Breast conservation for ductal carcinoma in situ: Results at an Australian institution with evidence to recommend prospective assessment of the utility of a lumpectomy boost

Aim: We reviewed outcomes for ductal carcinoma in situ (DCIS) of the breast at our institution to assess risk factors for ipsilateral breast tumour recurrence (IBTR) after breast conservation (BCT). Methods: Records were reviewed of all patients who presented with biopsy‐confirmed DCIS of the breast prior to 1 January 2004. Variables analyzed included patient age, tumour size, grade, resection margins, comedonecrosis, surgery, tamoxifen, whole breast radiotherapy dose and addition of a boost. We also attempted to validate the University of Southern California/Van Nuys prognostic index (USC/VNPI). Results: One hundred and thirty patients had DCIS: four were excluded from analysis and another 10 had mastectomies. A total of 116 patients had BCT and this group comprised the study population. Median follow‐up was 7.7 years (1.6–12.4) and median age was 58 years. Five‐ and 10‐year overall survivals were 98% (93.5–99.6 95% CI) and 89% (74–95 95% CI). Five‐ and 10‐year breast failure‐free survivals were 96% (90–98 95% CI) and 93% (85–97 95% CI). Young age was the only significant factor associated with IBTR (P = 0.018). Patients with a high USC/VNPI score were also significant for increased IBTR (P = 0.04), but this effect disappeared when age was omitted from the index. There was a trend towards an increased risk of IBTR with a lower whole breast dose of less than 50 Gy (P = 0.18). A boost was not associated with reduced IBTR. The 10‐year IBTR for patients under 55 who received adjuvant radiotherapy to a whole breast dose of <50 Gy but no tamoxifen was 25%. Conclusion: Overall BCT local control and survival outcomes are excellent. There is a suggestion that younger patients should be treated with a whole breast dose equivalent to 50 Gy in 25 daily fractions regardless of a boost. However, this requires confirmation in a randomized phase III trial and therefore the currently active Trans‐Tasman Radiation Oncology Group randomized controlled trial 07.01 should be supported by the breast cancer treating community.     

早期乳腺癌保乳术后全乳大分割照射同步瘤床加量的临床分析

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

The influence of the boost technique on local control in breast conserving treatment in the EORTC 'boost versus no boost' randomised trial.

BACKGROUND AND PURPOSE: The EORTC Trial 22881/10882 investigating the role of a boost dose in breast conserving therapy demonstrated a significantly better local control rate with the higher radiotherapy dose, especially in women younger than 50 years of age. This paper investigates the potential impact of the different boost techniques on local control and on fibrosis after breast conserving therapy. PATIENTS AND METHODS: From 1989 to 1996, 2661 patients were randomised to receive a boost dose of 16Gy to the primary tumour bed after microscopically complete tumorectomy and 50Gy whole breast irradiation. The choice of the boost technique was left to the treating investigator. Treatment data were prospectively recorded as well as the clinical outcome in terms of local control and fibrosis. Sixty-three percent of the patients received a boost dose with fast electrons, 28% with photon beams and 9% with interstitial brachytherapy. RESULTS: At 5 years, local recurrences were seen in 74 of the 1635 patients who received an electron boost (4.8%, CI 3.6-5.9%), in 28 of the 753 patients who received a photon boost (4.0%, CI 3.4-5.5%) and in 6 of the 225 patients after an interstitial boost (2.5%, CI 0.3-4.6%). The grade of fibrosis in the whole breast as well as at the primary tumour bed, as scored by the treating radiation oncologist, was similar in the three groups. CONCLUSIONS: Although the three groups are of a rather unequal size, the results of the interstitial boost seem similar in terms of fibrosis and at least as good in terms of local control, despite a lower treatment volume and a longer overall treatment time.     

基于VMAT的乳腺癌保乳术后全乳混合调强技术的建立与评价

目的 建立基于VMAT的乳腺癌保乳术后全乳混合调强技术并评价其临床应用价值。方法 选取10例乳腺癌保乳术后患者,分别基于固定角度IMRT的混合调强技术和基于VMAT的混合调强技术设计两组放疗计划。第1组仅以全乳作为放疗靶区,处方剂量50 Gy分25次完成;第2组以全乳及瘤床同步加量区为放疗靶区,处方剂量全乳50 Gy、瘤床同步加量区60 Gy,分25次同步完成。分别比较两组计划的剂量学参数及计划执行效率。配对t检验差异。结果 与基于固定角度IMRT的混合调强技术相比,基于VMAT的混合调强技术未能提高单纯全乳照射者靶区CI、HI值(P=0.866、0.056),反而全面增加了OAR受量和调强野机器跳数(P=0.000~0.050和P=0.002);但对全乳加瘤床同步加量照射患者,能减少肺受量、脊髓受量、调强野机器跳数、计划执行时间(P=0.004、0.001、0.000、0.000)。结论 对全乳加瘤床同步加量照射患者,基于VMAT的混合调强技术能更好保护OAR,提高计划执行效率,具有较高的临床应用潜力。     

Breast-conserving treatment with partial or whole breast irradiation for low-risk invasive breast carcinoma--5-year results of a randomized trial

PURPOSE: To report the 5-year results of a randomized study comparing the survival and cosmetic results of breast-conserving treatment with partial breast irradiation (PBI) or conventional whole breast irradiation (WBI). METHODS AND MATERIALS: Between 1998 and 2004, 258 selected patients with T1 N0-1mi, Grade 1-2, nonlobular breast cancer without presence of extensive intraductal component and resected with negative margins were randomized after breast-conserving surgery to receive 50 Gy/25 fractions WBI (n = 130) or PBI (n = 128). The latter consisted of either 7 x 5.2 Gy high-dose-rate (HDR) multicatheter brachytherapy (BT; n = 88) or 50 Gy/25 fractions electron beam (EB) irradiation (n = 40). RESULTS: At a median follow-up of 66 months, the 5-year actuarial rate of local recurrence was 4.7% and 3.4% in the PBI and WBI arms, respectively (p = 0.50). There was no significant difference in the 5-year probability of overall survival (94.6% vs. 91.8%), cancer-specific survival (98.3% vs. 96.0%), and disease-free survival (88.3% vs. 90.3%). The rate of excellent to good cosmetic result was 77.6% in the PBI group (81.2% after HDR BT; 70.0% after EB) and 62.9% in the control group (52.2% after telecobalt; 65.6% after 6-9-MV photons; p(WBI/PBI) = 0.009). CONCLUSIONS: Partial breast irradiation using interstitial HDR implants or EB to deliver radiation to the tumor bed alone for a selected group of early-stage breast cancer patients produces 5-year results similar to those achieved with conventional WBI. Significantly better cosmetic outcome can be achieved with carefully designed HDR multicatheter implants compared with the outcome after WBI.     

乳腺癌保乳术后1~3个腋窝淋巴结阳性者锁骨上淋巴结复发风险分析

目的 分析乳腺癌保乳术后1~3个腋窝淋巴结阳性患者锁骨上淋巴结复发率(SCFR)及高危因素。方法 回顾分析2001—2014年本院收治的保乳术+腋窝淋巴结清扫术后乳腺癌患者,病理证实1~3个腋窝淋巴结阳性,无内乳和锁骨上淋巴结转移或远处转移。256例均行全乳腺放疗,剂量46~50 Gy (2 Gy/次)或43.5 Gy (2.9 Gy/次),瘤床总剂量50~70 Gy。245例接受了辅助化疗,45例Her-2受体阳性者18例接受曲妥珠单抗治疗。Kaplan-Meier法计算同侧SCFR、LRR、DM及OS,并Logrank法检验。结果 随访时间满5年的样本量为101例。全组5年SCFR、LRR、DM、OS分别为2.1%、2.1%、5.0%、98.0%,2~3个腋窝淋巴结阳性(P= 0.010)、脉管瘤栓(P= 0.030)、LuminalB型(P= 0.006)为锁骨上淋巴结复发的高危因素。腋窝淋巴结阳性数为2~3个和1个者的5年SCFR分别为5.3%和2.8%(P=0.010);脉管瘤栓阳性和阴性的5年SCFR分别为5.3%和1.8%(P=0.030);Luminal B型、三阴性、Luminal A型和Her-2阳性型的5年SCFR分别为7.1%、3.2%、1.2%和0%(P=0.006)。有0、1、2~3个高危因素患者的5年SCFR分别为0%、3.0%、10.6%(P=0.000)。结论 在接受现代化疗前提下,乳腺癌保乳术后1~3个腋窝淋巴结阳性者SCFR较低,不需要全部行锁骨上区预防照射。有高危因素患者是否行预防性锁骨上区照射需进一步研究。     

Breast conserving surgery and definitive irradiation for early stage breast cancer

Breast conserving surgery and postoperative breast radiotherapy were used to treat 219 cases of AJCC Stage I and II breast carcinoma at the Michael Reese and University of Chicago Hospitals. Most patients were treated with lumpectomy and axillary sampling followed by breast irradiation to a dose of 46 Gy followed by a boost dose of 14-16 Gy to the surgical bed. The 5-year actuarial local control is 92%. Follow-up is 1 to 10 years and the median follow-up is 36 months. Of the seven patients who recurred in the breast, three failed in the boost site and three failed adjacent to the boost site. The seventh patient recurred diffusely in the breast and skin. Four of the seven recurrences were in patients with positive surgical margins. The 5-year actuarial relapse-free survival is 80%. Factors which had an adverse affect on the cosmetic results were a scar length greater than 8 cm and a volume of resected breast tissue greater than 100 cm3. Treatment related complications were minor and infrequent. Breast conserving surgery followed by radiation therapy is effective in achieving local control with good to excellent cosmetic results.     

乳腺癌保乳术后不同放疗方式的疗效及不良反应

目的:回顾性分析早期乳腺癌保乳术后不同放疗方式对局部正常器官的影响,观察不同放疗方式与生存率的关系。方法:收集我院1998-2010年保乳术后接受不同放疗方式治疗的乳腺癌患者121例,其中37例接受常规二维放疗,80例接受三维放射治疗,放疗采用6MV-X线全乳腺放疗50Gy,瘤床电子线外照射加量10Gy或同步加量至60Gy,4例未接受放疗,雌、孕激素受体阳性的患者加用内分泌治疗。治疗结束后每三个月复查至2年,每半年复查至5年,以后每年复查,放射性不良反应按照RTOG评价标准进行评价。结果:全组3年生存率为97.0％,5年生存率为95.0％,5年无瘤生存率为95.0％,局部复发率为0％。二维放疗放射性肺损伤的发生率明显高于三维放疗（P=0.010）。左侧乳腺癌放射性心脏损伤发生率稍高于右侧,但无明显统计学差异（P=0.210）,二维放疗放射性心脏损伤的发生率明显高于三维放疗（P=0.007）。二维放疗引起II°及III°急性放射性皮肤损伤发生率明显高于三维放疗（P=0.003）。美容效果与放射性皮肤反应相关,发生II°及以上皮肤反应的乳腺外观美容效果差于I°及以下皮肤反应的美容效果（P=0.030）。保乳术后接受局部放疗的患者3年生存率为98.0%,5年生存率为98.0%,T1与Ｔ2患者1、3、5年生存率分别为100%与97%、100%与94%、100%与94%,差异具有统计学意义（P=0.014）。结论:保乳术后行局部放疗明显延长生存时间,三维放疗与二维放疗相比5年生存优势未体现,但在保护肺、心脏、皮肤及美容效果方面明显好于二维放疗。     

Patients with early stage invasive cancer with close or positive margins treated with conservative surgery and radiation have an increased risk of breast recurrence that is delayed by adjuvant systemic therapy

Purpose: The association between a positive resection margin and the risk of ipsilateral breast tumor recurrence (IBTR) after conservative surgery and radiation is controversial. The width of the resection margin that minimizes the risk of IBTR is unknown. While adjuvant systemic therapy may decrease the risk of an IBTR in all patients, its impact on patients with positive or close margins is largely unknown. This study examines the interaction between margin status, margin width, and adjuvant systemic therapy on the 5- and 10-year risk of IBTR after conservative surgery and radiation.

Methods and Materials: A series of 1,262 patients with clinical Stage I or II breast cancer were treated by breast-conserving surgery, axillary node dissection, and radiation between March 1979 and December 1992. The median follow-up was 6.3 years (range 0.1–15.6). The median age was 55 years (range 24–89). Clinical size was T1 in 66% and T2 in 34%. Seventy-three percent of patients were node-negative. Only 5% of patients had tumors that were EIC-positive. Forty-one percent had a single excision, and 59% had a reexcision. The final margins were negative in 77%, positive in 12%, and close (≤ 2 mm) in 11%. The median total dose to the tumor bed was 60 Gy with negative margins, 64 Gy with close margins, and 66 Gy with positive margins. Chemotherapy ± tamoxifen was used in 28%, tamoxifen alone in 20%, and no adjuvant systemic therapy in 52%.

Results: The 5-year cumulative incidence (CI) of IBTR was not significantly different between patients with negative (4%), positive (5%), or close (7%) margins. However, by 10 years, a significant difference in IBTR became apparent (negative 7%, positive 12%, close 14%, p = 0.04). There was no significant difference in IBTR when a close or positive margin was involved by invasive tumor or DCIS. Reexcision diminished the IBTR rate to 7% at 10 years if the final margin was negative; however, the highest risk was observed in patients with persistently positive (13%) or close (21%) (p = 0.02) margins. The median interval to failure was 3.7 years after no adjuvant systemic therapy, 5.0 years after chemotherapy ± tamoxifen, and 6.7 years after tamoxifen alone. This delay to IBTR was observed in patients with close or positive margins, with little impact on the time to failure in patients with negative margins. The 5-year CI of IBTR in patients with close or positive margins was 1% with adjuvant systemic therapy and 13% with no adjuvant therapy. However, by 10 years, the CI of IBTR was similar (18% vs. 14%) due to more late failures in the patients who received adjuvant systemic therapy.

Conclusion: A negative margin (> 2 mm) identifies patients with a very low risk of IBTR (7% at 10 years) after conservative surgery and radiation. Patients with a close margin (≤ 2 mm) are at an equal or greater risk of IBTR as with a positive margin, especially following a reexcision. A margin involved by DCIS or invasive tumor has the same increased risk of IBTR. A reexcision of an initially close or positive margin that results in a negative final margin reduces the risk of IBTR to that of an initially negative margin. A close or positive margin is associated with an increased risk of IBTR even in patients who are EIC-negative or receiving higher boost doses of radiation. The median time to IBTR is delayed; however, the CI is not significantly decreased by adjuvant systemic therapy in patients with close or positive margins—the 5 year results in these patients underestimate their ultimate risk of recurrence.     

Conservative treatment in noninvasive breast cancer

BACKGROUND: The elective treatment for noninvasive breast carcinoma has not yet been established. As a result of mammographic screening programs, the incidence of noninvasive tumors has increased and has lead to the same controversy already present had with invasive carcinomas: mastectomy or conserving therapy. METHODS: Since 1990, 101 patients with noninvasive breast cancer were treated with irradiation following breast-conserving surgery. All the patients had irradiation of the whole breast (mean dose, 47.6 +/- 1.2 Gy). The radiation dose boost to the tumor bed was delivered in 28.7% of the cases (mean dose, 21.03 +/- 3.06 Gy), and in 71.3%, the boost was not administered. RESULTS: With a median follow-up of 34 months, survival is 100%. The disease-free survival at 5 years by the Kaplan-Meier method is 93.6 +/- 8.65. CONCLUSIONS: The conserving treatment is a valid option for treatment of patients with ductal carcinoma in situ.     

Conservative management of Paget disease of the breast with radiotherapy: 10- and 15-year results

BACKGROUND: At 5-year follow-up, patients with Paget disease of the breast who were treated with breast-conserving surgery (BCS) and radiotherapy (RT) had excellent results. The current report provides 10- and 15-year rates of tumor control in the breast, as well as disease-free and overall survival rates following BCS and RT in a cohort of patients with Paget disease presenting without a palpable mass or mammographic density. METHODS: Through a collaborative review of patients treated with BCS and RT from seven institutions, 38 cases of Paget disease of the breast presenting without a palpable mass or mammographic density were identified. All patients had pathologic confirmation of typical Paget cells at time of diagnosis. Thirty-six of 38 patients had a minimum follow-up greater than 12 months and constitute the study cohort. Ninety-four percent of patients underwent complete or partial excision of the nipple-areola complex and all patients received a median external beam irradiation dose of 50 Gy (range, 45-54 Gy) to the whole breast. Ninety-seven percent of patients also received a boost to the remaining nipple or tumor bed, a median total dose of 61.5 Gy (range, 50.4-70 Gy). RESULTS: With median follow-up of 113 months (range, 18-257 months), 4 of 36 patients (11%) developed a first recurrence of disease in the treated breast only. Two of the four recurrences in the breast were ductal carcinoma in situ (DCIS) only and two were invasive with DCIS. Two additional patients had a recurrence in the breast as a component of first failure. Actuarial local control rates for the breast as the only site of first recurrence were 91% at 5 years (95% confidence interval [CI], 80-100%) and 87% (95% CI, 75-99%) at both 10 and 15 years. Actuarial local control rates for breast recurrence, as a component of first failure, were 91% (95% CI, 80-100%), 83% (95% CI, 69-97%), and 76% (95% CI, 58-94%) at 5, 10, and 15 years, respectively. No clinical factors were identified as significant predictors for breast recurrence. Five-, 10- and 15-year actuarial rates for survival without disease of 97% (95% CI, 90-100%) and 5-, 10-, and 15-year actuarial rates of overall survival of 93% (95% CI, 84-100%) at 5 years and 90% (95% CI, 78-100%) at 10 and 15 years were reported. CONCLUSIONS: These data confirm excellent rates of local control, disease-free survival, and overall survival at 10 and 15 years following BCS and RT for Paget disease of the breast. This study continues to support the recommendation of local excision and definitive breast irradiation as an alternative to mastectomy in the treatment of patients with Paget disease presenting without a palpable mass or mammographic density.     

乳腺癌保乳术后放疗疗效和美观效果

目的　观察乳腺癌保乳术后放疗的疗效和美观效果。方法　保乳术后全乳外照射和瘤床加量共10 9例,79例除应用高剂量率插植技术[T1期肿瘤用单排插植,针距为1.5cm ,T2期以上肿瘤用双排或三排插植;针距间单次剂量(DB) 10～12Gy ,靶区周边剂量为85 %DB]外,其中4 8例还经组织间插植加量放疗;30例除采用电子线常规外照射15Gy外,其中2 7例还经电子线外照加量放疗。全乳照射应用6MV直线加速器,采用双切线半野照射技术,靶区剂量为4 5～5 2Gy(平均4 8.6Gy)。采用医生评分与患者问卷方法评价美观效果。结果　5年生存率为93.8% ,局部复发率为6 .5 %。全组无放射性溃疡发生,5例出现位于插植针孔周围急性皮肤炎症。在经临床随访体检的75例中,医生打分和患者自评满意度为优的比例分别占87%和81% (P >0 .0 5 )。两组满意度医生总评为优的患者比例分别为81.2 %和85 .2 % (P >0 .0 5 )。结论　乳腺癌保乳术后放疗可降低术后复发率,并发症少。不同的瘤床加量放疗方法不影响美观满意度。     

Factors associated with local recurrence and cause-specific survival in patients with ductal carcinoma in situ of the breast treated with breast-conserving therapy or mastectomy

PURPOSE: We reviewed our institution's experience treating patients with ductal carcinoma in situ (DCIS) of the breast to determine risk factors for ipsilateral breast tumor recurrence (IBTR) and cause-specific survival (CSS) after breast-conserving therapy (BCT) or mastectomy. MATERIALS AND METHODS: Between 1981 and 1999, 410 cases of DCIS (405 patients) were treated at our institution; 367 were managed with breast-conserving surgery (54 with lumpectomy alone and 313 with adjuvant radiation therapy (RT) [median dose, 45 Gy]). Of these 313 patients, 298 received also a supplemental boost of RT to the lumpectomy cavity (median dose, 16 Gy). Forty-three patients underwent mastectomy; 2 (5%) received adjuvant RT to the chest wall. A true recurrence/marginal miss (TR/MM) IBTR was defined as failure within or adjacent to the tumor bed in patients undergoing BCT. Median follow-up for all patients was 7 years (mean: 6.1 years). RESULTS: Thirty patients (8.2%) experienced an IBTR after BCT (25 [8%] after RT, 5 [9.3%] after no RT), and 2 patients (4.7%) developed a chest wall recurrence after mastectomy. Of the 32 local failures, 20 (63%) were invasive (18/30 [60%] after BCT and 2/2 [100%] after mastectomy), and 37% were DCIS alone. Twenty-four (80%) of the IBTRs were classified as TR/MM. The 10-year freedom from local failure, CSS, and overall survival after BCT or mastectomy were 89% vs. 90% (p = 0.4), 98% vs. 100% (p = 0.7), and 89% vs. 100% (p = 0.3), respectively. Factors associated with IBTR on Cox multivariate analysis were younger age (p = 0.02, hazard ratio [HR] 1.06 per year), electron boost energy < or = 9 MeV (p = 0.03, HR 1.41), final margins < or = 2 mm (p = 0.007; HR, 3.65), and no breast radiation (p = 0.002, HR 5.56). On Cox univariate analysis for BCT patients, IBTR, TR/MM failures, and predominant nuclear Grade 3 were associated with an increased risk of distant metastases and a reduced CSS. CONCLUSIONS: After treatment for DCIS, 10-year rates of local control, CSS, and overall survival were similar after mastectomy and BCT. Young age (<45 years), close/positive margins (< or = 2 mm), no breast radiation, and lower electron boost energies (< or = 9 MeV) were associated with IBTR. Local failure and predominant nuclear Grade 3 were found to have a small (4%-12%) but statistically significantly negative impact on the rates of distant metastasis and CSS. These results suggest that optimizing local therapy (surgery and radiation) is crucial to improve local control and CSS in patients treated with DCIS.     

早期乳腺癌保乳术后4种放疗技术的剂量参数比较

目的：比较早期乳腺癌保乳术后常规切线野（TW）、野中野调强（FIF - IMRT）、切线逆向调强（T -IMRT）和容积调强（VMAT）4种放射治疗技术的靶区和危及器官的剂量参数。方法：15例左侧早期（pT1-2 N0 M0）乳腺癌患者保乳术后接受放疗。CT 模拟定位扫描后勾画靶区和危及器官,在同一患者 CT 影像上分别做 TW、FIF - IMRT、T - IMRT 和 VMAT 4种治疗计划设计。PTV 剂量为50Gy,V47.5≥95%。4种计划的剂量限制相同。在剂量-体积直方图中读取4种计划靶区剂量的分布参数,心脏、双侧肺脏及对侧乳腺受照剂量和体积,对各参数的均数进行比较,并比较4组平均机器跳数差异。结果：4种计划都满足 V47.5≥95%。VMAT 与 T - IMRT、FIF - IMRT 和 TW 计划相比,明显提高了靶区适行指数（CI,P ﹤0.05）。VMAT、T - IMRT和 FIF - IMRT 与 TW 相比,明显改善了靶区均匀性指数（HI,P ﹤0.05）。VMAT 增加了危及器官（心脏和同侧肺脏）V 5、V10和 V20的受照射体积,但是没有增加﹥ V30的照射体积。VMAT 明显增加了右侧乳腺和右侧肺脏照射剂量（P ﹤0.05）,T - IMRT 和 FIF - IMRT 明显降低了右侧乳腺和右侧肺脏照射剂量（P ﹤0.05）。VMAT 与T - IMRT、FIF - IMRT 和 TW 相比,明显增加了机器跳数（P ﹤0.05）。结论：早期乳腺癌保乳术后放射治疗4种计划比较,VMAT 明显提高了靶区的适行性和均匀性,增加了正常组织的受照射剂量和机器跳数,延长了治疗时间。T - IMRT 和 FIF - IMRT 也提高了靶区的适行性和均匀性,降低了正常组织的受照射剂量。     

Outcome after ipsilateral breast tumor recurrence in patients who receive accelerated partial breast irradiation

BACKGROUND:

The objective of this study was to examine clinical outcomes and patterns of failure in patients with early stage breast cancer who developed an ipsilateral breast tumor recurrence (IBTR) after breast‐conserving therapy (BCT) using accelerated partial breast irradiation (APBI).

METHODS:

In total, 1440 patients (1449 tumors) with early stage breast cancer who underwent BCT were treated with the MammoSite device to deliver APBI (34 Gray [Gy] in 3.4‐Gy fractions). One thousand two hundred fifty‐five patients (87%) had invasive breast cancer (IBC) (median tumor size, 10 mm), and 194 patients (13%) had ductal carcinoma in situ (DCIS) (median tumor size, 8 mm). The median follow‐up was 60 months.

RESULTS:

Fifty patients (3.5%) developed an IBTR for a 5‐year actuarial rate of 3.61% (3.65% for IBC and 3.36% for DCIS). It was determined that 36 recurrences (72%) represented new primary cancers, and 14 recurrences (28%) represented recurrences of the index lesion. Of the 32 recurrences with known histology, 78% were IBC, and 22% were DCIS. After IBTR, 28 of 38 patients (74%) underwent salvage mastectomy, and 9 of 38 patients (26%) had a second attempt at BCT. Adjuvant therapies included tamoxifen in 8 patients (16%) and systemic chemotherapy in 6 patients (12%). The 3‐year rates of disease‐free survival, cause‐specific survival, and overall survival after IBTR were 58.7%, 92.1%, and 80.5%, respectively.

CONCLUSIONS:

With 5 years of follow‐up, APBI produced clinical outcomes and patterns of failure comparable to those achieved with whole breast irradiation. Patients who developed an IBTR after APBI had excellent 3‐year survival outcomes after salvage treatments. Cancer 2012. © 2012 American Cancer Society.     

Effect of margins on ipsilateral breast tumor recurrence after breast conservation therapy for lymph node-negative breast carcinoma

BACKGROUND: Breast conservative surgery (CS) with radiotherapy (RT) is the most commonly used treatment for early-stage breast carcinoma. However, there is controversy regarding the importance of the pathologic margin status on the risk of ipsilateral breast tumor recurrence (IBTR). The current study evaluated the effect of the pathologic margin status on IBTR rates in a cohort of women with lymph node-negative breast carcinoma treated with CS and RT. METHODS: Between August 1980 and December 1994, 452 women with pathologically lymph node-negative breast carcinoma were treated with CS and RT at Westmead Hospital (Westmead, Australia). Central pathology review was performed for all women. The final margins were negative for 352 women (77.9%), positive (invasive and/or in situ) for 42 women (9.3%), and indeterminate for 58 women (12.8%). Information regarding an extensive intraductal component (EIC), lymphovascular invasion, pathologic tumor size, histologic grade, and nuclear grade was available for most women. After macroscopic total excision of the tumor, all women received whole-breast irradiation (usually 45-50.4 grays [Gy]) and the majority of women also received a local tumor bed boost (range, 8-30 Gy). RESULTS: After a median follow-up of 80 months, 34 women (7.5%) developed an IBTR. The crude 5-year rates of IBTR for women with negative margins, positive margins, and indeterminate margins were 3.1%, 11.9%, and 6.9%, respectively. For women with negative margins, the 5-year and 10-year actuarial rates of freedom from IBTR were 96% and 92%, respectively, compared with 88% and 75%, respectively, for women with positive margins (P = 0.003). Univariate analysis demonstrated that the only factors associated with a significantly higher risk of IBTR were age at diagnosis (P < 0.050) and margin status (P = 0.005). Multivariate analysis showed that both age and margin status were independent predictors of IBTR. None of 24 patients with an EIC and negative margins were found to have developed an IBTR. CONCLUSIONS: The results of the current study were comparable to other published reports and supported the association of higher IBTR rates with positive or indeterminate margins compared with negative, pathologic margins. Furthermore, young age (age < 35 years at diagnosis) was associated with the highest risk of IBTR regardless of margin status.     

Late skin and subcutaneous soft tissue changes after 10-Gy boost for breast conserving therapy

PURPOSE: To evaluate the influence of boost irradiation for breast conserving therapy on skin and subcutaneous tissue. MATERIALS AND METHODS: Between 1989 and 1995, 468 patients were treated with breast conserving surgery (quadrantectomy or wide excision with axillary dissection) followed by 50 Gy whole breast irradiation. Among them, fifty-eight patients with positive or close margins were treated with 10 Gy external beam boost irradiation. Skin and subcutaneous soft tissue changes during 5-years of follow-up were examined by inspection and palpation and evaluated using the BCT follow-up form based on EORTC late effect toxicity scoring. RESULT: Four percent (20/468) of the patients showed grade 2 late changes in skin and soft tissue. Four of them had skin telangiectasis, which was limited to within the boost field. Boost irradiation had no definite influence on other late changes. Patients' age, extent of surgery, and pT size had no significant relation to the late changes. The cosmetic score 5 years after BCT was not significantly different between the patients with and without boost irradiation. CONCLUSION: Although 10 Gy boost irradiation after 50 Gy whole breast irradiation increased skin telangiectasis, the late skin and soft tissue changes caused by the boost irradiation were generally mild and there was no substantial deterioration of cosmetic outcome.     

Comparison of Photon with Electron Boost in Treatment of Early Stage Breast Cancer

In the treatment of early stage breast cancer breast conserving surgery (BCS) followed by whole breast irradiation (WBI) is a standard method. The impact of the tumor bed boost following WBI is well-defined, but there are various delivery methods. In this study the electron and the photon boost techniques were compared. For 78 early stage breast cancer patients both CT based 3D conformal photon boost and electron boost plans were created. For dosimetric comparison coverage index (CI), external volume index (EI) and conformality index (COIN) were studied. Lung volume receiving a dose of 2 Gy was also reviewed. Seventy-eight patients with 156 plans were compared. The mean tumor bed volume was measured as 61.39 cm(3) the mean tumor bed-skin distance was 3.13 cm. In the case of CI and COIN significant differences were found in favor of the photon boost. In the comparison of EI no significant difference was detected between the two techniques. The mean lung volume receiving 2 Gy were 42.3 and 168.35 cm(3), for photons and electrons respectively. In the adjuvant treatment of early stage breast cancer WBI followed by conformal photon boost showed to be superior to electron boost in focus of the COIN and CI.     

乳腺癌保乳术后同步加量调强放疗的临床疗效

目的:探讨乳腺癌保乳术后同步加量调强放疗的疗效、不良反应及美容效果。方法:2008年~2010年收治乳腺癌保乳术后患者78例,其中38例行瘤床同步加量调强放疗（A组）,剂量分割方案为全乳50Gy/25次（2Gy/次）,瘤床同步加量至60Gy/25次（2.4Gy/次）,总疗程33~35天;40例行常规分割调强放疗（B组）,剂量分割方案为全乳50Gy/25次,后续瘤床推量10Gy/5次（2Gy/次）,总疗程40~42天。应用Kaplan-Meier法生存分析,Log-rank法检验差异。结果:中位随访时间为73个月,随访率为100%。两组5年总生存率均为100%。A组和B组5年局部无复发生存率、无病生存率分别为97.4%、97.5%（P=0.978）;97.4%、95.0%（P=0.589)。A组和B组1、2级急性皮肤反应发生率分别为57.9%、52.5%(P＝0.632); 13.2%、12.5%(P＝0.931);A组和B组的1级皮肤及皮下组织晚期反应发生率分别为15.8%、15.0%（P=0.932）;1级白细胞减少发生率分别为7.9%、10.0%（P=0.745）。A组和B组在放疗前、放疗后3、5年美容效果优良率分别为86.8%、87.5%（P=0.931）;84.2%、85.0%（P=0.932）;81.6%、82.5%（P=0.916）。结论:保乳术后同步加量调强放疗的疗效与常规分割调强放疗相似,美容效果及不良反应相当。     

乳腺癌保留乳房术后大分割调强放疗初步临床观察

目的：观察早期乳腺癌保留乳房术后三维适形放疗（three-dimensional conformal radiotherapy,3-DCRT）、常规分割调强放疗（intensity-modulated radiotherapy,IMRT）及大分割调强放疗（hypo-fractionated intensity-modulated radiotherapy,hIMRT）的疗效、不良反应及美容效果。方法：选择2009～02—01—2013-01—31潍坊市人民医院放疗科早期乳腺癌保留乳房术后女性患者66例,根据患者意愿分别纳入3-DCRT、IMRT或kIMRT组行放疗。3DCRT组采用6Mv_X射线切线野照射,全乳腺Dr50Gy／25次,2Gy／次,后续9／12MeV电子线予瘤床区补量10Gy／5次,2Gy／次;IMRT组：采用逆向动态调强技术,以切线野方向为调强主野的入射方向,全乳腺50Gy／25次,2Gy／次,瘤床区用X射线同步加量至60Gy／25次,2．4Gy／次,或全乳腺放疗结束后行电子线补量（方式及剂量同3DCRT）;h-IMRT组：全乳腺42．5Gy／16次,2．66Gy／次,瘤床区同步X射线加量至48Gy。结果：3-DCRT组、IMRT组、h_IMRT组分别入组46、12和8例,中位随访23．9个月（2．1～48．0个月）,3组患者免疫组化结果、病理类型、TNM分期、放化疗顺序及化疗方案、年龄、手术与术后’放疗时间间隔、肿瘤最大径和腋窝淋巴结转移数目差异均无统计学意义,P〉0．05;3组放疗时间差异有统计学意义,P〈O．01,其中h-IMRT组周期最短。单变量一般线性模型三因素方差分析显示,放疗前后乳头纵向、横向位置,乳房横径,乳根位置差异均无统计学意义,P〉O．05;保留乳房术后患者健侧乳头比患侧低,P〈0．05;3组间乳头横向位置和乳房横径差异有统计学意义,P〈O．05。3组患者均发生不同程度的急性血液系统和皮肤反应,但差异无统计学意义,P〉0．05,无Ⅲ度及更严重的急性放射性皮肤反应,均未影响放疗计划的顺利进行。结论：短期随访结果显示,早期乳腺癌保留乳房术后大分割调强放疗组可以明显缩短放疗时间,未加重血液系统及皮肤急性毒副作用,未增加局部复发风险,未降低总生存,未降低美容效果,很有可能成为中国女性早期乳腺癌保留乳房术后安全有效的放疗模式。