Partial breast irradiation for locally recurrent breast cancer within a second breast conserving treatment: Alternative to mastectomy? Results from a prospective trial

Purpose

To assess the outcome of multi-catheter pulse dose rate (PDR) brachytherapy of re-irradiation for local ipsilateral breast tumour recurrence (IBTR) in regard to local control, survival, morbidity and quality of life (QoL).

Patients and methods

Between 1999 and 2006, 39 patients were included with histologically confirmed IBTR, Karnofsky index ?80% and refusal of mastectomy. Exclusion criteria were multicentric invasive growth pattern, unclear surgical margins, distant metastasis and a postoperative breast not suitable for interstitial brachytherapy. Primary endpoint was local tumour control. Morbidity, cosmetic outcome and QoL were assessed in 24/39 patients.

Results

The five year actuarial local control rate was 93% after a mean follow up of 57 (±30) months with two second local relapses. Overall survival and disease free survival, both at 5 years, were 87% and 77%, respectively. Late side effects Grade 1-2 were observed in 20/24 patients after a mean follow-up of 30 (±18) months. Late side effects ?Grade 3 occurred in 4/24 patients. Cosmetic outcome was excellent to fair in 76% of women. Overall QoL was comparable to a healthy control group. Mean scores of scales and items of QLQ-BR23 were comparable to primary breast conserving therapy.

Conclusions

Accelerated PDR-brachytherapy following breast conserving surgery (BCS) for local IBTR results in local tumour control comparable to mastectomy. Morbidity is moderate; the cosmetic outcome is good and hardly any impairment on QoL is observed.     

Ipsilateral breast recurrence after breast conserving surgery in patients with small (≤2 cm) breast cancer treated with modern adjuvant therapies

Background

Modern multimodality treatment greatly influences the rate and the predictive factors for ipsilateral cancer recurrence (IBR) after breast conserving surgery.

Material and nethods

The study is based on 1297 patients with pT1 breast cancer and treated with breast conserving surgery in February 2001-August 2005. The median duration of follow-up was 57 months.

Results

IBR occurred in 27 (2.1%) patients. It was located in the quadrant of prior breast resection in 17 (63%) cases. The median time to an IBR was 41 months (range, 6-78) regardless of whether the recurrence was located in the same or in another quadrant. Omission of radiotherapy was associated with a higher IBR incidence, HR 10,344 (95% CI 1904-56,184; p = 0.007). The IBRs occurred particularly often, in 27% of the 11 patients who refused radiotherapy. Patients diagnosed with ER+ cancer had a lower risk of IBR when compared with those with ER−/HER2+ cancer, HR 0.215 (95% CI 0.049-0.935; p = 0.040).

Conclusions

The risk of IBR was low during the first 5 years after breast resection among patients with pT1 breast cancer and treated with modern surgical and adjuvant therapies. The majority IBRs still occur at or close to the prior resection site underlining the importance of local therapies. Omission of radiotherapy was the most significant risk factor for IBR.     

Breast conserving surgery after neoadjuvant therapy for large primary breast cancer

Aim

The aim of this study was to evaluate the safety of breast conserving surgery in patients with breast tumours satisfactorily downstaged after neoadjuvant therapy.

Methods

A retrospective cohort study was undertaken to analyze the loco-regional recurrence (LRR) after breast conserving surgery. We enrolled 88 patients with breast cancer subjected to neoadjuvant therapy (NAT group) who achieved an objective response due to neoadjuvant treatment and compared them with 191 patients with early breast cancer (EBC group) who were submitted to primary conserving surgery. Lumpectomy or quadrantectomy with axillary lymph node dissection was performed in all patients who received adjuvant radiotherapy. Systemic adjuvant therapy was offered to all patients. The mean periods of observation were 61.3 months in the NAT group and 67.5 months in the EBC group.

Results

The mean age was 53 years in the NAT group and 56 years in the EBC group (p = 0.04). There was no histological type and histological grade difference between groups. In the NAT group, the mean diameter of residual tumour was lower and the mean volume of breast tissue resection was higher than in the EBC group (p = 0.01 and p = 0.002, respectively). The ipsilateral recurrence rate was 7.9% in the NAT group and 7.8% in the EBC group (p = 0.9). The most important predictive factor of recurrence in the NAT group was the age of patient.

Conclusion

Breast conserving therapy is a safe procedure in satisfactorily downstaged breast cancer after neoadjuvant therapy.     

Nomogram to predict ipsilateral breast relapse based on pathology review from the EORTC 22881-10882 boost versus no boost trial

Background and purpose

The EORTC 22881-10882 trial showed that for patients treated with breast conserving therapy (BCT), a 16 Gy boost dose significantly improved local control, but increased the risk of breast fibrosis. A model to estimate the risk of ipsilateral breast relapse (IBR) already exists, but now a model has been developed which takes boost treatment into account and is based on centrally reviewed pathology.

Materials and methods

A Cox model was developed based on central pathology review data and clinical data of 1603 patients from the EORTC 22881-10882 trial with a median follow-up of 11.5 years. From a predefined set of variables, predictors with a maximal effect on 10-year IBR rate >4% were retained in the model. Bootstrap re-sampling was used to assess model calibration and discrimination. The results are presented in the form of a nomogram.

Results

Apart from young age and no boost, presence of DCIS adjacent to the invasive tumor was associated with increased risk of IBR (HR 1.96, p = 0.001). Patients with high grade invasive tumors were younger than patients with low/intermediate grade (p < 0.0001). The nomogram includes histologic grade, DCIS, tumor diameter, age, tamoxifen, chemotherapy, and boost with a concordance probability estimate of 0.68.

Conclusions

The nomogram for predicting IBR 10 years after BCT includes seven factors, with young age, presence of DCIS and boost treatment as the most dominant factors. The nomogram estimates IBR and confirms the importance of a boost dose. Combined with a model to predict fibrosis published previously, the nomogram presented here may assist in decision making for individual patients.     

The influence of the use of CT-planning on the irradiated boost volume in breast conserving treatment

Background and purpose

The purpose of this study was to investigate the effect of CT-based delineation and planning on the irradiated boost volume. For this specific purpose we used the data as derived from 2 prospective phase III randomised trials.

Patients and methods

Data from 1331 patients (?50 years) were analyzed with a reported boost volume from a simulation-based treatment plan (EORTC boost vs no boost trial, n = 922), and a CT-scan-based treatment plan (Young Boost Trial, n = 409) group. Tumour diameter, irradiation technique (photons vs electrons), lumpectomy size, and age were used as covariates.

Results

Median V_95% in the conventional simulation-based treatment plans was 99 cc (range 9-628) for photons and was 98 cc (13-651) for electrons, whereas in the CT-planned patients, these figures were 178 cc (37-2699) and 150 cc (43-1272), respectively. Multivariable analysis showed an association of the irradiated boost volume with tumour size (p < 0.0067), lumpectomy size (p < 0.0002), and boost technique (p < 0.0004). The use of a CT-scan for volume delineation and treatment planning remained significant (p < 0.0001).

Conclusions

The use of a CT-scan for delineation and treatment planning led to a significant increase of the irradiated boost volume by a factor of 1.5-1.8, compared to conventional simulator-based plans.     

Early primary breast cancer in the elderly - Pattern of presentation and treatment

Introduction

The incidence of primary breast cancer in elderly patients is increasing. However, little is known about their biological profile and most appropriate clinical management, as most studies have been conducted in the younger population. This study aimed to identify a profile of characteristics in elderly women with operable primary breast cancer and investigate the dynamics influencing the treatment decision-making process.

Methods

A review of 268 consecutive female patients >70 years of age, diagnosed with early operable primary breast cancer (<5 cm) over a 30-month period at the Nottingham Breast Institute, was conducted. Age, co-morbidity, cancer characteristics, treatment offered and undertaken, and reason for patient choice were recorded and analysed.

Results

The median age was 78 (range 70-100) years. In our study, 82% of the patients had one or more co-morbidities, with 34% of them having three or more co-morbidities. The commonest pathological diagnosis (from needle core biopsies) was invasive ductal carcinoma of no special type (76%) with histological grade 2 (64%). Majority of them were oestrogen receptor (ER)-positive (84%) and had a high histochemical (H)-score (83% with H-score >200).Most of the patients (60%) underwent primary surgical management, of which 45.4% received breast-conserving surgery. Among the patients who had breast-conserving surgery, 68% of them received adjuvant radiotherapy. When offered genuine choice in treatment options, most patients chose non-operative treatment. Patients who underwent non-operative treatment were on average seven years older and had significantly more co-morbidities than those who had surgery.

Conclusion

The elderly population evidently have demographic and cancer characteristics distinct from their younger counterparts, with less patients receiving surgical management. Further work is underway to correlate this with their clinical outcomes and to examine the factors behind the treatment decision-making process.     

Long term follow-up and risk of breast cancer after a radial scar or complex sclerosing lesion has been identified in a benign open breast biopsy

Aims

Radial scars (RS)/complex sclerosing lesions (CSL) are rare, benign breast lesions of unknown aetiology. Associations with breast cancer have been suggested particularly with larger lesions. This study aims to identify the risk of developing subsequent breast cancer after excision of a benign RS/CSL with respect to lesion size and compared to expected rates in the normal UK population.

Methods

A prospective cohort analysis was performed on patients diagnosed with RS/CSL in benign, open breast biopsy specimens over a 20-year period. The rate of subsequent breast cancer development was compared to expected rates in the normal UK population. Subjects were divided into two groups according to lesion size and the rates of subsequent breast cancer compared.

Results

149 women without proliferative breast disease were followed for an average of 68 months. Five women developed subsequent cancer, equating to a rate of 0.84% per year. This compares to 0.32% per year in the normal population (RR 2.6, 95% CI 0.86-6.0). There were two subsequent cancers in the RS group and three subsequent cancers in the CSL group, P = 0.64.

Conclusions

The study finds no evidence to suggest that lesions greater than 10 mm (CSL) have any greater risk of developing cancer after excision than those below 10 mm (RS). Women treated for RS/CSL do not need any additional follow-up beyond routine mammographic breast screening. Additional surveillance should only be performed if there is associated pathology indicating an increased risk of subsequent malignancy.     

Tumour bed clip localisation for targeted breast radiotherapy: Compliance is proportional to trial-related research activity: Tumour bed clip localisation in breast radiotherapy

Background

In breast cancer, with the increasing use of intensity-modulated radiotherapy (IMRT), the need for accurate tumour bed localisation is paramount. We determined current practice of clip usage in patients referred to a regional centre for radiotherapy following breast conserving surgery. We also investigated whether participation of surgical units in IMRT trials, where tumour bed clip use is emphasised, was associated with clip insertion.

Methods

A retrospective cohort study of consecutive CT planning images (n = 205), of breast cancer patients treated with radiotherapy following breast conserving surgery. Presence and number of clips; referring hospital and referring surgeon of the patient was recorded. This was correlated to previous participation of referring hospital to IMRT trials.

Results

Of 196 eligible patients, 126 (64%) had clips sited, of which 15 (12%) had two or fewer clips. Five referring hospitals were high recruiters (≥14 patients), and five hospitals were low/non-recruiters (≤1 patient) to IMRT trials. Of patients from low/non-recruiting centres, 29 of 43 (67%) had clips omitted, compared to 41 of 153 (27%) from high-recruiting centres (p < 0.001). Median number of clips used in centres recruiting high numbers of patients was four, compared to zero in low recruiting centres. Ten of 31 referring surgeons routinely omitted clips.

Conclusion

Despite inclusion in national guidelines, clip insertion has not become routine in the UK in patients undergoing breast conserving surgery. However, hospitals involved in breast radiotherapy randomised controlled trials are more compliant with clip usage recommendations. Auditing of clip insertion should be considered as a quality control marker in breast surgery.     

Treatment of stage I NSCLC in elderly patients: A population-based matched-pair comparison of stereotactic radiotherapy versus surgery

Background

Elderly patients with stage I NSCLC who undergo surgical resection are at high risk of treatment-related toxicity. Stereotactic body radiation therapy (SBRT) may provide an alternative treatment with a favorable toxicity profile.

Methods

A population-based registry in North-Holland was used to conduct a matched-pair analysis of overall survival (OS) after surgery versus SBRT for elderly patients (age ?75) who were diagnosed between 2005 and 2007. Patients were matched by age, stage, gender, and treatment year; co-morbidity data was not available. SBRT was delivered at two centers; 17 centers provided surgery.

Results

A total of 120 patients could be matched (60 surgery, 60 SBRT). Median age was 79 years, 67% were male, and 64% had T1 disease. Median follow-up was 43 months. Thirty-day mortality was 8.3% after surgery and 1.7% after SBRT. OS at one- and three-years was 75% and 60% after surgery, and 87% and 42% after SBRT, respectively (log-rank p = 0.22). Limiting the analysis to SBRT patients with pathological confirmation of disease and their matches revealed no significant difference between groups.

Conclusion

Similar OS outcomes are achieved with surgery or SBRT for stage I NSCLC in elderly patients. Comorbidity data and outcomes from centralized surgical programs are needed for more robust conclusions.     

Prospective evaluation of quality of life after permanent prostate brachytherapy with I-125: Importance of baseline symptoms and of prostate-V150

Background and purpose

Detailed knowledge of quality of life (QoL) after permanent I-125 brachytherapy may aid in counselling patients with early-stage prostate cancer.

Materials and methods

Seventy-four consecutive patients with low-risk prostate cancer were asked to complete the EORTC QLQ-C30 questionnaire with the prostate-specific PR25 module before implant, four weeks and one year after implant (response rates 97%, 88% and 89%, respectively). Implant characteristics were correlated with QoL scores.

Results

Global QoL was stable from pre-treatment to one year after implant and similar to age-adjusted scores of healthy controls. Significant changes versus baseline in QLQ-C30 domains were worsened social function at four weeks, increased constipation at four weeks and at one year and improved emotional function at one year. PR25 urinary symptoms were significantly increased at four weeks and, despite some improvement, at one year; bowel symptoms were slightly increased. Both types of symptoms were most strongly related with pre-treatment symptom scores. Prostate-V150 was the only implant parameter significantly associated with both urinary and bowel symptoms at four weeks and one year.

Conclusions

Limiting the high-dose subvolume in the prostate may be beneficial to reduce urinary and bowel symptoms but the major determinant of symptoms after I-125 implant is the baseline symptom level.     

Surgery in metastatic breast cancer: Patients with a favorable profile seem to have the most benefit from surgery

Introduction

About 3-10% of breast cancer patients have distant metastases (Stage IV) at initial presentation; standard treatment (in the Netherlands) of these patients consists of palliative systemic therapy. However, retrospective studies have shown an improved survival in patients who received surgery for their primary tumor. The aim of this study was to assess characteristics associated with surgical treatment and to determine the impact on survival in women with stage IV breast cancer.

Methods

A cohort of women with a diagnosis of breast cancer and concomitant distant metastases was retrospectively studied. Patient characteristics, treatment and survival distilled from medical files were evaluated using univariate and multivariable analysis.

Results

Of 171 patients included in this analysis, 59 underwent surgery. In multivariable analysis lower age, no medication use, lower clinical T-stage and lower grade were associated with receiving surgery. In 21 of the 59 patients (35%) who received surgery it was unknown at the time of surgery that the patient had metastatic disease. Stratified survival analyses showed an association between surgery and improved survival for young patients (HR 0.3; p = 0.02), without comorbidity (HR 0.4; p = 0.002), with no medication use (HR 0.5; p = 0.009), with a small tumor (HR 0.4; p = 0.01), no regional lymph node involvement (HR 0.4; p = 0.01), with positive Estrogen (HR 0.6; p = 0.02) or Progesterone receptor (HR 0.4; p = 0.03) and with only visceral metastases (HR 0.5; p = 0.03). In multivariable analyses, younger patients and patients without comorbidity that received surgery had an increased survival (HR 0.3; p = 0.03 and HR 0.5; p = 0.03, respectively).

Conclusion

This study showed that patients with the most favorable profile receive local surgery and that a survival gain for operated patients was seen in young patients and in patients without comorbidity.     

Positive or close margins in breast conserving surgery: Is re-excision always necessary?

Background

More than half of re-excision specimens after breast conserving surgery (BCS) are found to be free of residual tumor at definitive histology. The aim of this study was to identify clinicopathological factors along with intrinsic subtypes of the tumor (luminal A, luminal B, HER2-overexpressing, triple-negative) associated with residual tumor in re-excision or mastectomy specimen.

Methods

Two hundred forty-eight patients with initial BCS, who underwent one or more re-excisions or mastectomy because of close or positive margins were reviewed.

Results

Residual cancer was found in 50% of re-excision(s) or mastectomy specimens. Patients with multifocality (vs unifocality; OR = 5.2; 95% CI, 2.6–10.4) or positive nodes (vs negative nodes; OR = 2.5; 95% CI, 1.4–4.4), or positive margins (vs close margins; OR = 1.7; 95% CI = 1.0–2.9) were more likely to have residual tumor in re-excision or mastectomy specimen compared to others.

Conclusion

Our results suggest that further surgery is often indicated in patients with node positive or multifocal cancers or positive margins after BCS since residual disease cannot be ruled out. Re-excision or mastectomy could be omitted in patients with close margins with favorable factors such unifocal tumor or node negative disease.     

Palliative partial pancreaticoduodenectomy impairs quality of life compared to bypass surgery in patients with advanced adenocarcinoma of the pancreatic head

Background

Some surgical centres consider palliative resection (PR) to be superior to double loop bypass (DLB) as treatment for advanced carcinoma of the pancreatic head. We performed a retrospective study with prospectively collected data at a single centre to compare PR and DLB in regard to quality of life (QoL).

Methods

From January 1996 to September 2008, 196 patients were given palliative surgery for advanced pancreatic cancer at the University Hospital of Kiel. Forty-two patients underwent PR and 154 underwent DLB. These groups were compared with regard to survival, post-operative morbidity, and QoL. The EORTC QLQ-C30 was used to assess QoL before surgery, at discharge, three months after surgery, and six months after surgery.

Results

The median survival time after PR was 7.5 months (95% CI: 4.95-10.05) and after DLB was 6 months (95% CI: 4.98-7.02; log rank test: p = 0.066). There were no significant differences in mortality and morbidity rates (7.1% and 45.2% for PR; 3.9% and 38.3% for DLB, respectively). Assessment of QoL indicated that patients who underwent PR had more impairment of some functional metrics and increased symptoms compared to those who underwent DLB.

Conclusion

There was no significant difference in survival or morbidity after PR and DLB, but patients who underwent DLB had better QoL than patients who underwent PR. Therefore, clinicians may want to reconsider the use of PR for patients with advanced pancreatic cancer.     

Re-evaluating the role of palliative radiotherapy in malignant pleural mesothelioma

Purpose

To determine the objective response rate of malignant pleural mesothelioma (MPM) to short course radiation therapy.

Methods

We reviewed the cases of 54 patients with advanced MPM who were treated with palliative radiotherapy according to a standardised institutional policy. Pre- and post-treatment computed tomography scans were used to assess response.

Results

Fifty-seven percent of patients reported some improvement in their symptoms following radiotherapy. The radiology response rate was 43% (22 patients had a partial response and 1 patient a complete response). Response to treatment was correlated with the European Organisation for Research and Treatment of Cancer (EORTC) prognostic index (p = 0.001), performance status (p = 0.02) and histological subtype (p = 0.04). In the EORTC good prognosis group 56% of patients responded, compared with only 7% in the poor prognosis group (p = 0.001). The median survivals from diagnosis and from the start of radiotherapy were 11.3 months and 5.2 months, respectively. Survival following treatment was correlated with the EORTC prognostic index (p < 0.001), histological subtype (p < 0.001), performance status (p = 0.001), treatment response (p = 0.002) and haemoglobin level (0.02). The EORTC good and poor prognostic groups had survivals of 7.1 and 2.1 months, respectively (p < 0.001). Neither tumour volume nor stage were associated with prognosis.

Conclusions

Palliative radiotherapy produces a response rate in MPM that is equivalent to chemotherapy. The EORTC prognostic index can be used to select patients who are most likely to benefit from this treatment.     

Long-term experience with transrectal and transperineal implantations of fiducial gold markers in the prostate for position verification in external beam radiotherapy; feasibility, toxicity and quality of life

Background and purpose

This study presents an overview of the experience with transrectal and transperineal implantations of fiducial markers for position verification in prostate radiotherapy, regarding the practical feasibility, procedure-related toxicity and influence on quality of life (QoL).

Material and methods

Since 2001, 914 patients scheduled for intensity-modulated radiotherapy (IMRT) have received gold markers in the prostate. The incidence of severe toxicity, defined by the CTCAE v3.0, was evaluated retrospectively. The influence on QoL was measured prospectively in 36 patients using a combination of three validated questionnaires: the Rand-36, the EORTC QLQ-C30(+3) and the prostate cancer-specific EORTC QLQ-PR25. Next, the incidence of marker migration was assessed.

Results

From 2001 to 2005, 402 patients received markers via the transrectal route. Two of these patients developed urosepsis (grade 3 toxicity). Since 2005, 512 patients received markers via the transperineal route. No grade 3 or 4 toxicity occurred in this group. No significant and clinically relevant differences were found in QoL between pre- and post-implant measures. In 5 patients marker migration led to discontinuation of the marker-based IMRT.

Conclusions

Clinical use of transperineal-implanted fiducial gold markers for position verification in external beam radiotherapy for prostate cancer is a feasible and safe procedure without influencing patients’ QoL.     

Role of MRI (magnetic resonance imaging) versus conventional imaging for breast cancer presurgical staging in young women or with dense breast

Aims

The role of magnetic resonance imaging (MRI) in the local staging of breast cancer is currently uncertain. The purpose of this prospective study is to evaluate the accuracy of preoperative MRI compared to conventional imaging in detecting breast cancer and the effect of preoperative MRI on the surgical treatment in a subgroup of women with dense breasts, young age, invasive lobular cancer (ILC) or multiple lesions.

Methods

Between January 2006 and October 2007, 91 patients with newly diagnosed breast cancer underwent preoperative clinical breast examination, mammography, bilateral breast ultrasonography and high-resolution breast MRI. All patients had histologically verified breast cancer. The imaging techniques were compared using the final pathological report as gold standard.

Results

The sensitivity of MRI for the main lesion was 98.9%, while for multiple lesions sensitivity was 90.7% and specificity 85.4%. After preoperative MRI, 13 patients (14.3%) underwent additional fine needle/core biopsies, 9 of whom had specimen positive for cancer. Preoperative MRI changed the surgical plan in 26 patients: in 19.8% of the cases breast conservative surgery was converted to mastectomy and in 7.7% of the patients a wider excision was performed. At a mean follow-up of 48 months, 2 local recurrences occurred (local failure rate = 2.5%).

Conclusions

Enhanced sensitivity of breast MRI may change the surgical approach, by increasing mastectomy rate or suggesting the need of wider local excision. MRI can play an important role in preoperative planning if used in selected patients with high risk of multifocal/multicentric lesions. However, the histologic confirmation of all suspicious findings detected by MRI is mandatory prior to definite surgery.     

Electronic portal images (EPIs) based position verification for the breast simultaneous integrated boost (SIB) technique

Background and purpose

To develop a method based on electronic portal images (EPIs) for the position verification of breast cancer patients that are treated with a simultaneous integrated boost (SIB) technique.

Method

3D setup errors of the breast outline and the thoracic wall were determined from EPIs of the tangential treatment fields and anterior posterior (AP) verification field. The method was verified with repeated CT scans of 38 patients with an average setup error larger than 5 mm.

Result

The 3D position deviation of the boost volume can best be determined from the position deviation of the breast outline in the ventrodorsal direction and the thoracic wall in the lateral and longitudinal directions from the tangential and AP EPIs. The method gives an average overestimation of the deviation of the boost volume in the ventrodorsal, lateral and longitudinal directions by 28%, 20% and 6%, respectively and an average underestimation of the deviation of the whole breast by 32%, 17% and 39%.

Conclusions

The described method is superior to using tangential EPIs only and is recommended for position verification of breast cancer patients that are treated with a SIB technique if no Cone beam CT (CBCT) or fiducial markers can be used.     

Treatment of recurrent central nervous system primitive neuroectodermal tumours in children and adolescents: results of a Children's Cancer and Leukaemia Group study

Background

The treatment of previously irradiated patients with recurrent central nervous system primitive neuroectodermal tumours (PNETs) is a considerable challenge. A study was undertaken to attempt to improve the outcome for such patients using a high dose chemotherapy (HDCT) based strategy.

Methods

Between 2000 and 2007, 40 patients with relapsed medulloblastoma (MB) and 5 with relapsed supratentorial PNETs (StPNETs) were accrued. All but one had received prior craniospinal radiotherapy. Patients were initially treated with cyclophosphamide (4 g/m²) together with surgery or local radiotherapy where appropriate. If complete or near complete remission was achieved, the patient proceeded to receive two sequential courses of HDCT with stem cell rescue. The first course consisted of thiotepa (900 mg/m²) and the second carboplatin (AUC 21).

Results

All five patients with StPNET died of tumour progression with a median OS of 0.4 years. Nineteen of the 40 patients with relapsed MB underwent surgery. Radiotherapy was administered to eight patients. All patients received at least one course of cyclophosphamide. Only 22 MB patients progressed to the HDCT phase; 10 patients received thiotepa only and 12 thiotepa and carboplatin. At a median follow-up of 7.4 years (Range 2.8-8.2 years), only three MB patients are still alive, one following a further relapse. Three and 5 year OS was 22.0% and 8.2%, respectively and 3 and 5 year EFS was 14.6% and 8.7%, respectively.

Conclusion

This national study based on a strategy including a particular tandem HDCT regimen showed no benefit for previously irradiated patients with relapsed StPNET and very limited benefit for patients with relapsed medulloblastoma.     

Localization of the surgical bed using supine magnetic resonance and computed tomography scan fusion for planification of breast interstitial brachytherapy

Purpose

To evaluate the feasibility of supine breast magnetic resonance imaging (MR) for definition and localization of the surgical bed (SB) after breast conservative surgery. To assess the inter-observer variability of surgical bed delineation on computed tomography (CT) and supine MR.

Materials and methods

Patients candidate for breast brachytherapy and no contra-indications for MR were eligible for this study. Patients were placed in supine position, with the ipsilateral arm above the head in an immobilization device. All patients underwent CT and MR in the same implant/treatment position. Four points were predefined for CT-MRI image fusion. The surgical cavity was drawn on CT then MRI, by three independent observers. Fusion and analysis of CT and MR images were performed using the ECLIPSE treatment planning software.

Results

From September 2005 to November 2008, 70 patients were included in this prospective study. For each patient, we were able to acquire axial T1 and T2 images of good quality. Using the predefined fusion points, the median error following the fusion was 2.7 mm. For each observer, volumes obtained on MR were, respectively, 30%, 38% and 40% smaller than those derived from CT images. A highly significant inter-observer variability in the delineation of the SB on CT was demonstrated (p < 0.0001). On the contrary, all three observers agreed on the volume of the SB drawn on MR.

Conclusion

Supine breast MRI yields a more precise definition of the SB with a smaller inter-observer variability than CT and may obviate the need for surgical clips. The volume of the SB is smaller with MRI. In our opinion, CT-MRI fusion should be used for SB delineation, in view of partial breast irradiation.     

Perioperative diagnosis of the positive axilla in breast cancer: A safe, time efficient algorithm

Background

This study evaluates the combined role of axillary ultrasound (Ax US), fine needle aspiration (FNAC) and intraoperative frozen section analysis of the sentinel node (FS SN) in a practical, time efficient algorithm to reduce the requirement for reoperation for axillary clearance in breast cancer in a busy tertiary unit.

Methods

Between October 2007 and June 2009 188 women underwent Ax US as a first investigation for nodal status. Suspicious nodes were biopsied, negative axillae proceeded to FS SN at time of primary breast surgery. All confirmed positive cases proceeded to immediate axillary clearance.

Results

93 women had positive axillary nodes at final histology. Ax US + FNAC identified 59 positive axillae and had a sensitivity of 63.4% and specificity of 100%. FS SN identified a further 26 cases with a sensitivity of 76.5% and specificity of 100%. Overall, only 8 women required reoperation for axillary clearance. Sensitivity for the combined procedures was 91.4%. Commencement of adjuvant therapy was significantly less in those women identified earlier compared to those requiring a second operation (23.3 days vs 49.0 days, p < 0.005).

Conclusion

95.7% of cases were diagnosed accurately in the perioperative period, preventing delay to triage to definitive oncological care and reducing requirement for costly reoperation.