Is There a Role for Postmastectomy Radiation Therapy in Ductal Carcinoma In Situ

Background. DCIS treated by mastectomy ensures high local control rates. There is limited data on risk for relapse and lack of clear indication for adjuvant radiation therapy (RT). We report a retrospective review on a population of DCIS patients treated with mastectomy. The objective was to identify the overall incidence of relapse, risk factors for local recurrence, and accordingly for whom adjuvant postmastectomy RT may be considered. Methods. This is an IRB-approved retrospective study on a prospective breast cancer database. From 1997 to 2007, we identified 969 patients with diagnoses of DCIS, among them 211 breasts in 207 patients were treated with mastectomy and comprise the study group. Results. With a median followup of 55 months (4.6 years) the 10-year relapse-free survival is 97%. Two of 211 breasts (0.9%) treated with mastectomy developed a local-regional recurrence. Both the relapses were among patients defined as having <1 mm final mastectomy margin. Conclusions. The rare local relapse after mastectomy limits our ability to reliably identify risk factors for relapse. The consideration for postmastectomy RT should be based on an individualized risk evaluating surgical technique used, presence of BRCA mutation, grade and extent of tumor, and proximity of lesion to the margin of resection

Assessment of nodal target definition and dosimetry using three different techniques: implications for re-defining the optimal pelvic field in endometrial cancer

1. To determine the optimal pelvic nodal clinical target volume for post-operative treatment of endometrial cancer. 2. To compare the DVH of different treatment planning techniques applied to this new CTV and the surrounding tissues. Based on the literature, we selected a methodology to delineate nodal target volume to define a NEW-CTV and NEW-PTV. Conventional 2D fields, 3D fields based on anatomic guidelines per RTOG 0418, 3D fields based on our guidelines, and IMRT based on our guidelines were assessed for coverage of NEW-CTV, NEW-PTV, and surrounding structures. CT scans of 10 patients with gynecologic malignancies after TAH/BSO were used. DVHs were compared. For NEW-PTV, mean V45Gy were 50% and 69% for 2D and RTOG 0418-3DCRT vs. 98% and 97% for NEW-3DCRT and NEW-IMRT (p < 0.0009). Mean V45Gy small bowel were 24% and 20% for 2D and RTOG 0418-3DCRT, increased to 32% with NEW-3DCRT, and decreased to 14% with IMRT (p = 0.005, 0.138, 0.002). Mean V45Gy rectum were 26%, 35%, and 52% for 2D, RTOG 0418-3DCRT, and NEW-3DCRT, and decreased to 26% with NEW-IMRT (p < 0.05). Mean V45Gy bladder were 83%, 51%, and 73% for 2D, RTOG 0418-3DCRT, and NEW-3DCRT, and decreased to 30% with NEW-IMRT (p < 0.002). Conventional 2D and RTOG 0418-based 3DCRT plans cover only a fraction of our comprehensive PTV. A 3DCRT plan covers this PTV with high doses to normal tissues, whereas IMRT covers the PTV while delivering lower normal tissue doses. Re-consideration of what specifically the pelvic target encompasses is warranted

Image guidance using 3D-ultrasound (3D-US) for daily positioning of lumpectomy cavity for boost irradiation

<p>Abstract</p> <p>Purpose</p> <p>The goal of this study was to evaluate the use of 3D ultrasound (3DUS) breast IGRT for electron and photon lumpectomy site boost treatments.</p> <p>Materials and methods</p> <p>20 patients with a prescribed photon or electron boost were enrolled in this study. 3DUS images were acquired both at time of simulation, to form a coregistered CT/3DUS dataset, and at the time of daily treatment delivery. Intrafractional motion between treatment and simulation 3DUS datasets were calculated to determine IGRT shifts. Photon shifts were evaluated isocentrically, while electron shifts were evaluated in the beam's-eye-view. Volume differences between simulation and first boost fraction were calculated. Further, to control for the effect of change in seroma/cavity volume due to time lapse between the 2 sets of images, interfraction IGRT shifts using the first boost fraction as reference for all subsequent treatment fractions were also calculated.</p> <p>Results</p> <p>For photon boosts, IGRT shifts were 1.1 ± 0.5 cm and 50% of fractions required a shift >1.0 cm. Volume change between simulation and boost was 49 ± 31%. Shifts when using the first boost fraction as reference were 0.8 ± 0.4 cm and 24% required a shift >1.0 cm. For electron boosts, shifts were 1.0 ± 0.5 cm and 52% fell outside the dosimetric penumbra. Interfraction analysis relative to the first fraction noted the shifts to be 0.8 ± 0.4 cm and 36% fell outside the penumbra.</p> <p>Conclusion</p> <p>The lumpectomy cavity can shift significantly during fractionated radiation therapy. 3DUS can be used to image the cavity and correct for interfractional motion. Further studies to better define the protocol for clinical application of IGRT in breast cancer is needed.</p

Management of Regional Nodes in the Treatment of Breast Cancer: An American Radium Society Appropriate Us Criteria Panel for Breast Cancer Systematic Review and Guideline

Background: The management of regional nodes in breast cancer patients is a complex and evolving area of significant clinical impact. Numerous recent randomized trials and other studies have reported improved survival outcomes associated with the inclusion of regional nodal irradiation in patients with node positive breast cancer or even high risk node negative breast cancer. The selection of patients for extent of axillary surgery has also been the subject of numerous randomized trials with a resulting reduction in the use of axillary dissection in many populations. Selection of systemic agent sis increasingly driven by molecular assays rather than clinicopathologic features such as number of positive nodes. Treatment of nodal volumes can also increase chronic toxicities such as lymphedema and reduced range of motion, so would ideally be used in patients who truly benefit. Many controversies remain, including optimal patient selection in the intermediate risk patients especially after mastectomy and after neoadjuvant chemotherapy, which nodal volumes to include in which patients, and the optimal dose fractionation. Several ongoing randomized trials are examining the role of nodal treatment after neoadjuvant chemotherapy and dosing regimens. Objectives: Due to the emerging body of data and the evolving standards, the ARS Breast Cancer AUC panel has launched a new topic on the management of regional nodes in breast cancer treatment. Our goal is to provide guidance for the multidisciplinary decision making regarding extent of surgery, use of nodal radiation and selection of sequencing of systemic agents as indicated by molecular subtyping and other genomic assays. Methods: A systematic literature review of the randomized controlled trials, meta-analyses and other prospective or population based studies was conducted to identify the studies published since January 2000. An evidence table was developed and studies ranked by study type, findings and level of evidence. Results: Topics for evidence-based guideline development include use of sentinel node lymphadenectomy for pathologic node negative and selection of patients for further axillary dissection with positive sentinel nodes, regional nodal irradiation instead of axillary dissection, regional node irradiation after neoadjuvant chemotherapy, design of radiation treatment parameters including target volumes, radiation fields and techniques and impact of genomic assays on selection of therapy. A review article and executive summary along with variants of clinical scenarios is under development to provide a guideline to clinicians regarding these patient populations. Variants are scored by consensus mythology to provide strength of evidence and consensus. Conclusions: The management of lymph nodes in early stage breast cancer patients at intermediate risk for recurrence involves several areas of controversy and evolving practice which this evidence-based appropriate use criteria project addresses in order to provide practical guidance to the multidisciplinary oncology community

Is There a Role for Postmastectomy Radiation Therapy in Ductal Carcinoma In Situ?

Background. DCIS treated by mastectomy ensures high local control rates. There is limited data on risk for relapse and lack of clear indication for adjuvant radiation therapy (RT). We report a retrospective review on a population of DCIS patients treated with mastectomy. The objective was to identify the overall incidence of relapse, risk factors for local recurrence, and accordingly for whom adjuvant postmastectomy RT may be considered. Methods. This is an IRB-approved retrospective study on a prospective breast cancer database. From 1997 to 2007, we identified 969 patients with diagnoses of DCIS, among them 211 breasts in 207 patients were treated with mastectomy and comprise the study group. Results. With a median followup of 55 months (4.6 years) the 10-year relapse-free survival is 97%. Two of 211 breasts (0.9%) treated with mastectomy developed a local-regional recurrence. Both the relapses were among patients defined as having <1 mm final mastectomy margin. Conclusions. The rare local relapse after mastectomy limits our ability to reliably identify risk factors for relapse. The consideration for postmastectomy RT should be based on an individualized risk evaluating surgical technique used, presence of BRCA mutation, grade and extent of tumor, and proximity of lesion to the margin of resection

Lymph nodes: Is total number or station number a better predictor of lymph node metastasis in endometrial cancer?

Gynecologic oncologists have sought to define adequate lymphadenectomy. The purpose of this study is to determine the probability of detecting lymph node metastasis by lymph node count compared to number of nodal stations sampled. This is a clinicopathologic review of surgically staged endometrial carcinoma patients from 2000 to 2008. Information was extracted from patients’ medical records. Student t-test, Wilcoxon rank sum test, Chi-square and Fisher exact tests were used. Elimination logistic regression was performed to identify independent significant predictors of lymph node metastasis. p < .05 was considered significant for all tests. The study population consisted of 352 patients with a mean age of 65. Forty patients (11.36%) had lymph node metastasis. Number of nodes sampled was not associated with lymph node status on univariate analyses. Patients with lymph node metastases detected was increased when 8 or more nodal stations were sampled compared to less than 8 (19.4% vs. 9.8%, p = .04). More significance was seen when 9 or more stations were sampled (32% vs. 9.8%, p = .004). Multivariate logistic regression analysis, controlling for age, grade, depth of myometrial invasion, number of nodes sampled, and number of nodal stations sampled, found only grade ( p = .002), depth of myometrial invasion ( p < .0003), and sampling of 9 or more nodal stations ( p = .03) to be independent predictors of node status. Lymph node count did not accurately predict risk of lymph node metastasis. Number of nodal stations sampled was a more precise predictor of lymph node metastases

Breast Implant-Associated Anaplastic Large Cell Lymphoma: Case Report and Review of the Literature

We are reporting the case of a 58-year-old woman with history of bilateral silicone breast implants for cosmetic augmentation. At 2-year interval from receiving the breast implants, she presented with swelling of the right breast with associated chest wall mass, effusion around the implant, and axillary lymphadenopathy. Pathology confirmed breast implant-associated anaplastic large cell lymphoma (stage III, T4N2M0, using BIA-ALCL TNM staging and stage IIAE, using Ann-Arbor staging). The patient underwent bilateral capsulectomy and right partial mastectomy with excision of the right breast mass and received adjuvant CHOP chemotherapy and radiation to the right breast and regional nodes. Since completion of multimodality therapy, the patient has sustained remission on both clinical exam and PET/CT scan. We report this case and review of the literature on this rare form of lymphoma