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Retrospective Analysis of Management of Phyllodes Tumours
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Abstracts / Clinical Oncology 28 (2016) e1ee7
Radiological Staging in Newly Diagnosed Breast Cancer S. Massalha, S. Walters, C. Bale, C. Fuller, J. Bishop Ysbyty Gwynedd, Bangor, UK
Purpose: Breast cancer is a common disease; 50 285 women in the UK were diagnosed in 2011 [1]. For women considered to be at higher risk of metastatic disease, it is appropriate to undergo staging scans with CT and bone scintography [2]. This is to ensure women receive appropriate local and systemic treatment whilst not unduly burdening stretched radiology services. Methods: This is a retrospective analysis of patients newly diagnosed with breast cancer in North Wales. Patients identified from MDT records from September 2014 to September 2015 were randomly selected. Based on the ESMO 2015 guidelines [3], we defined three groups whereby CT staging is appropriate: patients undergoing neoadjuvant chemotherapy, patients with symptoms indicative of metastatic disease and patients with a higher chance of metastatic disease at presentation, i.e. any T N2 or N1 with high risk features [4]. Patients with early stage breast cancer should not be routinely staged [5]. Results: We sampled 204 of 533 patients. 54 patients (26%) were staged. Of these, 30 (56%) patients were staged appropriately; 24 (44%) were overstaged. Of these, 8 (30%) could be considered high risk and require discussion. 5 patients (9%) were upstaged to M1 disease. 12 (22%) had equivocal lesions that required further scans. 35 (62%) patients were staged with CT chest/abdomen/pelvis only, 10 (18.5%) with CT chest/abdomen/pelvis and bone scintography, 8 (15%) with CT chest/abdomen and bone scintography and 1 (0.5%) with bone scintography only. Conclusions: Staging scans have an important role in the management of breast cancer. Patients with high risk features, e.g. aggressive tumour biology or high burden of nodal involvement, require clinical decision making to determine the need for CT staging. There is disparity within the trust regarding staging methods. For the future, clear, local guidelines are needed to ensure uniformity. References [1] Breast cancer incidence statistics, Cancer Research UK. [2] NICE guidelines [CG81]. Advanced breast cancer (update): diagnosis and treatment, February 2009. [3] Senkus E, Kyriakides S, Ohno S, et al. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015;26(Suppl. 5):v8ev30. [4] AJCC Cancer Staging Manual, 7th edn. American Joint Committee on Cancer, 2009. [5] Royal College of Radiologists’ guidelines: Recommendations for cross sectional imaging in cancer management, 2nd edn, 2014. Retrospective Analysis of Management of Phyllodes Tumours S. Nezafat Namini, R. Turner, K. Horgan, R. Achuthan, P. Dickinson St James’ Hospital, Leeds, UK Purpose: Phyllodes tumours are rare fibroepithelial malignancies graded depending on stromal component as benign, borderline and malignant [1]. Malignant phyllodes are highly aggressive and because of their clinical behaviour and prognosis should be treated as primary breast sarcomas rather than infiltrating ductal carcinomas [2]. Treatment principles are based on retrospective series and case reports. Surgery is the main treatment, aiming for surgical margin >1 cm (based on NCCN guidelines) with adjuvant RT considered [3]. To establish the incidence, management and patterns of recurrence of phyllodes tumours treated at Leeds Cancer Centre. Methods: Patients diagnosed with phyllodes tumours between 2004 and 2013 identified using an electronic patient record system. Data regarding histology, surgical management, adjuvant radiotherapy and evidence of recurrence were analysed. Results: 84 patients identified, 43 (51%) diagnosed with benign phyllodes tumours,14 (17%) with borderline tumours and 27 (32%) with malignant tumours. 1 (1%) patient had metastases at presentation. Of 27 patients with malignant phyllodes tumours, 9 (33%) had a wide local excision (WLE), of which 8 had adjuvant radiotherapy and 1 was not offered radiotherapy and had margins of >1 cm. 18 (67%) had a mastectomy, in 4 of these patients tumour reached posterior (deep) margin and were considered for adjuvant RT. Of which 3 received radiotherapy,1 declined radiotherapy and 1 had wound complications and therefore was unable to have radiotherapy. No patients with malignant
phyllodes suffered a local recurrence. 2 patients with malignant phyllodes developed metastases (1 chest wall and lung, 1 to pleura and pancreas). Conclusion: Malignant phyllodes tumours have the potential to recur locally and metastasise. Our local control rates are consistent with previously published data. We believe malignant phyllodes tumours should be managed by WLE followed by adjuvant radiotherapy or mastectomy with consideration of adjuvant radiotherapy if deep margin is involved. References [1] Norris HJ, et al. Relationship of histologic features to behaviour of cystosarcoma analysis of ninety four cases. Cancer 1978;20(12):2090e2099. [2] Reinfuss M, et al. The treatment and prognosis of patients with phyllodes tumour of the breast: an analysis of 170 cases. Cancer 1996;77(5):910. [3] Barth RJ, et al. A prospective multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumours. Ann Surg Oncol 2009;16(8):2288e2294. Further reading [4] Confavreux C, et al. Sarcomas and malignant phyllodes tumours of the breast e a retrospective study. Eur J Cancer 2006;42:2715. [5] Pezner RD, et al. Malignant phyllodes tumour of the breast: local control rates with surgery alone. Int J Radiat Oncol Biol Pys 2008;71:710. [6] Spitaleri G, et al. Breast phyllodes tumour: a review of literature and a single centre retrospective series analysis. Crit Rev Oncol Haematol 2013;88:427e436. Deep Inspiration Breath Holding (DIBH) Implementation: Heart Dosimetric Parameters in Selection of Patients R. Owens, S. Oliveros Churchill Hospital, Oxford, UK Purpose: Incidental heart irradiation in patients with breast cancer (BC) is known to increase risk of ischaemic heart disease. Several publications have reported a significant reduction in heart dose by using DIBH. DIBH implementation is currently on the way in the UK. Arbitrary cut-offs of maximum heart depth (MHD) ranging from 5 to 15 mm measured in free breathing scan to assess eligibility for DIBH have been used. We assessed MHD and mean heart dose (MD) in all left-sided BC treated with conventional tangential fields in a single centre over a period of 2 months aiming to set up a threshold above which patients will benefit most from DIBH. To compare heart doses between conventional tangential fields and IMRT. Methods: Retrospective review of 60 RT plans for left breast/chest wall. MHD was measured, heart was contoured to estimate MD and NTDmean (a biological weighted mean of total dose to tissue normalised to 2 Gy fractions using a standard linear quadratic model; a/b3 Gy for late cardiac effects). As a comparison, MD was assessed in patients treated using inverse-planned IMRT (n ¼ 15). Results: In the conventional tangential fields group, the MHD was 0.95 cm and MD was 2.19 Gy with a correlation coefficient of 0.84. The average heart NTDmean was 1.38 Gy. 50% of cases had 1 cm MHD. For the IMRT group, MD was 2.86 Gy with an average heart NTDmean of 1.83 Gy. Conclusion: MHD correlates well with MD. MHD and MD were lower using tangential fields compared with IMRT. It became obvious that given it is not possible to know what phase of the breathing cycle a free breathing scan is done in, the measurement of MHD is inaccurate to select patients for DIBH. The present audit justified offering DIBH to all left-sided BC patient having radiotherapy in our centre. A Retrospective Comparison of Subjective Side-effects from Aromatase Inhibitors for Breast Cancer in the Adjuvant and Metastatic Setting S. Prince, C. Archer, K. Bradley Queen Alexandra Hospital, Portsmouth, UK Purpose: Aromatase inhibitors (AI) are used adjuvantly for post-menopausal women with oestrogen receptor (ER) positive breast cancer to reduce the risk of recurrence, and in the metastatic setting to improve overall survival. Subjective side-effects such as arthralgias can result in discontinuation of AIs. We aimed to compare the rates of subjective side-effects in the adjuvant and metastatic settings. Methods: A retrospective review of clinical notes was conducted in patients receiving an AI with adjuvant or metastatic intent for a whole calendar year.
Abstracts / Clinical Oncology 28 (2016) e1ee7
Radiological Staging in Newly Diagnosed Breast Cancer S. Massalha, S. Walters, C. Bale, C. Fuller, J. Bishop Ysbyty Gwynedd, Bangor, UK
Purpose: Breast cancer is a common disease; 50 285 women in the UK were diagnosed in 2011 [1]. For women considered to be at higher risk of metastatic disease, it is appropriate to undergo staging scans with CT and bone scintography [2]. This is to ensure women receive appropriate local and systemic treatment whilst not unduly burdening stretched radiology services. Methods: This is a retrospective analysis of patients newly diagnosed with breast cancer in North Wales. Patients identified from MDT records from September 2014 to September 2015 were randomly selected. Based on the ESMO 2015 guidelines [3], we defined three groups whereby CT staging is appropriate: patients undergoing neoadjuvant chemotherapy, patients with symptoms indicative of metastatic disease and patients with a higher chance of metastatic disease at presentation, i.e. any T N2 or N1 with high risk features [4]. Patients with early stage breast cancer should not be routinely staged [5]. Results: We sampled 204 of 533 patients. 54 patients (26%) were staged. Of these, 30 (56%) patients were staged appropriately; 24 (44%) were overstaged. Of these, 8 (30%) could be considered high risk and require discussion. 5 patients (9%) were upstaged to M1 disease. 12 (22%) had equivocal lesions that required further scans. 35 (62%) patients were staged with CT chest/abdomen/pelvis only, 10 (18.5%) with CT chest/abdomen/pelvis and bone scintography, 8 (15%) with CT chest/abdomen and bone scintography and 1 (0.5%) with bone scintography only. Conclusions: Staging scans have an important role in the management of breast cancer. Patients with high risk features, e.g. aggressive tumour biology or high burden of nodal involvement, require clinical decision making to determine the need for CT staging. There is disparity within the trust regarding staging methods. For the future, clear, local guidelines are needed to ensure uniformity. References [1] Breast cancer incidence statistics, Cancer Research UK. [2] NICE guidelines [CG81]. Advanced breast cancer (update): diagnosis and treatment, February 2009. [3] Senkus E, Kyriakides S, Ohno S, et al. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015;26(Suppl. 5):v8ev30. [4] AJCC Cancer Staging Manual, 7th edn. American Joint Committee on Cancer, 2009. [5] Royal College of Radiologists’ guidelines: Recommendations for cross sectional imaging in cancer management, 2nd edn, 2014. Retrospective Analysis of Management of Phyllodes Tumours S. Nezafat Namini, R. Turner, K. Horgan, R. Achuthan, P. Dickinson St James’ Hospital, Leeds, UK Purpose: Phyllodes tumours are rare fibroepithelial malignancies graded depending on stromal component as benign, borderline and malignant [1]. Malignant phyllodes are highly aggressive and because of their clinical behaviour and prognosis should be treated as primary breast sarcomas rather than infiltrating ductal carcinomas [2]. Treatment principles are based on retrospective series and case reports. Surgery is the main treatment, aiming for surgical margin >1 cm (based on NCCN guidelines) with adjuvant RT considered [3]. To establish the incidence, management and patterns of recurrence of phyllodes tumours treated at Leeds Cancer Centre. Methods: Patients diagnosed with phyllodes tumours between 2004 and 2013 identified using an electronic patient record system. Data regarding histology, surgical management, adjuvant radiotherapy and evidence of recurrence were analysed. Results: 84 patients identified, 43 (51%) diagnosed with benign phyllodes tumours,14 (17%) with borderline tumours and 27 (32%) with malignant tumours. 1 (1%) patient had metastases at presentation. Of 27 patients with malignant phyllodes tumours, 9 (33%) had a wide local excision (WLE), of which 8 had adjuvant radiotherapy and 1 was not offered radiotherapy and had margins of >1 cm. 18 (67%) had a mastectomy, in 4 of these patients tumour reached posterior (deep) margin and were considered for adjuvant RT. Of which 3 received radiotherapy,1 declined radiotherapy and 1 had wound complications and therefore was unable to have radiotherapy. No patients with malignant
phyllodes suffered a local recurrence. 2 patients with malignant phyllodes developed metastases (1 chest wall and lung, 1 to pleura and pancreas). Conclusion: Malignant phyllodes tumours have the potential to recur locally and metastasise. Our local control rates are consistent with previously published data. We believe malignant phyllodes tumours should be managed by WLE followed by adjuvant radiotherapy or mastectomy with consideration of adjuvant radiotherapy if deep margin is involved. References [1] Norris HJ, et al. Relationship of histologic features to behaviour of cystosarcoma analysis of ninety four cases. Cancer 1978;20(12):2090e2099. [2] Reinfuss M, et al. The treatment and prognosis of patients with phyllodes tumour of the breast: an analysis of 170 cases. Cancer 1996;77(5):910. [3] Barth RJ, et al. A prospective multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumours. Ann Surg Oncol 2009;16(8):2288e2294. Further reading [4] Confavreux C, et al. Sarcomas and malignant phyllodes tumours of the breast e a retrospective study. Eur J Cancer 2006;42:2715. [5] Pezner RD, et al. Malignant phyllodes tumour of the breast: local control rates with surgery alone. Int J Radiat Oncol Biol Pys 2008;71:710. [6] Spitaleri G, et al. Breast phyllodes tumour: a review of literature and a single centre retrospective series analysis. Crit Rev Oncol Haematol 2013;88:427e436. Deep Inspiration Breath Holding (DIBH) Implementation: Heart Dosimetric Parameters in Selection of Patients R. Owens, S. Oliveros Churchill Hospital, Oxford, UK Purpose: Incidental heart irradiation in patients with breast cancer (BC) is known to increase risk of ischaemic heart disease. Several publications have reported a significant reduction in heart dose by using DIBH. DIBH implementation is currently on the way in the UK. Arbitrary cut-offs of maximum heart depth (MHD) ranging from 5 to 15 mm measured in free breathing scan to assess eligibility for DIBH have been used. We assessed MHD and mean heart dose (MD) in all left-sided BC treated with conventional tangential fields in a single centre over a period of 2 months aiming to set up a threshold above which patients will benefit most from DIBH. To compare heart doses between conventional tangential fields and IMRT. Methods: Retrospective review of 60 RT plans for left breast/chest wall. MHD was measured, heart was contoured to estimate MD and NTDmean (a biological weighted mean of total dose to tissue normalised to 2 Gy fractions using a standard linear quadratic model; a/b3 Gy for late cardiac effects). As a comparison, MD was assessed in patients treated using inverse-planned IMRT (n ¼ 15). Results: In the conventional tangential fields group, the MHD was 0.95 cm and MD was 2.19 Gy with a correlation coefficient of 0.84. The average heart NTDmean was 1.38 Gy. 50% of cases had 1 cm MHD. For the IMRT group, MD was 2.86 Gy with an average heart NTDmean of 1.83 Gy. Conclusion: MHD correlates well with MD. MHD and MD were lower using tangential fields compared with IMRT. It became obvious that given it is not possible to know what phase of the breathing cycle a free breathing scan is done in, the measurement of MHD is inaccurate to select patients for DIBH. The present audit justified offering DIBH to all left-sided BC patient having radiotherapy in our centre. A Retrospective Comparison of Subjective Side-effects from Aromatase Inhibitors for Breast Cancer in the Adjuvant and Metastatic Setting S. Prince, C. Archer, K. Bradley Queen Alexandra Hospital, Portsmouth, UK Purpose: Aromatase inhibitors (AI) are used adjuvantly for post-menopausal women with oestrogen receptor (ER) positive breast cancer to reduce the risk of recurrence, and in the metastatic setting to improve overall survival. Subjective side-effects such as arthralgias can result in discontinuation of AIs. We aimed to compare the rates of subjective side-effects in the adjuvant and metastatic settings. Methods: A retrospective review of clinical notes was conducted in patients receiving an AI with adjuvant or metastatic intent for a whole calendar year.