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Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy
ensure sufficient dose to the axillary nodes.3 Reed and colleagues2 surmised that with standard tangential fields, level I-II lymph nodes were not amply encompassed and frequently demonstrated subtherapeutic doses. Furthermore, some have found that even with adjusted radiation fields, portions of the level I axillary nodes continue to be underdosed, warranting further customization of the fields.4 In the current article, Garg and colleagues have examined level III/axillary apex lymph nodes in 20 patients with varying anatomy and concluded that placement of the inferior border of the supraclavicular field below the clavicular head improves therapeutic coverage. Additionally, the authors feel that despite the larger volume of lung exposed to daily radiation with their approach, the long-term sequelae were inconsequential. Garg and colleagues have pictorially established the variability of regional nodes and the importance of proper nodal coverage. By consistently extending the inferior border below the clavicular head across the board, the level III/ axillary apex will receive the
Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy Rashtian A, Iganej S, Amy Liu I-L, et al (Southern California Permanente Med Group, Los Angeles; Res and Evaluation, Kaiser Permanente, Pasadena, CA) Int J Radiat Oncol Biol Phys 72:1016-1020, 2008
appropriate therapeutic dose. However, as the field of radiation therapy has become more reliant on imaging techniques, including computed tomography, magnetic resonance imaging, and positron emission tomography, is it truly necessary to standardize fields? Other authors have emphasized the benefits of contouring nodal target volumes to ensure adequate coverage.5 Some patients will achieve better coverage of the level III nodes by placing the inferior border of the supraclavicular field at the inferior edge of the clavicular head. Others may not require this for adequate coverage and may avoid the extra lung dose that results from placement of the field edge at this location. Further attempts at a one-size-fits-all approach may be obsolete and unnecessary. Clearly, the authors advocate the utilization of diagnostic imaging and advanced treatment planning as the first consideration to carefully and thoroughly customize treatment fields to an individual patient’s anatomy.
References 1. Koh WJ, Chiu M, Stelzer KJ, et al. Femoral vessel depth and the implications for groin node radiation. Int J Radiat Oncol Biol Phys. 1993; 27:969-974. 2. Reed D, Lindsley S, Mann G, et al. Axillary lymph node dose with tangential breast irradiation. Int J Radiat Oncol Biol Phys. 2005;61: 358-364. 3. Harris EE, Hwang WT, Seyednejad F, Solin LJ. Prognosis after regional lymph node recurrence in patients with stage I-II breast carcinoma treated with breast conservation therapy. Cancer. 2003;98:2144-2151. 4. Reznik J, Cicchetti MG, Degaspe B, Fitzgerald TJ. Analysis of axillary coverage during tangential radiation therapy to the breast. Int J Radiat Oncol Biol Phys. 2005;61:163-168. 5. Liengsawangwong R, Yu TK, Sun TL, et al. Treatment optimization using computed tomography delineated targets should be used for supraclavicular irradiation in breast cancer. Int J Radiat Oncol Biol Phys. 2007;69:711-715.
J. N. Kim, MD E. Y. Kim, MD
Purpose.—Mastectomies result in very high local control rates for pure ductal carcinoma in situ; however, close or involved tumor margins are occasionally encountered. Data regarding the patterns of relapse in this setting are limited. Methods and Materials.—Between 1994 and 2002, the pathology reports of 574 patients who had undergone mastectomy at our institution for pure ductal carcinoma in situ were retrospectively
reviewed. Of the 574 patients, 84 were found to have margins of <10 mm. Of the 84 patients, 4 underwent postoperative radiotherapy and were excluded, leaving 80 patients for this analysis. Of the 80 patients, 31 had margins <2 mm and 49 had margins of 2.1–10 mm. High-grade disease was observed in 47 patients; 45 patients had comedonecrosis; and 30 had multifocal disease. Of the 80 patients, 51 were <60 years of age. Results.—With a median follow-up of 61 months, 6 (7.5%) of the 80
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patients developed local recurrence. Of the 31 patients with a margin of #2 mm, 5 (16%) developed local recurrence vs. only 1 (2%) of 49 patients with a margin of 2.1–10 mm (p ¼ 0.0356). Of the 6 patients with local recurrence, 5 had high-grade disease and/or comedonecrosis. All six recurrences were noted in patients <60 years old. Conclusion.—The findings of this review suggest that patients with pure ductal carcinoma in situ who undergo mastectomy with a margin of <2 mm have a greater-than-expected incidence of local recurrence. Patients with additional unfavorable features such as high-grade disease, comedonecrosis, and age <60 years are particularly at risk of local recurrence. These patients might benefit from postmastectomy radiotherapy. Retrospective series have demonstrated very low rates of recurrence following mastectomy for pure ductal carcinoma in situ (DCIS). However, radiation oncologists will occasionally be asked whether
Intervals Longer Than 20 Weeks From Breast-Conserving Surgery to Radiation Therapy Are Associated With Inferior Outcome for Women With Early-Stage Breast Cancer Who Are Not Receiving Chemotherapy Olivotto IA, Lesperance ML, Trnong PT, et al (Univ of British Columbia; Univ of Victoria, British Columbia, Canada) J Clin Oncol 27:16-23, 2009
Purpose.—To determine the interval from breast-conserving surgery
324
patients with close or positive mastectomy margins should undergo radiation therapy. There is a paucity of data, and certainly no randomized studies, regarding the role of radiation therapy for this group. Rashtian and colleagues at the Southern California Kaiser Permanente Medical Group in Los Angeles found that women with margins less than 2 mm had a statistically significant increase in recurrence when compared to those with 2- to 10-mm margins. Carlson and colleagues at Emory University found similar results, using a margin width cut-off of less than 1 mm versus 1 mm or wider.1 Rashtian and colleagues found that grade, age younger than 60 years, and the presence of comedo-type necrosis were not statistically significant in their own right, but the combination of these factors resulted in a very high risk of local failure for patients with such narrow margins. Several aspects of this study need to be taken into account when interpreting the meaning of these
findings. This study was a singleinstitution study, which allowed for greater uniformity of the pathologic assessment, including margin measurements; however, this also means that the findings might not apply to other institutions. The length of follow-up was quite long, but the number of patients was relatively small; thus, the results are subject to substantial statistical uncertainty (particularly for the smaller patient subgroups). Nonetheless, while this study is not definitive, it certainly helps clinicians and patients decide what to do when faced with this scenario.
(BCS) to radiation therapy (RT) that affects local control or survival. Patients and Methods.—The 10-year Kaplan-Meier (KM) local recurrencefree survival (LRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) were computed for 6,428 women who had T1 to 2, N0 to 1, M0 breast cancer that was diagnosed in British Columbia between 1989 and 2003, and who were treated with BCS and RT without chemotherapy. Intervals from BCS to RT were grouped by weeks as follows: # 4 (n ¼ 83), greater than 4 to 8 (n ¼ 2,288; reference group); greater than 8 to 12 (n ¼ 2,606); greater than 12 to 16
(n ¼ 961); greater than 16 to 20 (n ¼ 358); and greater than 20 weeks (n ¼ 132). Cox proportional hazards models and matching were used to control for confounding variables. Results.—The median follow-up time was 7.5 years. The 10-year KM outcomes were as follows: LRFS, 95.4%; DRFS, 90.5%; and BCSS, 92.5%. Compared with the greater than 4 to 8 weeks group, hazard ratios (HR) were not significantly different for any outcome among patients who were treated up to 20 weeks after BCS. However, LRFS (hazard ratio [HR], 2.00; P ¼ .15), DRFS (HR, 1.86; P ¼ .02) and BCSS (HR, 2.15;
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 3 2009
J. Keam, MD, MPH A. Recht, MD
Reference 1. Carlson GW, Page A, Johnson E, et al. Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy. J Am Coll Surg. 2007; 204:1074-1078.
Close or positive margins after mastectomy for DCIS: pattern of relapse and potential indications for radiotherapy Rashtian A, Iganej S, Amy Liu I-L, et al (Southern California Permanente Med Group, Los Angeles; Res and Evaluation, Kaiser Permanente, Pasadena, CA) Int J Radiat Oncol Biol Phys 72:1016-1020, 2008
appropriate therapeutic dose. However, as the field of radiation therapy has become more reliant on imaging techniques, including computed tomography, magnetic resonance imaging, and positron emission tomography, is it truly necessary to standardize fields? Other authors have emphasized the benefits of contouring nodal target volumes to ensure adequate coverage.5 Some patients will achieve better coverage of the level III nodes by placing the inferior border of the supraclavicular field at the inferior edge of the clavicular head. Others may not require this for adequate coverage and may avoid the extra lung dose that results from placement of the field edge at this location. Further attempts at a one-size-fits-all approach may be obsolete and unnecessary. Clearly, the authors advocate the utilization of diagnostic imaging and advanced treatment planning as the first consideration to carefully and thoroughly customize treatment fields to an individual patient’s anatomy.
References 1. Koh WJ, Chiu M, Stelzer KJ, et al. Femoral vessel depth and the implications for groin node radiation. Int J Radiat Oncol Biol Phys. 1993; 27:969-974. 2. Reed D, Lindsley S, Mann G, et al. Axillary lymph node dose with tangential breast irradiation. Int J Radiat Oncol Biol Phys. 2005;61: 358-364. 3. Harris EE, Hwang WT, Seyednejad F, Solin LJ. Prognosis after regional lymph node recurrence in patients with stage I-II breast carcinoma treated with breast conservation therapy. Cancer. 2003;98:2144-2151. 4. Reznik J, Cicchetti MG, Degaspe B, Fitzgerald TJ. Analysis of axillary coverage during tangential radiation therapy to the breast. Int J Radiat Oncol Biol Phys. 2005;61:163-168. 5. Liengsawangwong R, Yu TK, Sun TL, et al. Treatment optimization using computed tomography delineated targets should be used for supraclavicular irradiation in breast cancer. Int J Radiat Oncol Biol Phys. 2007;69:711-715.
J. N. Kim, MD E. Y. Kim, MD
Purpose.—Mastectomies result in very high local control rates for pure ductal carcinoma in situ; however, close or involved tumor margins are occasionally encountered. Data regarding the patterns of relapse in this setting are limited. Methods and Materials.—Between 1994 and 2002, the pathology reports of 574 patients who had undergone mastectomy at our institution for pure ductal carcinoma in situ were retrospectively
reviewed. Of the 574 patients, 84 were found to have margins of <10 mm. Of the 84 patients, 4 underwent postoperative radiotherapy and were excluded, leaving 80 patients for this analysis. Of the 80 patients, 31 had margins <2 mm and 49 had margins of 2.1–10 mm. High-grade disease was observed in 47 patients; 45 patients had comedonecrosis; and 30 had multifocal disease. Of the 80 patients, 51 were <60 years of age. Results.—With a median follow-up of 61 months, 6 (7.5%) of the 80
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 3 2009
323
patients developed local recurrence. Of the 31 patients with a margin of #2 mm, 5 (16%) developed local recurrence vs. only 1 (2%) of 49 patients with a margin of 2.1–10 mm (p ¼ 0.0356). Of the 6 patients with local recurrence, 5 had high-grade disease and/or comedonecrosis. All six recurrences were noted in patients <60 years old. Conclusion.—The findings of this review suggest that patients with pure ductal carcinoma in situ who undergo mastectomy with a margin of <2 mm have a greater-than-expected incidence of local recurrence. Patients with additional unfavorable features such as high-grade disease, comedonecrosis, and age <60 years are particularly at risk of local recurrence. These patients might benefit from postmastectomy radiotherapy. Retrospective series have demonstrated very low rates of recurrence following mastectomy for pure ductal carcinoma in situ (DCIS). However, radiation oncologists will occasionally be asked whether
Intervals Longer Than 20 Weeks From Breast-Conserving Surgery to Radiation Therapy Are Associated With Inferior Outcome for Women With Early-Stage Breast Cancer Who Are Not Receiving Chemotherapy Olivotto IA, Lesperance ML, Trnong PT, et al (Univ of British Columbia; Univ of Victoria, British Columbia, Canada) J Clin Oncol 27:16-23, 2009
Purpose.—To determine the interval from breast-conserving surgery
324
patients with close or positive mastectomy margins should undergo radiation therapy. There is a paucity of data, and certainly no randomized studies, regarding the role of radiation therapy for this group. Rashtian and colleagues at the Southern California Kaiser Permanente Medical Group in Los Angeles found that women with margins less than 2 mm had a statistically significant increase in recurrence when compared to those with 2- to 10-mm margins. Carlson and colleagues at Emory University found similar results, using a margin width cut-off of less than 1 mm versus 1 mm or wider.1 Rashtian and colleagues found that grade, age younger than 60 years, and the presence of comedo-type necrosis were not statistically significant in their own right, but the combination of these factors resulted in a very high risk of local failure for patients with such narrow margins. Several aspects of this study need to be taken into account when interpreting the meaning of these
findings. This study was a singleinstitution study, which allowed for greater uniformity of the pathologic assessment, including margin measurements; however, this also means that the findings might not apply to other institutions. The length of follow-up was quite long, but the number of patients was relatively small; thus, the results are subject to substantial statistical uncertainty (particularly for the smaller patient subgroups). Nonetheless, while this study is not definitive, it certainly helps clinicians and patients decide what to do when faced with this scenario.
(BCS) to radiation therapy (RT) that affects local control or survival. Patients and Methods.—The 10-year Kaplan-Meier (KM) local recurrencefree survival (LRFS), distant recurrence-free survival (DRFS), and breast cancer-specific survival (BCSS) were computed for 6,428 women who had T1 to 2, N0 to 1, M0 breast cancer that was diagnosed in British Columbia between 1989 and 2003, and who were treated with BCS and RT without chemotherapy. Intervals from BCS to RT were grouped by weeks as follows: # 4 (n ¼ 83), greater than 4 to 8 (n ¼ 2,288; reference group); greater than 8 to 12 (n ¼ 2,606); greater than 12 to 16
(n ¼ 961); greater than 16 to 20 (n ¼ 358); and greater than 20 weeks (n ¼ 132). Cox proportional hazards models and matching were used to control for confounding variables. Results.—The median follow-up time was 7.5 years. The 10-year KM outcomes were as follows: LRFS, 95.4%; DRFS, 90.5%; and BCSS, 92.5%. Compared with the greater than 4 to 8 weeks group, hazard ratios (HR) were not significantly different for any outcome among patients who were treated up to 20 weeks after BCS. However, LRFS (hazard ratio [HR], 2.00; P ¼ .15), DRFS (HR, 1.86; P ¼ .02) and BCSS (HR, 2.15;
Breast Diseases: A Year BookÒ Quarterly Vol 20 No 3 2009
J. Keam, MD, MPH A. Recht, MD
Reference 1. Carlson GW, Page A, Johnson E, et al. Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy. J Am Coll Surg. 2007; 204:1074-1078.