- Email: [email protected]
In Regard to Kased N et al. (Int J Radiat Oncol Biol Phys 2009;75:1132–1140)
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I. J. Radiation Oncology d Biology d Physics
8. McCarten KM, Rosen N, Friedman D, Schwartz CL, Voss S, BishopJodoin M, et al. Feasibility of real time diagnostic imaging central review in multicenter cancer trials. ARRS; Boston, MA, 2009. 9. Laprise NK, Hanusik R, Fitzgerald TJ, Rosen N, White KS. Developing a multi-institutional PACS archive and designing processes to manage the shift from a film to a digital-based archive. J Digit Imaging 2009;22(1):15– 24.
RESPONSE TO ‘‘BENEFIT OF RADIATION BOOST AFTER WHOLE-BREAST RADIOTHERAPY’’ (INT J RADIAT ONCOL BIOL PHYS 2009;75:1029–1034) To the Editor: Livi and colleagues reported on the effect of boost irradiation of the tumor bed after breast-conserving surgery for early breast cancer on the risk of cancer relapse in the treated breast (1). Their results showed that a boost significantly reduced the risk of local breast cancer relapse and that the effect was stronger in young patients, thus confirming the results from randomized controlled trials. Of the 399 patients without a boost, only 9% received chemotherapy and 20% received tamoxifen, whereas of the patients with a boost, 37% received chemotherapy and 58% tamoxifen. Several studies have confirmed the favorable effect of adjuvant systemic therapy on local control after breast-conserving therapy (2–4). The observed risk reductions in these studies vary between 50% and 70%. In the study by Livi and colleagues, adjustments were made for the use of adjuvant systemic treatment by performing a multivariate analysis, which confirmed the beneficial effect of tamoxifen on local control of disease. For a better understanding of the role of the boost dose in current practice, it would also be interesting to know the effect of boost irradiation on local recurrence risk for patients with and without adjuvant systemic treatment. Indications for the use of adjuvant systemic treatment have changed in such a way during the past decade that the large majority of patients are currently receiving chemotherapy, hormonal therapy, or a combination of both. The absolute benefit of boost irradiation with respect to the risk of local recurrence is probably smaller for patients who also receive adjuvant systemic treatment. This could be checked by doing an analysis for the patients with and without a boost, stratified according to the use of adjuvant systemic treatment. ADRI C. VOOGD, PH.D. Eindhoven Cancer Registry Eindhoven, The Netherlands MAURICE J.C. VAN DER SANGEN, M.D. Department of Radiotherapy Catharina Hospital Eindhoven, The Netherlands doi:10.1016/j.ijrobp.2009.12.027 1. Livi L, Borghesi S, Saieva C, et al. Benefit of radiation boost after wholebreast radiotherapy. Int J Radiat Oncol Biol Phys 2009;75:1029–1034. 2. van der Leest M, Evers L, van der Sangen MJ, et al. The safety of breastconserving therapy in patients with breast cancer aged \ or = 40 years. Cancer 2007;109:1957–1964. 3. Buchholz TA, Tucker SL, Erwin J, et al. Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breast-conservation therapy. J Clin Oncol 2001;19:2240–2246. 4. Haffty BG, Wilmarth L, Wilson L, et al. Adjuvant systemic chemotherapy and hormonal therapy: Effect on local recurrence in the conservatively treated breast cancer patient. Cancer 1994;73:2543–2548.
Volume 77, Number 1, 2010 This effect seems to be even lower in the group not receiving tamoxifen (hazard ratio [HR] 0.39; 95% confidence interval [CI] 0.179–0.850) than in the group of patients who received tamoxifen (HR 0.195; 95% CI 0.053–0.717). Regarding the role of chemotherapy, we found that the boost maintained its importance in patients not receiving chemotherapy (HR 0.281; 95% CI 0.136–0.584) and lost its significance in patients receiving chemotherapy, but this is probably due to the low number of events in this group (only six recurrences). Therefore we cannot confirm the hypothesis of Voogd and van der Sangen, although we have to take into account that performing a stratified analysis reduces the number of patients in each group and the statistical power, and also that the retrospective nature of this study did not allow us to draw definitive conclusions. Nevertheless, at the moment we have no data that could justify not prescribing surgical bed boost to patients receiving systemic adjuvant treatments. LORENZO LIVI, M.D. GABRIELE SIMONTACCHI, M.D. ICRO MEATTINI, M.D. GIAMPAOLO BITI, M.D. Department of Radiotherapy-Oncology University of Florence Florence, Italy doi:10.1016/j.ijrobp.2009.12.028 1. van der Leest M, Evers L, van der Sangen MJ, et al. The safety of breastconserving therapy in patients with breast cancer aged \ or = 40 years. Cancer 2007;109:1957–1964. 2. Buchholz TA, Tucker SL, Erwin J, et al. Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breast-conservation therapy. J Clin Oncol 2001;19:2240–2246. 3. Haffty BG, Wilmarth L, Wilson L, et al. Adjuvant systemic chemotherapy and hormonal therapy: Effect on local recurrence in the conservatively treated breast cancer patient. Cancer 1994;73:2543–2548. 4. Livi L, Borghesi S, Saieva C, et al. Benefit of radiation boost after wholebreast radiotherapy. Int J Radiat Oncol Biol Phys 2009;75:1029–1034.
IN REGARD TO KASED N ET AL. (INT J RADIAT ONCOL BIOL PHYS 2009;75:1132–1140) To the Editor: We would like to inform Kased et al. (1) that in the cited articles from Goyal et al. (2) and Akyurek et al. (3) in their Table 8, SIR means ‘‘score index for stereotactic radiosurgery for brain metastases’’ and not ‘‘standardized incidence ratio,’’ as it was quoted there. The SIR is an index developed to determine the prognosis of patients with brain metastases treated with stereotactic radiosurgery (4, 5). These articles showed that SIR was more accurate than Radiation Therapy Oncology Group recursive partitioning analysis in predicting the prognosis in breast cancer patients with brain metastases treated with stereotactic radiosurgery. EDUARDO WELTMAN, M.D. Department of Radiation Oncology REYNALDO ANDRE´ BRANDT, M.D. Department of Neurosurgery Hospital Israelita Albert Einstein Sa˜o Paulo, SP, Brazil doi:10.1016/j.ijrobp.2009.12.034
IN REPLY TO DRS. VOOGD AND VAN DER SANGEN To the Editor: As stated in the letter by Voogd and van der Sangen, several studies have confirmed the favorable effect of adjuvant systemic therapy on local control after breast-conserving therapy (1–3). In our study (4), the use of tamoxifen resulted in a lower local relapse rate at the multivariate analysis (p = 0.014) but actually lost its significance at the multivariate analysis, where only the boost and the medium age resulted in a significant association with a lower risk of local relapse. As suggested, we performed a stratified analysis investigating the benefit of surgical bed boost in patients according to adjuvant systemic treatment. The effect of boost in reducing local relapses at the multivariate analysis seems to maintain its importance independently of the use of tamoxifen.
1. Kased N, Binder DK, McDermont MW, et al. Gamma knife radiosurgery for brain metastases from primary breast cancer. Int J Radiat Oncol Biol Phys 2009;75:1132–1140. 2. Goyal S, Prasad D, Harrell F, et al. Gamma knife surgery for the treatment of intracranial metastases from breast cancer. J Neurosurg 2005;103: 218–223. 3. Akyurek S, Chang EL, Mahajan A, et al. Stereotactic radiosurgery of cerebral metastases arising from breast cancer. Am J Clin Oncol 2007;30:310–314. 4. Weltman E, Salvajoli JV, Oliveira VC, et al. Score index for stereotactic radiosurgery of brain metastases. J Radiosur 1998;2:89–97. 5. Weltman E, Salvajoli JV, Brandt RA, et al. Radiosurgery for brain metastases: A score index for predicting prognosis. Int J Radiat Oncol Biol Phys 2000;46:1155–1161.
I. J. Radiation Oncology d Biology d Physics
8. McCarten KM, Rosen N, Friedman D, Schwartz CL, Voss S, BishopJodoin M, et al. Feasibility of real time diagnostic imaging central review in multicenter cancer trials. ARRS; Boston, MA, 2009. 9. Laprise NK, Hanusik R, Fitzgerald TJ, Rosen N, White KS. Developing a multi-institutional PACS archive and designing processes to manage the shift from a film to a digital-based archive. J Digit Imaging 2009;22(1):15– 24.
RESPONSE TO ‘‘BENEFIT OF RADIATION BOOST AFTER WHOLE-BREAST RADIOTHERAPY’’ (INT J RADIAT ONCOL BIOL PHYS 2009;75:1029–1034) To the Editor: Livi and colleagues reported on the effect of boost irradiation of the tumor bed after breast-conserving surgery for early breast cancer on the risk of cancer relapse in the treated breast (1). Their results showed that a boost significantly reduced the risk of local breast cancer relapse and that the effect was stronger in young patients, thus confirming the results from randomized controlled trials. Of the 399 patients without a boost, only 9% received chemotherapy and 20% received tamoxifen, whereas of the patients with a boost, 37% received chemotherapy and 58% tamoxifen. Several studies have confirmed the favorable effect of adjuvant systemic therapy on local control after breast-conserving therapy (2–4). The observed risk reductions in these studies vary between 50% and 70%. In the study by Livi and colleagues, adjustments were made for the use of adjuvant systemic treatment by performing a multivariate analysis, which confirmed the beneficial effect of tamoxifen on local control of disease. For a better understanding of the role of the boost dose in current practice, it would also be interesting to know the effect of boost irradiation on local recurrence risk for patients with and without adjuvant systemic treatment. Indications for the use of adjuvant systemic treatment have changed in such a way during the past decade that the large majority of patients are currently receiving chemotherapy, hormonal therapy, or a combination of both. The absolute benefit of boost irradiation with respect to the risk of local recurrence is probably smaller for patients who also receive adjuvant systemic treatment. This could be checked by doing an analysis for the patients with and without a boost, stratified according to the use of adjuvant systemic treatment. ADRI C. VOOGD, PH.D. Eindhoven Cancer Registry Eindhoven, The Netherlands MAURICE J.C. VAN DER SANGEN, M.D. Department of Radiotherapy Catharina Hospital Eindhoven, The Netherlands doi:10.1016/j.ijrobp.2009.12.027 1. Livi L, Borghesi S, Saieva C, et al. Benefit of radiation boost after wholebreast radiotherapy. Int J Radiat Oncol Biol Phys 2009;75:1029–1034. 2. van der Leest M, Evers L, van der Sangen MJ, et al. The safety of breastconserving therapy in patients with breast cancer aged \ or = 40 years. Cancer 2007;109:1957–1964. 3. Buchholz TA, Tucker SL, Erwin J, et al. Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breast-conservation therapy. J Clin Oncol 2001;19:2240–2246. 4. Haffty BG, Wilmarth L, Wilson L, et al. Adjuvant systemic chemotherapy and hormonal therapy: Effect on local recurrence in the conservatively treated breast cancer patient. Cancer 1994;73:2543–2548.
Volume 77, Number 1, 2010 This effect seems to be even lower in the group not receiving tamoxifen (hazard ratio [HR] 0.39; 95% confidence interval [CI] 0.179–0.850) than in the group of patients who received tamoxifen (HR 0.195; 95% CI 0.053–0.717). Regarding the role of chemotherapy, we found that the boost maintained its importance in patients not receiving chemotherapy (HR 0.281; 95% CI 0.136–0.584) and lost its significance in patients receiving chemotherapy, but this is probably due to the low number of events in this group (only six recurrences). Therefore we cannot confirm the hypothesis of Voogd and van der Sangen, although we have to take into account that performing a stratified analysis reduces the number of patients in each group and the statistical power, and also that the retrospective nature of this study did not allow us to draw definitive conclusions. Nevertheless, at the moment we have no data that could justify not prescribing surgical bed boost to patients receiving systemic adjuvant treatments. LORENZO LIVI, M.D. GABRIELE SIMONTACCHI, M.D. ICRO MEATTINI, M.D. GIAMPAOLO BITI, M.D. Department of Radiotherapy-Oncology University of Florence Florence, Italy doi:10.1016/j.ijrobp.2009.12.028 1. van der Leest M, Evers L, van der Sangen MJ, et al. The safety of breastconserving therapy in patients with breast cancer aged \ or = 40 years. Cancer 2007;109:1957–1964. 2. Buchholz TA, Tucker SL, Erwin J, et al. Impact of systemic treatment on local control for patients with lymph node-negative breast cancer treated with breast-conservation therapy. J Clin Oncol 2001;19:2240–2246. 3. Haffty BG, Wilmarth L, Wilson L, et al. Adjuvant systemic chemotherapy and hormonal therapy: Effect on local recurrence in the conservatively treated breast cancer patient. Cancer 1994;73:2543–2548. 4. Livi L, Borghesi S, Saieva C, et al. Benefit of radiation boost after wholebreast radiotherapy. Int J Radiat Oncol Biol Phys 2009;75:1029–1034.
IN REGARD TO KASED N ET AL. (INT J RADIAT ONCOL BIOL PHYS 2009;75:1132–1140) To the Editor: We would like to inform Kased et al. (1) that in the cited articles from Goyal et al. (2) and Akyurek et al. (3) in their Table 8, SIR means ‘‘score index for stereotactic radiosurgery for brain metastases’’ and not ‘‘standardized incidence ratio,’’ as it was quoted there. The SIR is an index developed to determine the prognosis of patients with brain metastases treated with stereotactic radiosurgery (4, 5). These articles showed that SIR was more accurate than Radiation Therapy Oncology Group recursive partitioning analysis in predicting the prognosis in breast cancer patients with brain metastases treated with stereotactic radiosurgery. EDUARDO WELTMAN, M.D. Department of Radiation Oncology REYNALDO ANDRE´ BRANDT, M.D. Department of Neurosurgery Hospital Israelita Albert Einstein Sa˜o Paulo, SP, Brazil doi:10.1016/j.ijrobp.2009.12.034
IN REPLY TO DRS. VOOGD AND VAN DER SANGEN To the Editor: As stated in the letter by Voogd and van der Sangen, several studies have confirmed the favorable effect of adjuvant systemic therapy on local control after breast-conserving therapy (1–3). In our study (4), the use of tamoxifen resulted in a lower local relapse rate at the multivariate analysis (p = 0.014) but actually lost its significance at the multivariate analysis, where only the boost and the medium age resulted in a significant association with a lower risk of local relapse. As suggested, we performed a stratified analysis investigating the benefit of surgical bed boost in patients according to adjuvant systemic treatment. The effect of boost in reducing local relapses at the multivariate analysis seems to maintain its importance independently of the use of tamoxifen.
1. Kased N, Binder DK, McDermont MW, et al. Gamma knife radiosurgery for brain metastases from primary breast cancer. Int J Radiat Oncol Biol Phys 2009;75:1132–1140. 2. Goyal S, Prasad D, Harrell F, et al. Gamma knife surgery for the treatment of intracranial metastases from breast cancer. J Neurosurg 2005;103: 218–223. 3. Akyurek S, Chang EL, Mahajan A, et al. Stereotactic radiosurgery of cerebral metastases arising from breast cancer. Am J Clin Oncol 2007;30:310–314. 4. Weltman E, Salvajoli JV, Oliveira VC, et al. Score index for stereotactic radiosurgery of brain metastases. J Radiosur 1998;2:89–97. 5. Weltman E, Salvajoli JV, Brandt RA, et al. Radiosurgery for brain metastases: A score index for predicting prognosis. Int J Radiat Oncol Biol Phys 2000;46:1155–1161.