Radiotherapy after Conservative Surgery in Ductal Carcinoma In Situ of the Breast: A Review

Several large prospective and retrospective studies have demonstrated excellent long-term outcomes after breast conservative treatment with radiation in invasive breast cancer. Breast-conserving surgery (BCS) followed by radiotherapy (RT) is an accepted management strategy for patients with DCIS. Adding radiation treatment after conservative surgery enables to reduce, without any significant risks, the rate of local recurrence (LR) by approximately 50% in retrospective and randomized clinical trials. As about 50% of LRs are invasive and have a negative psychological impact, minimizing recurrence is important. Local and local-regional recurrences after initial breast conservation treatment with radiation can be salvaged with high rates of survival and freedom from distant metastases

FMECA Application to Intraoperative Electron Beam Radiotherapy Procedure As a Quality Method to Prevent and Reduce Patient's Risk in Conservative Surgery for Breast Cancer

Failure Mode Effects and Criticalities Analysis (FMECA) represents a prospective method for risk assessment in complex medical practices. Our objective was to describe the application of FMECA approach to intraoperative electron beam radiotherapy (IOERT), delivered using a mobile linear accelerator, for the treatment of early breast cancer as an anticipated boost

State of the art in breast intraoperative electron radiation therapy after intraoperative ultrasound introduction

Background. Breast intraoperative electron radiation therapy (B-IOERT) can be used in clinical practice both as elective irradiation (partial breast irradiation - APBI) in low risk breast cancer patients, and as an anticipated boost. The procedure generally includes the use of a shielding disk between the residual breast and the pectoralis fascia for the protection of the tissues underneath the target volume. The aim of the study was to evaluate the role of intraoperative ultrasound (IOUS) in improving the quality of B-IOERT. Patients and methods. B-IOERT was introduced in Trieste in 2012 and its technique was improved in 2014 with IOUS. Both, needle and IOUS were used to measure target thickness and the latter was used even to check the correct position of the shielding disk. The primary endpoint of the study was the evaluation of the effectiveness of IOUS in reducing the risk of a disk misalignment related to B-IOERT and the secondary endpoint was the analysis of acute and late toxicity, by comparing two groups of patients treated with IOERT as a boost, either measured with IOUS and needle (Group 1) or with needle alone (Group 2). Acute and late toxicity were evaluated by validated scoring systems. Results. From the institutional patients who were treated between June 2012 and October 2019, 109 were eligible for this study (corresponding to 110 cases, as one patients underwent bilateral conservative surgery and bilateral B-IOERT). Of these, 38 were allocated to group 1 and 72 to group 2. The target thickness measured with the IOUS probe and with the needle were similar (mean difference of 0.1 mm, p = 0.38). The percentage of patients in which the shield was perfectly aligned after IOUS introduction increased from 23% to more than 70%. Moreover, patients treated after IOUS guidance had less acute toxicity (36.8% vs. 48.6%, p = 0.33) from radiation therapy, which reached no statistical significance. Late toxicity turned out to be similar regardless of the use of IOUS guidance: 39.5% vs. 37.5% (p = 0.99). Conclusions. IOUS showed to be accurate in measuring the target depth and decrease the misalignment between collimator and disk. Furthermore there was an absolute decrease in acute toxicity, even though not statistically significant, in the group of women who underwent B-IOERT with IOUS guidance

Gestione delle pazienti con tumore fillode della mammella: esperienza triestina nel periodo 2006-2014

La diagnosi e la gestione dei tumori fillodi della mammella \ue8 complessa a causa del basso tasso di incidenza e dell\u2019imprevedibilit\ue0 del comportamento di questo tipo di neoplasie (meno dell\u20191% tra tutti i tumori della mammella [1]). L\u2019obiettivo di questo studio \ue8 analizzare i casi di tumori filloidi diagnosticati a Trieste nel periodo 2006-2014 al fine di contestualizzare il comportamento particolarmente aggressivo di un tumore fillode maligno insorto in una paziente con pregressi fillodi benigni

AIRO Breast Cancer Group Best Clinical Practice 2022 Update

Introduction: Breast cancer is the most common tumor in women and represents the leading cause of cancer death. Radiation therapy plays a key-role in the treatment of all breast cancer stages. Therefore, the adoption of evidence-based treatments is warranted, to ensure equity of access and standardization of care in clinical practice.Method: This national document on the highest evidence-based available data was developed and endorsed by the Italian Association of Radiation and Clinical Oncology (AIRO) Breast Cancer Group.We analyzed literature data regarding breast radiation therapy, using the SIGN (Scottish Intercollegiate Guidelines Network) methodology (www.sign.ac.uk). Updated findings from the literature were examined, including the highest levels of evidence (meta-analyses, randomized trials, and international guidelines) with a significant impact on clinical practice. The document deals with the role of radiation therapy in the treatment of primary breast cancer, local relapse, and metastatic disease, with focus on diagnosis, staging, local and systemic therapies, and follow up. Information is given on indications, techniques, total doses, and fractionations.Results: An extensive literature review from 2013 to 2021 was performed. The work was organized according to a general index of different topics and most chapters included individual questions and, when possible, synoptic and summary tables. Indications for radiation therapy in breast cancer were examined and integrated with other oncological treatments. A total of 50 questions were analyzed and answered.Four large areas of interest were investigated: (1) general strategy (multidisciplinary approach, contraindications, preliminary assessments, staging and management of patients with electronic devices); (2) systemic therapy (primary, adjuvant, in metastatic setting); (3) clinical aspects (invasive, non-invasive and micro-invasive carcinoma; particular situations such as young and elderly patients, breast cancer in males and cancer during pregnancy; follow up with possible acute and late toxicities; loco-regional relapse and metastatic disease); (4) technical aspects (radiation after conservative surgery or mastectomy, indications for boost, lymph node radiotherapy and partial breast irradiation).Appendixes about tumor bed boost and breast and lymph nodes contouring were implemented, including a dedicated web application. The scientific work was reviewed and validated by an expert group of breast cancer key-opinion leaders.Conclusions: Optimal breast cancer management requires a multidisciplinary approach sharing therapeutic strategies with the other involved specialists and the patient, within a coordinated and dedicated clinical path. In recent years, the high-level quality radiation therapy has shown a significant impact on local control and survival of breast cancer patients. Therefore, it is necessary to offer and guarantee accurate treatments according to the best standards of evidence-based medicine

Radiotherapy after Conservative Surgery in Ductal Carcinoma In Situ of the Breast: A Review

Several large prospective and retrospective studies have demonstrated excellent long-term outcomes after breast conservative treatment with radiation in invasive breast cancer. Breast-conserving surgery (BCS) followed by radiotherapy (RT) is an accepted management strategy for patients with DCIS. Adding radiation treatment after conservative surgery enables to reduce, without any significant risks, the rate of local recurrence (LR) by approximately 50% in retrospective and randomized clinical trials. As about 50% of LRs are invasive and have a negative psychological impact, minimizing recurrence is important. Local and local-regional recurrences after initial breast conservation treatment with radiation can be salvaged with high rates of survival and freedom from distant metastases

In vivo dosimetry and shielding disk alignment verification by EBT3 GAFCHROMIC film in breast IOERT treatment

Intraoperative electron radiation therapy (IOERT) cannot usually benefit, as conventional external radiotherapy, from software systems of treatment planning based on computed tomography and from common dose verify procedures. For this reason, in vivo film dosimetry (IVFD) proves to be an effective methodology to evaluate the actual radiation dose delivered to the target. A practical method for IVFD during breast IOERT was carried out to improve information on the dose actually delivered to the tumor target and on the alignment of the shielding disk with respect to the electron beam. Two EBT3 GAFCHROMIC films have been positioned on the two sides of the shielding disk in order to obtain the dose maps at the target and beyond the disk. Moreover the postprocessing analysis of the dose distribution measured on the films provides a quantitative estimate of the misalignment between the collimator and the disk. EBT3 radiochromic films have been demonstrated to be suitable dosimeters for IVD due to their linear dose-optical density response in a narrow range around the prescribed dose, as well as their capability to be fixed to the shielding disk without giving any distortion in the dose distribution. Off-line analysis of the radiochromic film allowed absolute dose measurements and this is indeed a very important verification of the correct exposure to the target organ, as well as an estimate of the dose to the healthy tissue underlying the shielding. These dose maps allow surgeons and radiation oncologists to take advantage of qualitative and quantitative feedback for setting more accurate treatment strategies and further optimized procedures. The proper alignment using elastic bands has improved the absolute dose accuracy and the collimator disk alignment by more than 50%

Conservative treatment of breast ductal carcinoma in situ: results of an Italian multi-institutional retrospective study

<p>Abstract</p> <p>Background</p> <p>The incidence of ductal carcinoma in situ (DCIS) has increased markedly in recent decades. In the past, mastectomy was the primary treatment for patients with DCIS, but as with invasive cancer, breast-conserving surgery followed by radiation therapy (RT) has become the standard approach. We present the final results of a multi-institutional retrospective study of an Italian Radiation Oncology Group for the study of conservative treatment of DCIS, characterized by a very long period of accrual, from February 1985 to March 2000, and a median follow-up longer than 11 years.</p> <p>Methods</p> <p>A collaborative multi-institutional study was conducted in Italy in 10 Radiation Oncology Departments. A consecutive series of 586 women with DCIS histologically confirmed, treated between February 1985 and March 2000, was retrospectively evaluated. Median age at diagnosis was 55 years (range: 29–84); 32 patients were 40 years old or younger. All women underwent conservative surgery followed by whole breast RT. Irradiation was delivered to the entire breast, for a median total dose of 50 Gy; the tumour bed was boosted in 295 cases (50%) at a median dose of 10 Gy.</p> <p>Results</p> <p>After a median follow-up of 136 months (range: 16–292 months), 59/586 patients (10%) experienced a local recurrence: invasive in 37 cases, intraductal in 20 and not specified in two. Salvage mastectomy was the treatment of choice in 46 recurrent patients; conservative surgery in 10 and it was unknown in three patients. The incidence of local recurrence was significantly higher in women younger than 40 years (31.3%) (p= 0.0009). Five patients developed distant metastases. Furthermore 40 patients developed a contralateral breast cancer and 31 a second primary tumour in a different site. The 10-year actuarial overall survival (OS) was 95.5% and the 10-year actuarial disease-specific survival (DSS) was 99%.</p> <p>Conclusions</p> <p>Our results are consistent with those reported in the literature. In particular it has been defined the importance of young age (40 years or less) as a relevant risk factor for local recurrence. This retrospective multi-institutional Italian study confirms the long term efficacy of breast conserving surgery with RT in women with DCIS.</p

The role of palliative interventional radiotherapy (brachytherapy) in esophageal cancer. An AIRO (Italian Association of Radiotherapy and Clinical Oncology) systematic review focused on dysphagia-free survival

Purpose: The aim of this review was to examine efficacy of palliative interventional radiotherapy (IRT) in esophageal cancer compared with other treatment in terms of dysphagia-free survival (DyFS) and safety. Methods and Material: A systematic research using PubMed, Scopus, and Cochrane library was performed to identify full articles evaluating the efficacy of IRT as palliation in patients with esophageal cancer. ClinicalTrials.gov was searched for ongoing or recently completed trials, and PROSPERO was searched for ongoing or recently completed systematic reviews. We analyzed only clinical study as full text of patients with symptomatic esophageal cancer treated with IRT alone or in combination with other treatment. Conference paper, survey, letter, editorial, book chapter, and review were excluded. Time restriction (1990–2018) as concerns the years of the publication was considered. The primary outcome was the duration of dysphagia relief (DyFS) after brachytherapy vs. other treatment (external-beam radiotherapy, photodynamic therapy, argon plasma coagulation, stent, and laser) during followup. Secondary outcomes included overall survival and adverse event rates. Results: The literature search resulted in 554 articles. Sixty-six articles were assessed via full text for eligibility. Of these, 59 articles were excluded for various reasons, leaving seven randomized studies. The number of evaluated patients was 905 patients, and median age was 70.5 years. In the IRT group, the median DyFS was 99 days, the most relevant G3–G4 toxicity were fistula development and stenosis reported, respectively, in 8.3% and 12.2%; the overall median survival was 175.5 days. Conclusion: In conclusion, we provided evidence-based support that IRT is an effective and safe treatment option; therefore, its underuse is no longer justified

Parit\ue0 e Allattamento quali fattori protettivi di carcinoma mammario nelle donne triestine

Introduzione: Il ruolo dell\u2019allattamento come fattore protettivo nell\u2019insorgenza del carcinoma (ca) mammario trova posizioni contrastanti in letteratura. Questo studio analizza i fattori legati alla storia riproduttiva della donna per confrontare la realt\ue0 della popolazione femminile triestina rispetto a quanto proposto in letteratura. A Trieste l\u2019 incidenza standardizzata europea \ue8 di 148 nuove diagnosi di ca mammario all\u2019anno ogni 100.000 donne residenti, che \ue8 ben pi\uf9 alta della media italiana (105 nuovi casi, IARC 2006). Materiali e Metodi: Dal 2006 presso l\u2019unit\ue0 senologica della provincia di Trieste, a tutte le donne con patologia mammaria benigna e maligna e ad un ampio campione di donne sane, viene somministrato un questionario per valutare i fattori correlati all\u2019insorgenza di ca mammario per complessive 4307 donne (pari al 6.2% della popolazione femminile triestina). La casistica \ue8 stata suddivisa in base alla decade di nascita (1930-39,\u20261970-79) e sono state analizzate le variabili \u201cnumero figli\u201d, \u201cet\ue0 al primo parto\u201d e \u201callattamento\u201d. Inoltre \ue8 stato condotto uno studio retrospettivo caso-controllo per valutare l\u2019eventuale ruolo protettivo delle gravidanze e dell\u2019allattamento nell\u2019\u2019insorgenza del carcinoma, studio focalizzato sulle donne nate nel periodo 1930-1969 (\ue8 stata esclusa per scarsa numerosit\ue0 la decade 1970-79). Ogni caso \ue8 stato appaiato ad un controllo con lo stesso anno di nascita. Per l\u2019analisi statistica \ue8 stato utilizzato il software R. Risultati: Lo studio \ue8 rappresentativo degli importanti cambiamenti a livello \u201csociale\u201d registrati nel corso delle decadi: incremento delle donne nullipare (dal 15% al 27%) ed un aumento dell\u2019et\ue0 delle donne al primo parto, (da un\u2019et\ue0 mediana di 24 anni a 30 anni). L\u2019analisi conferma il dato, gi\ue0 segnalato dalla letteratura, che l\u2019avere avuto figli riduce, soprattutto per le donne pi\uf9 giovani, il rischio di ca mammario: per le nate negli anni 1950-1959 il rischio relativo (RR) \ue8 pari a 0.56 [0.39-0.97], che passa a 0.40 [0.21-0.74], per quelle nate negli anni 1960-69; la parit\ue0 invece, in accordo con la letteratura non \ue8 pi\uf9 un fattore rilevante nelle donne della classe 1930-1949. Nel nostro campione anche l\u2019allattamento risulta un fattore protettivo nelle donne in et\ue0 fertile (RR=0.30 [0.11-0.76] ) soprattutto se questo si protrae fino al 12\ub0 mese (RR=0.16 [0.06-0.44]). Al contrario, e in accordo con i dati di letteratura, l'allattamento non riduce il rischio di ca mammario dopo la menopausa. Discussioni e Conclusioni: Nello studio triestino, la parit\ue0 e l\u2019allattamento risultano fattori protettivi per il ca della mammella solo per le donne in et\ue0 fertile e, in accordo con la letteratura , non riscontra significativa protezione nelle donne in post menopausa