative treatment (mastectomy with or without postoperative irradiation) were referred to the University Clinic for Radiotherapy and Radiobiology of Vienna. Following radiotherapy, survival was analysed in 134 patients with regard to the amount of disease in the chest wall at the time of treatment and local tumour control. Patients with "subclinical" disease (after excision of solitary recurrences) had a median survival time of 55 and 50 months for controlled and uncontrolled disease in the entire chest wall, respectively. The corresponding survival times for patients with "macroscopic" chest wall disease was 36 and 25 months, respectively. Local tumour control within the irradiated field was 69% for patients with subclinical disease and 49% for patients with macroscopic tumour manifestation. Freedom from tumours in the entire chest wall could be achieved in 41% of patients with subclinical and 24% of patients with macroscopic disease. The 5-year survival rate for patients with subclinical disease, with tumour control in the entire chest wall is 53%. Of all 134 patients, 22% survived 5 years from the time of local recurrence.     

Outcomes in breast cancer patients relative to margin status after treatment with breast-conserving surgery and radiation therapy: the University of Pennsylvania experience

Purpose: To evaluate the significance of final microscopic resection margin status on treatment outcomes in women with early breast cancer who are treated with breast-conserving surgery and definitive breast irradiation.

Methods and Materials: An analysis was performed of 1021 consecutive women with clinical Stage I or II invasive carcinoma of the breast treated with breast-conserving surgery and definitive breast irradiation. Complete gross excision of tumor was performed in all cases, and an axillary staging procedure was performed to determine pathologic axillary lymph node status. The 1021 patients were divided into four groups based on the final microscopic margin from the tumor excision or from the re-excision if performed. These four groups were: (a) 518 patients with negative margins; (b) 124 patients with focally positive margins; (c) 96 patients with focally close margins (≤ 2 mm); and (d) 283 patients with unknown margins.

Results: Local failure was not significantly different in patients with negative, focally positive, focally close or unknown final pathologic margins of resection at 8 years (8% vs. 10% vs. 17% vs. 16%, respectively, p = 0.21). The 8-year outcome also was not different among the four groups for overall survival (86% vs. 83% vs. 88% vs. 81%, respectively, p = 0.13), cause-specific survival (89% vs. 86% vs. 88% vs. 83%, respectively, p = 0.14), no evidence of disease survival (81% vs. 73% vs. 86% vs. 77%, respectively, p = 0.09), and freedom from distant metastases (85% vs. 75% vs. 86% vs. 79%, respectively, p = 0.08).

Conclusion: These results demonstrate that selected patients with focally positive or focally close microscopic resection margins can be treated with breast-conserving surgery and definitive breast irradiation with 8-year local control rates and survival rates that are similar to those seen in breast-conservation patients with negative or unknown final resection margins.     

乳腺癌根治术后单纯胸壁复发放疗和胸壁再复发的预后分析

目的 探究乳腺癌根治术后单纯胸壁复发(ICWR)患者的照射野及剂量选择,同时分析胸壁再复发的预后因素。方法 回顾性分析1998—2018年间解放军总医院第五医学中心和医科院肿瘤医院收治的乳腺癌改良根治术后ICWR患者 201例,患者术后均未行辅助放疗。胸壁复发后 48例(73.6%)患者接受手术治疗,155例(77.1%)患者接受放疗。无进展生存(PFS)率的计算采用Kaplan-Meier法和log-rank检验,多因素分析采用Cox回归法。胸壁再复发的计算采用竞争风险模型和Gray检验,多因素分析采用F&G回归法。结果 复发后中位随访时间92.8个月,5年PFS率为23.2%,5年胸壁再复发率为35.7%。多因素分析显示联合手术+放疗和复发间隔时间>12个月患者有较低的胸壁再复发率,复发间隔时间>48个月、联合局部+全身治疗及联合手术+放疗的患者有较高PFS率。155例患者ICWR后接受胸壁放疗,全胸壁照射+局部补量比全胸壁照射可以改善首次胸壁复发后的 5年PFS率(34.0%∶15.4%,P=0.004)。胸壁放疗剂量(≤60Gy∶>60Gy)对胸壁再复发率及PFS率无明显影响(P>0.05)。53例未手术患者胸壁瘤床剂量≤60Gy和>60Gy的 5年PFS率分别为9.1%和20.5%(P=0.061)。结论 乳腺癌根治术后ICWR患者局部放疗建议包括全胸壁照射+局部补量,复发灶剂量需加至60Gy,对未行手术切除者需>60Gy。ICWR患者仍有较高的胸壁再复发风险,需要探索更有效的治疗方法。     

Electron arc irradiation of the postmastectomy chest wall with CT treatment planning: 20-year experience.

PURPOSE: Since 1980, electron arc irradiation of the postmastectomy chest wall has been the preferred radiotherapy technique at the University of Utah for patients with advanced breast cancer. We report the results of this technique in 156 consecutive Stage IIA-IIIB patients treated from 1980 to 1998. METHODS: CT treatment planning was used in all patients to identify chest wall thickness and internal mammary lymph node depth. Computerized dosimetry was used to deliver total doses of 50 Gy in 5-1/2 weeks to the chest wall and the internal mammary lymph nodes with electron arc therapy. Patients were assessed for local, regional, and distant control of disease and for survival. Univariate and multivariate proportional hazards were modeled using a hierarchical nonproportional semiparametric model testing the following prognostic factors: age, stage, tumor size, number of positive lymph nodes, estrogen receptor status, and dose. End points evaluated included disease-free survival, cause-specific survival, and overall survival. RESULTS: Eighty-one percent of patients were at high risk for local-regional failure because of > T2 primary tumor or > 3 positive axillary lymph nodes. The median number of positive lymph nodes was 5, and the median tumor size was 3.5 cm. Actuarial 10-year local-regional control and overall survival were 95% and 52%, respectively. In multivariate analysis, the only factor prognostic for disease-free survival, cause-specific survival, and overall survival was the number of positive lymph nodes (p < 0.001). The 10-year rates of local-regional control for patients with 0, 1-3, 4-9, and > or = 10 involved lymph nodes were 100%, 98%, 93%, and 89%, respectively. The only rates of acute and chronic radiotherapy toxicity > or = 2 by RTOG/EORTC criteria were skin related and observed in 44% and 10% for acute and late reactions, respectively. CONCLUSION: These data demonstrate excellent local-regional control rates with electron arc therapy of the postmastectomy chest wall in patients with advanced breast cancer. Our 20-year experience with electron arc radiotherapy has demonstrated the safety and efficacy of this technique. The advantage of this technique is that the internal mammary lymph node chain can be easily encompassed while the dose to heart and lung is minimized; it also obviates match lines in areas of high risk.     

Aichi Cancer Center 10-year experience with conservative breast treatment of early breast cancer: retrospective analysis regarding failure patterns and factors influencing local control

Purpose: We analyzed the clinical results of conservative breast therapy in our institute to determine the risk factors influencing local and distant disease recurrence.

Methods and Materials: From 1989 to 1997, 301 breasts of 295 women with early breast cancer were treated with conservative surgery and adjuvant radiotherapy. There were 212 incidences of Stage I breast cancer, and 89 of Stage II. Patients were routinely treated with local resection, axillar dissection, and 46–50 Gy irradiation given in 23–25 fractions. Some also received a radiation boost to the tumor bed.

Results: The 5-/8-year overall survival, disease-free survival, and local control rates were 93.2/91.5%, 86.0/80.6%, and 95.1/92.5%, respectively. Using both univariate and multivariate analyses, tumor volume, estrogen receptor status, and age < 40 years were significant prognostic factors for disease-free survival. Both age < 40 years and surgical method had a strong effect on local control by uni- and multivariate analysis. Surgical margin status was a significant prognostic factor for local control at the univariate level (p < 0.0001), though it had only borderline significance at the multivariate level (p = 0.08). No patient experienced severe morbidity due to radiotherapy.

Conclusion: The results obtained are comparable to previously reported data. Although the follow-up period was too short to draw definite conclusions about long-term outcomes, the outcome from conservative breast treatment was acceptable.     

乳腺癌术后胸壁低分割放疗的长期疗效观察

目的探讨乳腺癌术后胸壁低分割放疗的长期疗效和不良反应。方法 106例Ⅱ、Ⅲ期（UICC,1989）乳腺癌患者,均为首次治疗,手术方式为根治术或改良根治术。术后胸壁放疗采用6 MeV电子线,3.6Gy/次,隔日照射,3次/周,总剂量为39.6 Gy,分11次,近4周完成。结果随访时间为61～160个月,中位随访时间为106.7个月。低分割放疗后5年胸壁复发7例（6.6%）,5年无瘤生存率为67.9%（72/106）,5年总生存率为74.5%（79/106）,10年总生存率为74.5%（79/106）。急性皮肤湿性反应发生率为4.7%（5/106）,晚期中上肺部局部放射性纤维化发生率为5.1%（4/78）。结论低分割放疗与常规照射方案比较,疗效相当,早晚期不良反应无明显增加。     

3-D Conformal Photon Boost in the Treatment of Early Stage Breast Cancer: Four Year Follow Up Results

In the treatment of early stage breast cancer, breast conserving surgery (BCS) followed by whole breast irradiation (WBI) is the standard treatment. The impact of the tumor bed boost following WBI is well-defined, but there are various delivery methods. In this study we demonstrate our 4?year experience with the 3-D conformal boost technique. Between January 2004 and June 2005, 77 early stage (Stage I?CII) breast cancer patients were treated in our institute with whole breast irradiation (WBI, 50.4?Gy in 28 fractions) after breast conserving surgery. Following WBI, 3-D conformal photon boost was delivered (10?C16?Gy in five to eight fractions) for all patients. The clinical outcome was retrospectively recorded in terms of survival and local control. The side effect profile (fibrosis, fat necrosis and cosmetic outcome) was also recorded and studied. In our patient group the mean follow up time was 46.8?months (median: 52, range: 17?C71, SD: 14.4) The 4-year probability of local tumor control was 96% (crude rate: 74/77?C96.1%), the 4-year probability of overall survival was 96% (crude rate: 74/77?C96.1%) in this patient group. In case of the distant metastasis free survival the probability was 89, 5% (crude rate: 70/77?C90, 1%). Probability of disease specific survival was 98% (crude rate: 76/77?C98. 7%). Local relapse occurred in three cases (3.9%). In ten cases (12.9%) asymptomatic grade I?CII breast fibrosis, in eight cases (10.4%) asymptomatic breast fat necrosis were registered. For 14 patients (18.2%) asymptomatic lung fibrosis was recorded on the control CT scans. In term of the relapse free survival, the close resection margin and the nodal positivity resulted in significant difference in favor of the clear resection margin group and the node negative group. In this study the 3-D conformal photon boost resulted in good local control and side effect profile. The presence of tumor bed clips resulted in significantly lower boost PTV volumes, but no correlation was found between the irradiated boost volume and the breast fibrosis. In the relapse free survival analysis, nodal negativity and clear margin status resulted in significantly better RFS.