Residual disease after re-excision lumpectomy for close margins

Introduction While a positive margin after an attempt at breast conservation therapy (BCT) is a reason for concern, there is more controversy regarding close margins. When re-excisions are performed, there is often no residual disease in the new specimen, calling into question the need for the procedure. We sought to examine the incidence of residual disease after re-excision for close margins and to identify predictive factors that may better select patients for re-excision. Methods Our IRB-approved prospective breast cancer database was queried for all breast cancer patients who underwent a re-excision lumpectomy for either close or positive margins after an attempt at BCT. Close margins are defined as ≤2 mm for invasive carcinoma and ≤3 mm for DCIS. Clinicopathologic features were correlated with the presence of residual disease in the re-excision specimen. Results Three hundred three patients (32%) underwent re-operation for either close (173) or positive (130) margins. Overall, 33% had residual disease identified, 42% of DCIS patients and 29% of patients with invasive disease, nearly identical to patients with positive margins. For patients with DCIS, only younger age was significantly related to residual disease. For patients with invasive cancer, only multifocality was significantly associated with residual disease (OR 3.64 [1.26–10.48]). However, patients without multifocality still had a substantial risk of residual disease. Discussion The presence of residual disease appears equal between re-excisions for close and positive margins. No subset of patients with either DCIS or invasive cancer could be identified with a substantially lower risk of residual disease. J. Surg. Oncol. 2009;99: 99–103. © 2008 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/61535/1/21215_ftp.pd

Doses to internal organs for various breast radiation techniques - implications on the risk of secondary cancers and cardiomyopathy

<p>Abstract</p> <p>Background</p> <p>Breast cancers are more frequently diagnosed at an early stage and currently have improved long term outcomes. Late normal tissue complications induced by adjuvant radiotherapy like secondary cancers or cardiomyopathy must now be avoided at all cost. Several new breast radiotherapy techniques have been developed and this work aims at comparing the scatter doses of internal organs for those techniques.</p> <p>Methods</p> <p>A CT-scan of a typical early stage left breast cancer patient was used to describe a realistic anthropomorphic phantom in the MCNP Monte Carlo code. Dose tally detectors were placed in breasts, the heart, the ipsilateral lung, and the spleen. Five irradiation techniques were simulated: whole breast radiotherapy 50 Gy in 25 fractions using physical wedge or breast IMRT, 3D-CRT partial breast radiotherapy 38.5 Gy in 10 fractions, HDR brachytherapy delivering 34 Gy in 10 treatments, or Permanent Breast ¹⁰³Pd Seed Implant delivering 90 Gy.</p> <p>Results</p> <p>For external beam radiotherapy the wedge compensation technique yielded the largest doses to internal organs like the spleen or the heart, respectively 2,300 mSv and 2.7 Gy. Smaller scatter dose are induced using breast IMRT, respectively 810 mSv and 1.1 Gy, or 3D-CRT partial breast irradiation, respectively 130 mSv and 0.7 Gy. Dose to the lung is also smaller for IMRT and 3D-CRT compared to the wedge technique. For multicatheter HDR brachytherapy a large dose is delivered to the heart, 3.6 Gy, the spleen receives 1,171 mSv and the lung receives 2,471 mSv. These values are 44% higher in case of a balloon catheter. In contrast, breast seeds implant is associated with low dose to most internal organs.</p> <p>Conclusions</p> <p>The present data support the use of breast IMRT or virtual wedge technique instead of physical wedges for whole breast radiotherapy. Regarding partial breast irradiation techniques, low energy source brachytherapy and external beam 3D-CRT appear safer than ¹⁹²Ir HDR techniques.</p

Second malignancies after breast cancer: the impact of different treatment modalities

Treatment for non-metastatic breast cancer (BC) may be the cause of second malignancies in long-term survivors. Our aim was to investigate whether survivors present a higher risk of malignancy than the general population according to treatment received. We analysed data for 16 705 BC survivors treated at the Curie Institute (1981–1997) by either chemotherapy (various regimens), radiotherapy (high-energy photons from a 60Co unit or linear accelerator) and/or hormone therapy (2–5 years of tamoxifen). We calculated age-standardized incidence ratios (SIRs) for each malignancy, using data for the general French population from five regional registries. At a median follow-up 10.5 years, 709 patients had developed a second malignancy. The greatest increases in risk were for leukaemia (SIR: 2.07 (1.52–2.75)), ovarian cancer (SIR: 1.6 (1.27–2.04)) and gynaecological (cervical/endometrial) cancer (SIR: 1.6 (1.34–1.89); P<0.0001). The SIR for gastrointestinal cancer, the most common malignancy, was 0.82 (0.70–0.95; P<0.007). The increase in leukaemia was most strongly related to chemotherapy and that in gynaecological cancers to hormone therapy. Radiotherapy alone also had a significant, although lesser, effect on leukaemia and gynaecological cancer incidence. The increased risk of sarcomas and lung cancer was attributed to radiotherapy. No increased risk was observed for malignant melanoma, lymphoma, genitourinary, thyroid or head and neck cancer. There is a significantly increased risk of several kinds of second malignancy in women treated for BC, compared with the general population. This increase may be related to adjuvant treatment in some cases. However, the absolute risk is small

Urinary quality of life outcomes in men who were treated with image-guided intensity-modulated radiation therapy for prostate cancer

Purpose: Quality of life (QoL) outcomes play a major role in the treatment selection for prostate cancer (CaP). We evaluated the urinary QoL outcomes in men who were treated with image-guided intensity-modulated radiation therapy (IG-IMRT) for CaP. Methods and materials: We enrolled men who were diagnosed with CaP and underwent IG-IMRT in a large urological group practice into a prospectively maintained database. The typical radiation treatment dosage to prostates and seminal vesicles was 8100 cGy in 45 fractions. Urinary QoL was self-assessed using the standardized incontinence grade and International Prostate Symptom Score (IPSS) at baseline and at each follow-up visit. We evaluated the cumulative incidence of urinary incontinence and changes in both continence and IPSS over time. Results: Of the 3602 men who were eligible for analysis, 3086 (85.7%) had no urinary incontinence; 479 (13.3 %) had minimal incontinence (no requirement for pads), and 37 (1.0 %) had significant urinary incontinence that required the use of pads or interfered with activities of daily living, at baseline. After a median follow-up of 24 months (range: 12.0-41.0 months), these numbers were 80.6%, 17.4%, and 2.0%, respectively. Radiation therapy appeared to have a beneficial effect on some men: 54.1% of men with minimal incontinence became completely continent of urine during follow-up. Of those with significant urinary incontinence, 29.7% reported resolution and 27.0% reported improved symptoms with no requirement for pads. Of the 1276 men with moderate IPSS, the mean IPSS decreased from 12 to 9.8 at the time of the last follow-up (P < .001). Similarly, of the 233 men with severe IPSS, the mean IPSS decreased from 24 to 13 at the time of the last follow-up (P < .001). Conclusion: IG-IMRT for clinically localized CaP is associated with a relatively low incidence of urinary incontinence. Although unexplained, IG-IMRT seems to improve symptoms in some men with baseline urinary incontinence and moderate-to-severe IPSS