Integrated breast conservation and intraoperative radiation therapy

The introduction of innovative radiotherapy approaches for early breast cancer patients is rapidly changing the radiation oncologists' attitude and their expectations to obtain a good local control while decreasing morbidity therefore improving patient's quality of life. Intraoperative radiotherapy is a very attractive treatment modality in the multidisciplinary approach to breast conservation as is testified by the rapidly growing number of patients accrued in numerous studies all over Europe since 2000. A major advantage of intraoperative radiotherapy in breast cancer treatment is the administration of a large dose of radiation directly to the tumour bed, avoiding the possible geographic miss. Accurate localization and precise definition of the tumour bed volume is essential to achieve maximal efficacy in terms of local control while minimizing unnecessary damage to the normal breast tissue. Intraoperative radiotherapy reduces radiation exposure of the skin, lung, heart and normal subcutaneous tissues thus contributing to the low incidence of side effects and the generally excellent cosmetic results. Compared to other intraoperative techniques, the superiority of intraoperative radiotherapy appears to be the high homogeneity of dose distribution. The linear quadratic model used to calculate the biologic equivalent dose of intraoperative radiotherapy treatments for both tumour and normal tissue effects, is not considered totally reliable for large dose per fraction. The main concern is the potential increase in severe late side effects. Conversely, we expect an enhanced local control due to the radiobiologic efficacy of a large single dose delivered soon after tumour excision, with an immediate cell killing effect over any potential microscopic disease. The advantage of shortening the overall treatment time is that it avoids any delay in the administration of chemotherapy. The safety of intraoperative radiotherapy as a treatment modality in the context of breast conservation has been proved but conclusive data on local control and survival are expected from long term results of the ongoing studies

Assessment of pulmonary fibrosis after radiotherapy (RT) in breast conserving surgery: comparison between conventional external beam RT (EBRT) and intraoperative RT with electrons (ELIOT)

The aim of this study was to assess the frequency and the grade of RT-induced pulmonary fibrosis in patients who underwent EBRT compared to patients who underwent ELIOT. One-hundred-seventy-eight patients enrolled in a prospective randomized phase III trial to compare the efficacy of ELIOT (a single dose of 21 Gy prescribed at the 90% isodose) versus EBRT (50 Gy to the whole breast plus a 10 Gy boost to the tumour bed), underwent a spiral 16-detector row Computed Tomography (CT) examination to assess RT-induced pulmonary fibrosis: 83 patients in the EBRT arm and 95 in the ELIOT arm. All patients (age range 48-75 years) were affected by unicentric infiltrating carcinoma of the breast with diameter < 2.5 cm. This study was approved by our Institutional Ethical Committee and informed consent was obtained from each patient. Two observers, blinded to patient's randomization, independently evaluated each CT examination and assigned a fibrosis score (Grades 0 to 3). Inter-observer agreement for the fibrosis score was evaluated and a consensus between observers was obtained. Differences in fibrosis score between the two arms were evaluated by Chi Square test and Odds Ratio (OR) with 95% Confidence Intervals (CI). Pulmonary fibrosis was diagnosed in 42 patients (23.6%): 38 (90%) were in the EBRT arm and 4 (10%) in the ELIOT arm (p < 0.0001); twenty-six of them were Grade 1 (one ELIOT), fifteen were Grade 2 (three ELIOT) and one was Grade 3. The post-radiotherapy risk in the EBRT arm to develop at least Grade 1 fibrosis was 19 times higher than in the ELIOT one (OR: 19.20; 95%CI: 6.46-57.14) and 6 times higher to develop at least Grade 2 (OR: 5.70; 95%CI: 1.56-20.76). In conclusion, CT detected pulmonary fibrosis in patients treated with ELIOT is significantly less frequent compared to patients treated with EBR

A double-blind, randomised, vehicle-controlled clinical study to evaluate the efficacy of MAS065D in limiting the effects of radiation on the skin : interim analysis

Our aim was to assess the efficacy of MAS065D, a non-steroidal water-in-oil cream, in preventing and limiting skin reactions caused by radiation therapy (RT). 40 women treated with conservative breast cancer surgery followed by radiotherapy, were randomised to receive MAS065D (22 pts) or vehicle (18 pts). Radiotherapy was delivered in 20 fractions: 2.25 Gy to the whole breast plus a concomitant boost of 0.25 Gy to the tumour bed up to a total dose of 50 Gy. Evaluations of skin toxicity, erythema, and subjective symptoms were carried out weekly and 3 weeks after treatment completion. A statistically significant difference between vehicle and MAS065D groups was recorded regarding the maximum severity of skin toxicity (p < 0.0001), burning within the radiation field (p = 0.039) and desquamation (p = 0.02), in favour of the latter. We conclude that MAS065D may be considered a safe and effective treatment in the prevention and minimization of skin reactions and associated symptoms

Could radiotherapy play a major role in misidentification of sentinel lymph node in breast cancer recurrence?

Misidentification of sentinel lymph node via lymphoscintigraphy for breast cancer is an infrequent event. We analysed 35.022 consecutive procedures from a single institution and tried to find a correlation between failures of sentinel node identification and previous oncologic treatments received by the patients

3D-conformal hypofractionated radiotherapy for prostate cancer with daily transabdominal ultrasonography prostate localization: toxicity and outcome of a pilot study

Aims and background. To evaluate the feasibility, toxicity and patient outcome of hypofractionated 3-dimensional conformal radiotherapy for low- and intermediate-risk prostate cancer, using daily an ultrasound targeting system (BAT\u2122). Methods. Between May 2005 and October 2006, 25 patients (cT1-T2, GS 647,mean initial PSA = 7.06 ng/ml) received a dose of 72 Gy in 30 fractions. Only the prostate was included in the clinical target volume. Immediately before each radiotherapy session, BAT\u2122 ultrasound alignment was performed. Acute and late toxicity was evaluated according to the Radiation Therapy Oncology Group criteria; the Phoenix definition (PSA = nadir + 2 ng/ml) was applied to define biochemical failure. BAT\u2122 localization data were provided for 300 out of 750 procedures. Results. No interruptions in 3-dimensional conformal radiotherapy due to toxicity were registered. There was no acute rectal toxicity in 52% of patients; 28% had G1, 16% had G2, and 1 patient had a G3 event. No acute urinary toxicity was observed in 28% of the patients. G1 toxicity occurred in 40%, G2 in 28%, and G3 in 1 patient; no G4 event was observed. With an average follow-up of 45 months, one biochemical relapse was observed; late toxicity showed an excellent profile: 78% of the patients had no rectal toxicity, 16% had G1, and 1 patient had G2 toxicity. Most of the patients (68%) had no late urinary complications, whereas 32% had G1 toxicity. Localization data showed systematic and random errors in relation to some procedure biases. Conclusions. Promising tumor control and toxicity profile were observed with this mildly hypofractionated BAT-based 3-dimensional conformal radiotherapy. Free full text available at www.tumorionline.it

One-step intraoperative radiotherapy optimizes conservative treatment of breast cancer with advantages in quality of life and work resumption

Background: Intraoperative radiotherapy (IORT) could be not-inferior to external beam radiotherapy (EBRT) in selected patients, but toxicities, self-perception of body image, quality of life, and resumption of work or daily activities have been poorly explored. The aim of the present study was to compare these outcomes between EBRT, IORT full-dose (IORT-f) and IORT boost (IORT-b). Methods: 443 consecutive patients, candidates for breast-conserving surgery, were included: EBRT was performed in 220 patients (49.7%), IORT-f in 140 patients (31.6%), and IORT-b in 83 patients (18.7%). Radiotherapy-related toxicities were registered. Patients were evaluated at 6 months for Body Image after Breast Cancer Questionnaire (BIBCQ) to assess possible changes in self-perception of body image and limitations. A second questionnaire explored the impact of EBRT, IORT-f and IORT-b on resumption of work and normal daily activities. Results: EBRT had a higher risk of breast fibrosis and retraction (OR 3.58, 95% CI 1.024\u201312.526, p = 0.046) and breast edema (OR 6, 95% CI 2.077\u201317.335, p = 0.001) compared to IORT-f, but a lower risk of seroma compared to IORT-b (OR 0.36, 95% CI 0.166\u20130.785, p = 0.01). The BIBCQ scores showed a better outcome in arm concerns with IORT-f ( 123.3) vs. IORT-b ( 121.3, p = 0.002) and EBRT ( 121.7, p = 0.006), although biased by the lower rate in axillary dissections. Return to daily activities occurred after 70.6 days with EBRT vs. 41 days with IORT-f (p < 0.0001) and 53.3 days with IORT-b (p = 0.07), without any effect of age or axillary dissection. Conclusion: IORT could reduce adverse effects, allowing faster resumption of job and houseworks

Long-term side effects and cosmetic outcome in a pool of breast cancer patients treated with intraoperative radiotherapy with electrons as sole treatment

AIMS: To evaluate late toxicity and cosmetic outcome after intraoperative radiotherapy using electrons (ELIOT) as sole treatment modality in early breast cancer patients. METHODS: A total of 119 patients selected randomly among 1200 cases was analyzed. Late toxicities were documented using the LENT-SOMA scoring system, cosmesis was evaluated with the Harvard scale, and a numeric rating scale was used to assess symptoms. RESULTS: After a median follow-up of 71 months, grade II fibrosis was observed in 38 patients (31.9%) and grade III fibrosis in 7 patients (5.9%). Postoperative complications (12.6%) did not correlate with late toxicity. Physicians and patients scored cosmesis as excellent or good in 84% and 77.3% of the cases, respectively. Patient satisfaction was higher than 90%. CONCLUSIONS: In the study, ELIOT gives low and acceptable long-term toxicity. A longer follow-up and a larger number of patients are needed to confirm these promising results