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Impacts of Surgical Margin Status in Breast-conserving Surgery on Local Recurrence
Proceedings of the 51st Annual ASTRO Meeting neoadjuvant therapy is the achievement of a pathological response which has been shown to correlate with decreased recurrence rates and improved survival. We have conducted a series of prospective trials of concurrent chemo-radiation to enhance the rate of pathological responses and to identify tumor characteristics predictive of treatment response. We report the association of the original tumor’s hormonal receptor status and the occurrence of pathological responses among LABC patients treated in three chemoradiation protocols. Materials/Methods: 84 patients with LABC (stages IIB-IIIC) prospectively treated in three IRB-approved consecutive neoadjuvant chemo-radiation protocols were analyzed. Chemotherapy consisted of either capecitabine in 13 patients (750 mg/m2 twice a day) or paclitaxel in 71 patients (30 mg/m2 twice a week) for a total of 10 weeks. Concurrent radiotherapy was delivered to the breast and regional lymph nodes during weeks 2-7, daily, at 1.8 Gy per fraction to a total dose 45 Gy. A 14 Gy at 3 Gy per fraction boost was added to the area of the originally palpable tumor site. Weekly trastuzumab (2mg/kg) was added for 12 patients whose tumor over-expressed HER-2/neu. Estrogen and progesterone receptor status were defined by immunohistochemistry as positive when staining was recorded in $10% of tumor cells. Tumor response was assessed at definitive cancer surgery and defined as pathological complete response (pCR) in the absence of invasive cancer in breast or lymph nodes; pathological partial response (pPR) as the persistence of\10 microscopic foci of invasive carcinoma in breast or lymph nodes. All other patients were classified as having achieved no pathologic response (pNR). Results: The median age of patients was 48 years of age (range 28-74). Pathological response (pCR and pPR) after neoadjuvant chemo-radiation was achieved in 19/84 patients (22.6%). Patients with hormone receptor positive tumors (ER+/PR+, ER+/PR- or ER-/PR+) had a pathological response in 5.9% (3/51); patients with hormone receptor negative tumors (ER-/PR-) achieved a pathological response in 48.5% (16/33; 2-sided p \ 0.00001, Fisher’s exact test, Cytel StatXact 8.0, Cytel, 2008). Conclusions: Hormone receptor status is highly predictive of response to neoadjuvant chemo-radiation. Approximately half of the patients with hormone receptor negative tumors achieved a pathological response; this group should be selected for preoperative chemo-radiation. Author Disclosure: S. Adams, None; M. Donach, None; B. Singh, None; J.D. Goldberg, None; S.C. Formenti, None.
2090
Impacts of Surgical Margin Status in Breast-conserving Surgery on Local Recurrence
T. Han, E. Chie, S. Ha Seoul National University Hospital, Seoul, Republic of Korea Purpose/Objective(s): To investigate how margin status and other clinicopathologic factors influence the local recurrence in patients with invasive breast cancer. Materials/Methods: Between August 1999 and February 2004, 373 patients who were diagnosed as invasive breast carcinoma after breast-conserving surgery received adjuvant radiation therapy at Seoul National University Hospital. Among Of them, 7 were excluded due to incompleteness of radiotherapy or loss of medical records. Thus, 366 patients were analyzed retrospectively in this study. Surgical margin status were as follows; 312 negative margins, 17 close(\ or = 2 mm) margins by DCIS, 25 close margins by invasive carcinoma, 4 positive margins by DCIS. 8 patients had positive margins by invasive carcinoma, and then 6 of them underwent further resection and achieved negative margin eventually. Results: The median duration of follow-up was 72 months (range; 8-110 months). The 5 years local recurrence-free survival (LRFS) in patients with positive margin by invasive carcinoma was significantly lower than that of patients with negative margin (50.0% vs. 95.4%, p = 0.01), but there were no statistical differences in patients with close or positive margin by DCIS and close margin by invasive carcinoma. Other pathologic factors such as T stage (p = 0.34), N stage (p = 0.95), presence of DCIS component (p = 0.29), presence of infiltrative tumor border (p = 0.15), presence of endolymphatic tumor emboli (p = 0.12) had no significance for LRFS. Also the time interval between surgery and radiotherapy (p = 0.22) as well as the sequence between radiotherapy and chemotherapy (p = 0.89) had no significance for LRFS. However, The sequence of hormone therapy was revealed to be important; initiation of hormone therapy after completion of radiotherapy resulted in lower 5 years LRFS (80.0% vs. 93.1%, p \ 0.01). Conclusions: According to this study, close or positive margin by DCIS and close by invasive carcinoma did not raise the risk of local recurrence with adjuvant radiotherapy, but positive margin by invasive carcinoma did. Regardless to margin status, delayed hormone therapy also was associated with increased risk of local recurrence. Therefore, patients with positive margin by invasive carcinoma should undergo further resection to achieve negative margin and patients with positive hormone receptor should receive hormone therapy as soon as possible. Author Disclosure: T. Han, None; E. Chie, None; S. Ha, None.
2091
An Autologous Abdominal Free-fat Patch Surmounts the Problem of Skin Spacing during Accelerated Partial Breast Radiation (APBR)
P. Bretz1, D. Mantik2, T. Mesek2, S. Ling2, P. Dreisbach3 Desert Breast and Osteoporosis Institute, La Quinta, CA, 221st Century Oncology, Palm Desert, CA, 3Eisenhower Medical Center, Rancho Mirage, CA 1
Purpose/Objective(s): A problem in dosimetry planning using a partial breast radiation device is lack of skin spacing. As a consequence of this lack of skin spacing many after-loading catheters must be extracted without treatment. Each member of the comprehensive team must be aware of the surgical and radiation techniques that optimize individualized treatment. In order to solve this problem of skin overdosing, we have developed two techniques. Material/Methods: APBR is used to treat the area most likely to develop a local recurrence, i.e., that centimeter around the original lumpectomy margin. If successful, high dose rate brachytherapy using Iridium-192 is administrated in two sessions per day over five days for a total dose of 34 Gy. Instead of elliptically excising the tumor, often leaving little skin spacing and frequent skin indentation, the surgeon enters the breast through the areola. The initial incision is carried down for at least a centimeter and then cautery is used to divide the tissue until the tumor is reached. The tumor is excised (with clear margins) preferably in the shape
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2090
Impacts of Surgical Margin Status in Breast-conserving Surgery on Local Recurrence
T. Han, E. Chie, S. Ha Seoul National University Hospital, Seoul, Republic of Korea Purpose/Objective(s): To investigate how margin status and other clinicopathologic factors influence the local recurrence in patients with invasive breast cancer. Materials/Methods: Between August 1999 and February 2004, 373 patients who were diagnosed as invasive breast carcinoma after breast-conserving surgery received adjuvant radiation therapy at Seoul National University Hospital. Among Of them, 7 were excluded due to incompleteness of radiotherapy or loss of medical records. Thus, 366 patients were analyzed retrospectively in this study. Surgical margin status were as follows; 312 negative margins, 17 close(\ or = 2 mm) margins by DCIS, 25 close margins by invasive carcinoma, 4 positive margins by DCIS. 8 patients had positive margins by invasive carcinoma, and then 6 of them underwent further resection and achieved negative margin eventually. Results: The median duration of follow-up was 72 months (range; 8-110 months). The 5 years local recurrence-free survival (LRFS) in patients with positive margin by invasive carcinoma was significantly lower than that of patients with negative margin (50.0% vs. 95.4%, p = 0.01), but there were no statistical differences in patients with close or positive margin by DCIS and close margin by invasive carcinoma. Other pathologic factors such as T stage (p = 0.34), N stage (p = 0.95), presence of DCIS component (p = 0.29), presence of infiltrative tumor border (p = 0.15), presence of endolymphatic tumor emboli (p = 0.12) had no significance for LRFS. Also the time interval between surgery and radiotherapy (p = 0.22) as well as the sequence between radiotherapy and chemotherapy (p = 0.89) had no significance for LRFS. However, The sequence of hormone therapy was revealed to be important; initiation of hormone therapy after completion of radiotherapy resulted in lower 5 years LRFS (80.0% vs. 93.1%, p \ 0.01). Conclusions: According to this study, close or positive margin by DCIS and close by invasive carcinoma did not raise the risk of local recurrence with adjuvant radiotherapy, but positive margin by invasive carcinoma did. Regardless to margin status, delayed hormone therapy also was associated with increased risk of local recurrence. Therefore, patients with positive margin by invasive carcinoma should undergo further resection to achieve negative margin and patients with positive hormone receptor should receive hormone therapy as soon as possible. Author Disclosure: T. Han, None; E. Chie, None; S. Ha, None.
2091
An Autologous Abdominal Free-fat Patch Surmounts the Problem of Skin Spacing during Accelerated Partial Breast Radiation (APBR)
P. Bretz1, D. Mantik2, T. Mesek2, S. Ling2, P. Dreisbach3 Desert Breast and Osteoporosis Institute, La Quinta, CA, 221st Century Oncology, Palm Desert, CA, 3Eisenhower Medical Center, Rancho Mirage, CA 1
Purpose/Objective(s): A problem in dosimetry planning using a partial breast radiation device is lack of skin spacing. As a consequence of this lack of skin spacing many after-loading catheters must be extracted without treatment. Each member of the comprehensive team must be aware of the surgical and radiation techniques that optimize individualized treatment. In order to solve this problem of skin overdosing, we have developed two techniques. Material/Methods: APBR is used to treat the area most likely to develop a local recurrence, i.e., that centimeter around the original lumpectomy margin. If successful, high dose rate brachytherapy using Iridium-192 is administrated in two sessions per day over five days for a total dose of 34 Gy. Instead of elliptically excising the tumor, often leaving little skin spacing and frequent skin indentation, the surgeon enters the breast through the areola. The initial incision is carried down for at least a centimeter and then cautery is used to divide the tissue until the tumor is reached. The tumor is excised (with clear margins) preferably in the shape
S221