- Email: [email protected]
ACR Appropriateness Criteria® Ductal Carcinoma In Situ
more than 37% of patients who underwent SSM with IR and in 5% of patients who did not undergo SSM. The rate of complications before the start of XRT was almost twice as high in the SSM group than in the non-SSM group (60% vs 33%). The authors acknowledged that the complication rates varied by the type of reconstruction performed after SSM. The rate of complications in patients who underwent reconstruction with tissue expanders was twice as high as that in patients treated without tissue expanders (50% vs 25%). The rate of complications may have also been underreported, given that the follow-up time was short. The 2-year distant failure rate was still 30% in patients who underwent SSM with IR. The authors did not comment on this, but adjuvant chemotherapy may have been delayed because of increased complication rates, with SSM and IR potentially causing a higher distant failure rate. Over half of the patients who did not require adjuvant chemotherapy and had a complication prior to PMRT began XRT more than 12 weeks after surgery, which was concerning.
As increasing numbers of patients opt for SSM followed by IR, we must be mindful not to compromise the timing or delivery of PMRT, which has been shown to increase survival in randomized trials.6,7 It is important that we continue to evaluate and optimize surgical and reconstruction techniques and minimize acute and long-term toxic effects without compromising locoregional control. The optimal techniques, types, and timing of reconstruction continue to be controversial topics that warrant randomized clinical trials.
ACR Appropriateness CriteriaÒ Ductal Carcinoma In Situ
surgery (BCS) followed by wholebreast radiation (RT) is supported by multiple Phase III studies, but mastectomy may be appropriate in selected patients. Omission of RT may also be reasonable in some patients, though which criteria are to be utilized remain unclear, and the existing data are contradictory with limited follow-up. Various RT techniques such as boost to the tumor bed, partial breast radiation or hypofractionated, whole-breast RT are increasingly utilized but the data to support their use specifically in DCIS is limited. Tamoxifen also increases local
Moran MS, Bai HX, Harris EER, et al (Yale Univ School of Medicine, New Haven, CT; Moffitt Cancer Ctr, Tampa, FL; et al) Breast J 18:8-15, 2012
Ductal carcinoma in situ (DCIS) describes a wide spectrum of noninvasive tumors which carry a significant risk of invasive relapse, thus prevention of local recurrence is vital. For appropriate patients with limited disease, management with breast conserving
270
S. B. Motwani, MD B. G. Haffty, MD
References 1. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235:814-819. 2. Schechter NR, Strom EA, Perkins GH, et al. Immediate breast reconstruction can impact postmastectomy irradiation. Am J Clin Oncol. 2005;28:485-494.
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
3. Motwani SB, Strom EA, Schechter NR, et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys. 2006;66: 76-82. 4. Bedwinek J. Natural history and management of isolated localregional recurrence following mastectomy. Semin Radiat Oncol. 1994;4:260-269. 5. Huang J, Barbera L, Brouwers M, Browman G, Mackillop WJ. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol. 2003;21: 555-563. 6. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337:949-955. 7. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337:956-962.
control for ER + DCIS, adding to the complexity of the local treatment management. This article reviews the existing scientific evidence, the controversies surrounding local management, and clinical guidelines for DCIS based on the group consensus by the ACR Breast Expert Panel. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical
literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The American College of Radiology (ACR) Appropriateness Criteria have been used for many years as valuable consensus documents regarding the use of various diagnostic imaging modalities. Historically, the discipline of radiation oncology emerged from the specialty of diagnostic radiology, although that association has become increasingly vestigial over the past 2 decades. Nevertheless, ACR Appropriateness Criteria for various therapeutic uses of ionizing
Clinical outcomes using accelerated partial breast irradiation in patients with invasive lobular carcinoma Shah C, Wilkinson JB, Shaitelman S, et al (Oakland Univ William Beaumont School of Medicine, Royal Oak, MI) Int J Radiat Oncol Biol Phys 81:e547-e551, 2011
Purpose.dWe compared clinical outcomes of women diagnosed with either invasive lobular carcinoma (ILC) or invasive ductal carcinoma (IDC) treated with accelerated partial breast irradiation (APBI). Methods and Materials.dA total of 16 patients with ILC received APBI as part of their breast-conservation therapy (BCT) and were compared with 410 patients with IDC that received
radiation have been generated, although these recommendations are probably best known and used in the diagnostic imaging arena. This article by Moran and colleagues provides a succinct summary regarding the appropriate management of LABC by presenting clinical vignettes in table form and highlighting the importance of multimodality therapy. In addition, the article provides valuable guidelines to the practicing radiation oncologist regarding appropriate targets and doses of radiation. Of interest, in patients with advanced axillary disease, the ACR states in this document that irradiation of the internal mammary chain of lymphatics is usually appropriate. This recommendation was supported by the preliminary results of the National Cancer Institute of Canada Clinical Trials Group MA.20 protocol, which
were presented at the American Society of Clinical Oncology meeting in 2011 and showed improvement in diseasefree survival and a trend toward improved survival when this nodal region was irradiated. In patients with intact breasts, however, irradiation of the internal mammary lymph nodes can create technical challenges that may preclude its use. Nevertheless, in the postmastectomy setting, this region can be easily irradiated using a variety of techniques, including arc therapy or electron beam radiotherapy. The publication of this article suggests that some consensus may be evolving within the radiation oncology community regarding the irradiation of internal mammary lymph nodes in patients with LABC.
APBI as part of their BCT. Clinical, pathologic, and treatment related variables were analyzed including age, tumor size, hormone receptor status, surgical margins, lymph node status, adjuvant hormonal therapy, adjuvant chemotherapy, and APBI modality. Clinical outcomes including local recurrence (LR), regional recurrence (RR), disease-free survival (DFS), causespecific survival (CSS), and overall survival (OS) were analyzed. Results.dMedian follow-up was 3.8 years for the ILC patients and 6.0 years for the IDC patients. ILC patients were more likely to have positive margins (20.0% vs. 3.9%, p ¼ 0.006), larger tumors (14.1 mm vs. 10.9 mm, p ¼ 0.03) and less likely to be node positive (0% vs. 9.5%, p < 0.001) when compared with patients diagnosed with IDC. The 5-year rate of LR was 0% for
the ILC cohort and 2.5% for the IDC cohort (p ¼ 0.59). No differences were seen in the rates of RR (0% vs. 0.7%, p ¼ 0.80), distant metastases (0% vs. 3.5%, p ¼ 0.54), DFS (100% vs. 94%, p ¼ 0.43), CSS (100% vs. 97%, p ¼ 0.59), or OS (92% vs. 89%, p ¼ 0.88) between the ILC and IDC patients, respectively. Additionally, when nodepositive patients were excluded from the IDC cohort, no differences in the rates of LR (0% vs. 2.2%, p ¼ 0.62), RR (0% vs. 0%), DFS (100% vs. 95%, p ¼ 0.46), CSS (100% vs. 98%, p ¼ 0.63), or OS (92% vs. 89%, p ¼ 0.91) were noted between the ILC and IDC patients. Conclusion.dWomen with ILC had excellent clinical outcomes after APBI. No difference in local control was seen between patients with invasive lobular versus invasive ductal histology.
G. Chronowski, MD
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
271
As increasing numbers of patients opt for SSM followed by IR, we must be mindful not to compromise the timing or delivery of PMRT, which has been shown to increase survival in randomized trials.6,7 It is important that we continue to evaluate and optimize surgical and reconstruction techniques and minimize acute and long-term toxic effects without compromising locoregional control. The optimal techniques, types, and timing of reconstruction continue to be controversial topics that warrant randomized clinical trials.
ACR Appropriateness CriteriaÒ Ductal Carcinoma In Situ
surgery (BCS) followed by wholebreast radiation (RT) is supported by multiple Phase III studies, but mastectomy may be appropriate in selected patients. Omission of RT may also be reasonable in some patients, though which criteria are to be utilized remain unclear, and the existing data are contradictory with limited follow-up. Various RT techniques such as boost to the tumor bed, partial breast radiation or hypofractionated, whole-breast RT are increasingly utilized but the data to support their use specifically in DCIS is limited. Tamoxifen also increases local
Moran MS, Bai HX, Harris EER, et al (Yale Univ School of Medicine, New Haven, CT; Moffitt Cancer Ctr, Tampa, FL; et al) Breast J 18:8-15, 2012
Ductal carcinoma in situ (DCIS) describes a wide spectrum of noninvasive tumors which carry a significant risk of invasive relapse, thus prevention of local recurrence is vital. For appropriate patients with limited disease, management with breast conserving
270
S. B. Motwani, MD B. G. Haffty, MD
References 1. Medina-Franco H, Vasconez LO, Fix RJ, et al. Factors associated with local recurrence after skin-sparing mastectomy and immediate breast reconstruction for invasive breast cancer. Ann Surg. 2002;235:814-819. 2. Schechter NR, Strom EA, Perkins GH, et al. Immediate breast reconstruction can impact postmastectomy irradiation. Am J Clin Oncol. 2005;28:485-494.
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
3. Motwani SB, Strom EA, Schechter NR, et al. The impact of immediate breast reconstruction on the technical delivery of postmastectomy radiotherapy. Int J Radiat Oncol Biol Phys. 2006;66: 76-82. 4. Bedwinek J. Natural history and management of isolated localregional recurrence following mastectomy. Semin Radiat Oncol. 1994;4:260-269. 5. Huang J, Barbera L, Brouwers M, Browman G, Mackillop WJ. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol. 2003;21: 555-563. 6. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337:949-955. 7. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337:956-962.
control for ER + DCIS, adding to the complexity of the local treatment management. This article reviews the existing scientific evidence, the controversies surrounding local management, and clinical guidelines for DCIS based on the group consensus by the ACR Breast Expert Panel. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical
literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The American College of Radiology (ACR) Appropriateness Criteria have been used for many years as valuable consensus documents regarding the use of various diagnostic imaging modalities. Historically, the discipline of radiation oncology emerged from the specialty of diagnostic radiology, although that association has become increasingly vestigial over the past 2 decades. Nevertheless, ACR Appropriateness Criteria for various therapeutic uses of ionizing
Clinical outcomes using accelerated partial breast irradiation in patients with invasive lobular carcinoma Shah C, Wilkinson JB, Shaitelman S, et al (Oakland Univ William Beaumont School of Medicine, Royal Oak, MI) Int J Radiat Oncol Biol Phys 81:e547-e551, 2011
Purpose.dWe compared clinical outcomes of women diagnosed with either invasive lobular carcinoma (ILC) or invasive ductal carcinoma (IDC) treated with accelerated partial breast irradiation (APBI). Methods and Materials.dA total of 16 patients with ILC received APBI as part of their breast-conservation therapy (BCT) and were compared with 410 patients with IDC that received
radiation have been generated, although these recommendations are probably best known and used in the diagnostic imaging arena. This article by Moran and colleagues provides a succinct summary regarding the appropriate management of LABC by presenting clinical vignettes in table form and highlighting the importance of multimodality therapy. In addition, the article provides valuable guidelines to the practicing radiation oncologist regarding appropriate targets and doses of radiation. Of interest, in patients with advanced axillary disease, the ACR states in this document that irradiation of the internal mammary chain of lymphatics is usually appropriate. This recommendation was supported by the preliminary results of the National Cancer Institute of Canada Clinical Trials Group MA.20 protocol, which
were presented at the American Society of Clinical Oncology meeting in 2011 and showed improvement in diseasefree survival and a trend toward improved survival when this nodal region was irradiated. In patients with intact breasts, however, irradiation of the internal mammary lymph nodes can create technical challenges that may preclude its use. Nevertheless, in the postmastectomy setting, this region can be easily irradiated using a variety of techniques, including arc therapy or electron beam radiotherapy. The publication of this article suggests that some consensus may be evolving within the radiation oncology community regarding the irradiation of internal mammary lymph nodes in patients with LABC.
APBI as part of their BCT. Clinical, pathologic, and treatment related variables were analyzed including age, tumor size, hormone receptor status, surgical margins, lymph node status, adjuvant hormonal therapy, adjuvant chemotherapy, and APBI modality. Clinical outcomes including local recurrence (LR), regional recurrence (RR), disease-free survival (DFS), causespecific survival (CSS), and overall survival (OS) were analyzed. Results.dMedian follow-up was 3.8 years for the ILC patients and 6.0 years for the IDC patients. ILC patients were more likely to have positive margins (20.0% vs. 3.9%, p ¼ 0.006), larger tumors (14.1 mm vs. 10.9 mm, p ¼ 0.03) and less likely to be node positive (0% vs. 9.5%, p < 0.001) when compared with patients diagnosed with IDC. The 5-year rate of LR was 0% for
the ILC cohort and 2.5% for the IDC cohort (p ¼ 0.59). No differences were seen in the rates of RR (0% vs. 0.7%, p ¼ 0.80), distant metastases (0% vs. 3.5%, p ¼ 0.54), DFS (100% vs. 94%, p ¼ 0.43), CSS (100% vs. 97%, p ¼ 0.59), or OS (92% vs. 89%, p ¼ 0.88) between the ILC and IDC patients, respectively. Additionally, when nodepositive patients were excluded from the IDC cohort, no differences in the rates of LR (0% vs. 2.2%, p ¼ 0.62), RR (0% vs. 0%), DFS (100% vs. 95%, p ¼ 0.46), CSS (100% vs. 98%, p ¼ 0.63), or OS (92% vs. 89%, p ¼ 0.91) were noted between the ILC and IDC patients. Conclusion.dWomen with ILC had excellent clinical outcomes after APBI. No difference in local control was seen between patients with invasive lobular versus invasive ductal histology.
G. Chronowski, MD
Breast Diseases: A Year BookÒ Quarterly Vol 23 No 3 2012
271