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110 Results of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS)
213
Proceedings of the 38th Annual ASTRO Meeting 109 SELECTIVE
TUMOR
IRRADIATION
WITHOUT
Order SE, *Siegel JA, Lustig RA, Principato Institute Division Purpose: radiation
NORMAL
LS, **Zeiger
TISSUE
EXPOSURE
L, Lang P, Wallner
IN NON-RESECTABLE
dose of colloidal
CANCER
PE
for Systemic Radiation Therapy; *Division of Radiological Physics; Department of Nuclear Medicine, Cooper Hospital/University Medical Center, Camden, NJ To determine the maximum [60 Gy + 5FU].
PANCREATIC
3zP that may be interstitially
of Radiation
Oncology;
infused in non-resectable
**Interventional
pancreatic
Radiology;
cancer prior to external
Materials and Methods: Forty-seven patients with non-resectable pancreatic cancer with and without metastasis entered a dose escalation Phase I study beginning at a specific activity of 4 mCi. Under CT guidance the center of the pancreatic tumor was localized by computer the distance and angle from a grid on the abdomen to the center of the tumor mass determined. Three drugs were infused: 4 mg Decadron - 10 minute delay; 2.5 million particles of macroaggregated albumin [MAA]; and with final dose escalation two infusions of 30 mCi colloidal chromic phosphate 3zP [3.5 ml] followed by a needle cleansing dose of .25 ml of macroaggregated albumin. Bremsstrahlung scans on three separate days determined tumor localization and radiation dose. One week later infusional brachytherapy was repeated, that is Decadron, MAA, colloidal s*P, followed by three additional bremsstrahlung scans. Two weeks later a course of 60 Gy external radiation was initiated with four doses of 5FU [500 mg] administered with every other radiation treatment day. Toxicity was recorded using RTOG cooperative group criteria. CA19-9 and CEA were used as biomarkers to evaluate tumor progression or remission in conjunction with CT scans and clinical course. Results: Completion of the Phase I study was limited, not by toxicity, but by the volume of colloidal 3zP that could be infused into the stroma of the tumor, i.e. 3.5 ml containing 30 mCi. No significant (grade 3-4) toxicity occurred in patients with pancreatic cancer only. Patients without metastasis had reduction and, in some cases, elimination of CA19-9, etc. The median survival in 28 patients within the Phase 1 nonresectable pancreas cancer study without metstasis was one year in 19 patients; with metastasis was 6.9 months. The two infusions of 30 mCi 32P ordinarily yields a total tumor dose of one million centigray (10,000 Gy) and is to be used in the Phase II trial. Conclusions: In These preliminary offers a potential also be applied in
the first six patients treated in Phase II, two have sufficient follow-up to be evaluated, and both have complete remissions. results in pancreatic cancer are encouraging. A national Phase II pancreatic trial will now be initiated in five centers. This new and exciting modality in radiation therapy. These principles of infusional brachytherapy used in pancreatic cancer may tumors of the brain, head, neck, lung and other sites.
110 RESULTS OF CONSERVATIVE CARCINOMA IN SITU (DCIS) Fowble,
B., Hanloo,
Fox Chase Cancer
SURGERY
A.L., Fein, D.A., Hoffman, Center,
Philadelphia,
AND RADIATION J.P., Sip&on,
FOR MAMMOGRAPHICALLY E.R., Patcbefsky,
A., Kessler,
DETECTED
DUCTAL
II.
PA
Purpose: The role of conservative surgery and radiation for mammographically detected DCIS is controversial In particular, there is a paucity of data for outcome with radiation in a group of patients comparable to those treated with local excision and surveillance (mammographically detected DCIS ~2.5 cm, negative resection margins, negative post-biopsy mammogram). The purpose of this study is to report long term outcome of conservative surgery and radiation for mammographically detected DCIS with emphasis on the results in patients (pts.) considered candidates for excision alone. Materials and Methods: From 1983 to 1992, 110 women with mammographically detected DCIS (calcifications 72%. mass + calcifications 27%) and no prior history of breast cancer underwent needle localization biopsy followed by radiation. The median age of the patient population was 56 yrs. (range 37-81). The median followup was 5.3 yrs. (range .5-12). Re-excision was performed in 55%. Final margins of resection were negative in 62%. positive 7%. close 11% and unknown 20%. Axillary dissection was performed in 31 pts. and all had negtive nodes. 31% had a positive family history of breast cancer (1 affected relative-25 pts., two-7 pts., three-2 pts.). The most common predominant histologic subtype was comedo (54%) followed by cribriform (22%). The median pathologic tumor size was 8 mm (range 2 mm to 5 cm). A post-biopsy mammogram prior to radiation was performed in 46% of the patients. Radiation consisted of treatment to the entire breast (median 5000 cGy) with a boost to the primary site (97%) of an additional 1000 cGy. The median total dose to the primary site was 6040 cGy (range 5ooo to 6660). Results: Three patients developed a recurrence in the treated breast at 52, 106, and 107 months. All 3 recurrences were invasive ductal cancers and all were treated with mastectomy. The location of the recurrence was in the same quadrant as the primary in 1 pt. and in a separate quadrant in 2 pts. The 5 and 10 yr. actuarial rates of breast recurrence were 1% and 15% respectively. The 5 and 10 yr. overall survival were 96% and 94%. The cause-specific survival was 100% at 5 and 10 yrs. Two patients subseouentlv . . developed a contralateral invasive breast cancer. There was no significant correlation between the risk of a breast recurrence and race, the location of the primary, patient age, mammographic finding, the histologic subtype, pathologic tumor size, or a positive family history. One of 34 pts. (3%) with a positive family history (single affected relative) developed an invasive recurrence in a separate quadrant compared to 2/72 (3%) pts. with a negative family history (one separate quadrant, one same quadrant). Patients with a positive margin had a higher risk of breast recurrence (12%) when compared to those with negative margins (1.5%). 29 pts. had negative resection margins and a negative post-biopsy mammogram (52% comedo histologic subtype). None of these patients has developed a breast recurrence. Them were only 16 pts. who met all of the criteria for surveillance (path size 22.5 cm, negative resection margins, negative post-biopsy mammogram) and none of these has recurred (44% comedo). Considering all patients with negative margins, 1 of 68 developed an ipsilateral invasive cancer at 8.8 yrs. 6% of the patients who did not have a post-biopsy mammogram prior to radiation experienced a breast recurrence. Conclusion: Conservative surgery and radiation for mammographically detected DCIS results in a low risk of recurrence in the treated breast and a 100% cause-specific survival at 5 and 10 yrs. A positive family history of breast cancer was not associated with an increased risk of breast recurrence. In the subgroup of patients considered candidates for surveillance, there have been no breast recurrences. Negative margins of resection and a negative post-biopsy mammogram are important to decrease the risk of a breast recurrence. Long term follow-up is essential as late failures tend to predominate in patients with adequate surgical resection followed by radiation.
Proceedings of the 38th Annual ASTRO Meeting 109 SELECTIVE
TUMOR
IRRADIATION
WITHOUT
Order SE, *Siegel JA, Lustig RA, Principato Institute Division Purpose: radiation
NORMAL
LS, **Zeiger
TISSUE
EXPOSURE
L, Lang P, Wallner
IN NON-RESECTABLE
dose of colloidal
CANCER
PE
for Systemic Radiation Therapy; *Division of Radiological Physics; Department of Nuclear Medicine, Cooper Hospital/University Medical Center, Camden, NJ To determine the maximum [60 Gy + 5FU].
PANCREATIC
3zP that may be interstitially
of Radiation
Oncology;
infused in non-resectable
**Interventional
pancreatic
Radiology;
cancer prior to external
Materials and Methods: Forty-seven patients with non-resectable pancreatic cancer with and without metastasis entered a dose escalation Phase I study beginning at a specific activity of 4 mCi. Under CT guidance the center of the pancreatic tumor was localized by computer the distance and angle from a grid on the abdomen to the center of the tumor mass determined. Three drugs were infused: 4 mg Decadron - 10 minute delay; 2.5 million particles of macroaggregated albumin [MAA]; and with final dose escalation two infusions of 30 mCi colloidal chromic phosphate 3zP [3.5 ml] followed by a needle cleansing dose of .25 ml of macroaggregated albumin. Bremsstrahlung scans on three separate days determined tumor localization and radiation dose. One week later infusional brachytherapy was repeated, that is Decadron, MAA, colloidal s*P, followed by three additional bremsstrahlung scans. Two weeks later a course of 60 Gy external radiation was initiated with four doses of 5FU [500 mg] administered with every other radiation treatment day. Toxicity was recorded using RTOG cooperative group criteria. CA19-9 and CEA were used as biomarkers to evaluate tumor progression or remission in conjunction with CT scans and clinical course. Results: Completion of the Phase I study was limited, not by toxicity, but by the volume of colloidal 3zP that could be infused into the stroma of the tumor, i.e. 3.5 ml containing 30 mCi. No significant (grade 3-4) toxicity occurred in patients with pancreatic cancer only. Patients without metastasis had reduction and, in some cases, elimination of CA19-9, etc. The median survival in 28 patients within the Phase 1 nonresectable pancreas cancer study without metstasis was one year in 19 patients; with metastasis was 6.9 months. The two infusions of 30 mCi 32P ordinarily yields a total tumor dose of one million centigray (10,000 Gy) and is to be used in the Phase II trial. Conclusions: In These preliminary offers a potential also be applied in
the first six patients treated in Phase II, two have sufficient follow-up to be evaluated, and both have complete remissions. results in pancreatic cancer are encouraging. A national Phase II pancreatic trial will now be initiated in five centers. This new and exciting modality in radiation therapy. These principles of infusional brachytherapy used in pancreatic cancer may tumors of the brain, head, neck, lung and other sites.
110 RESULTS OF CONSERVATIVE CARCINOMA IN SITU (DCIS) Fowble,
B., Hanloo,
Fox Chase Cancer
SURGERY
A.L., Fein, D.A., Hoffman, Center,
Philadelphia,
AND RADIATION J.P., Sip&on,
FOR MAMMOGRAPHICALLY E.R., Patcbefsky,
A., Kessler,
DETECTED
DUCTAL
II.
PA
Purpose: The role of conservative surgery and radiation for mammographically detected DCIS is controversial In particular, there is a paucity of data for outcome with radiation in a group of patients comparable to those treated with local excision and surveillance (mammographically detected DCIS ~2.5 cm, negative resection margins, negative post-biopsy mammogram). The purpose of this study is to report long term outcome of conservative surgery and radiation for mammographically detected DCIS with emphasis on the results in patients (pts.) considered candidates for excision alone. Materials and Methods: From 1983 to 1992, 110 women with mammographically detected DCIS (calcifications 72%. mass + calcifications 27%) and no prior history of breast cancer underwent needle localization biopsy followed by radiation. The median age of the patient population was 56 yrs. (range 37-81). The median followup was 5.3 yrs. (range .5-12). Re-excision was performed in 55%. Final margins of resection were negative in 62%. positive 7%. close 11% and unknown 20%. Axillary dissection was performed in 31 pts. and all had negtive nodes. 31% had a positive family history of breast cancer (1 affected relative-25 pts., two-7 pts., three-2 pts.). The most common predominant histologic subtype was comedo (54%) followed by cribriform (22%). The median pathologic tumor size was 8 mm (range 2 mm to 5 cm). A post-biopsy mammogram prior to radiation was performed in 46% of the patients. Radiation consisted of treatment to the entire breast (median 5000 cGy) with a boost to the primary site (97%) of an additional 1000 cGy. The median total dose to the primary site was 6040 cGy (range 5ooo to 6660). Results: Three patients developed a recurrence in the treated breast at 52, 106, and 107 months. All 3 recurrences were invasive ductal cancers and all were treated with mastectomy. The location of the recurrence was in the same quadrant as the primary in 1 pt. and in a separate quadrant in 2 pts. The 5 and 10 yr. actuarial rates of breast recurrence were 1% and 15% respectively. The 5 and 10 yr. overall survival were 96% and 94%. The cause-specific survival was 100% at 5 and 10 yrs. Two patients subseouentlv . . developed a contralateral invasive breast cancer. There was no significant correlation between the risk of a breast recurrence and race, the location of the primary, patient age, mammographic finding, the histologic subtype, pathologic tumor size, or a positive family history. One of 34 pts. (3%) with a positive family history (single affected relative) developed an invasive recurrence in a separate quadrant compared to 2/72 (3%) pts. with a negative family history (one separate quadrant, one same quadrant). Patients with a positive margin had a higher risk of breast recurrence (12%) when compared to those with negative margins (1.5%). 29 pts. had negative resection margins and a negative post-biopsy mammogram (52% comedo histologic subtype). None of these patients has developed a breast recurrence. Them were only 16 pts. who met all of the criteria for surveillance (path size 22.5 cm, negative resection margins, negative post-biopsy mammogram) and none of these has recurred (44% comedo). Considering all patients with negative margins, 1 of 68 developed an ipsilateral invasive cancer at 8.8 yrs. 6% of the patients who did not have a post-biopsy mammogram prior to radiation experienced a breast recurrence. Conclusion: Conservative surgery and radiation for mammographically detected DCIS results in a low risk of recurrence in the treated breast and a 100% cause-specific survival at 5 and 10 yrs. A positive family history of breast cancer was not associated with an increased risk of breast recurrence. In the subgroup of patients considered candidates for surveillance, there have been no breast recurrences. Negative margins of resection and a negative post-biopsy mammogram are important to decrease the risk of a breast recurrence. Long term follow-up is essential as late failures tend to predominate in patients with adequate surgical resection followed by radiation.