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The Impact of a Boost on Outcomes after Breast-conserving Surgery and Radiation
Proceedings of the 51st Annual ASTRO Meeting
2018
Three Year Local Control following Single Dose Intraoperative Radiotherapy for Early Stage Breast Cancer
R. J. Kimple, C. I. Sartor, D. T. Moore, W. M. Chiu, L. Esler, N. Klauber-DeMore, D. W. Ollila University of North Carolina, Chapel Hill, NC Purpose/Objective(s): To determine the feasibility of obtaining an acceptable cosmetic outcome and local control rate using partial breast irradiation with a single fraction of intraoperative radiotherapy (IORT) targeting the tumor in situ. Materials/Methods: In 2003, we initiated a Phase II trial of IORT delivered partial breast irradiation for women with early stage breast cancer. Women age 48 or older with ultrasound-visible tumors \3 cm and clinically negative lymph nodes were eligible. Following sentinel lymph node procedure, skin flaps were raised to retract the breast skin from the field and 1500 cGy was delivered using an electron irradiator (Mobetron, IntraOP Medical Corp, Sunnyvale, CA). The target volume included the tumor, a 1.5-2 cm radial margin, and a 1 cm deep margin. Tumor excision followed IORT. Whole breast radiation or re-excision was performed if pre-specified criteria were met. Patients who received whole breast radiation or mastectomy were excluded from these analyses. The primary endpoints, cosmetic outcome and grade III/IV toxicity, were assessed by a physician. Ipsilateral breast recurrence, a secondary endpoint, was classified as true/marginal, elsewhere, or regional. Kaplan-Meier methods were used to estimate all survival functions. Results: From March 2003 to July 2007, 71 women were enrolled and underwent subsequent IORT with an average follow-up of 2.8 years (median 2.6). Seven patients underwent subsequent mastectomy and 11 received whole breast radiation. Of 53 evaluable patients, the age range was 48-92 (mean 64) with a mean follow-up of 2.6 years (median 2.6). ER-positive disease was seen in 79% of patients, while 15% were triple negative (i.e., negative for ER, PR, and HER2). Grade 1, 2, and 3 tumors were seen in 38%, 38%, and 24% of patients, respectively. Pathologic evaluation revealed 4% of patients had pT1a tumors, 22% had pT1b, 57% had pT1c, and 17% had pT2. Two women experienced pathologically confirmed ipsilateral breast failures: a true/marginal failure at 5.8 months and an elsewhere failure at 13.4 months, for a three-year local control rate of 51/53 (96%; 95% CI: 85% - 99%). Three year adjusted overall survival for patients treated with only IORT was 91%, and breast cancer-specific survival was 100%. Physician assessment of cosmetic outcome at the 2 year follow-up visit was available for 27/53 patients; all had good or excellent cosmetic outcomes. Finally, grade 1 toxicities were seen in 2/53 patients (4%; exact 95% CI: 0% -13%). No grade 2, 3, or 4 toxicities or serious adverse events have been seen to date. Conclusions: Intraoperative radiotherapy delivered to an in situ tumor is feasible for selected patients. Three-year local control and breast cancer-specific survival are acceptable, but longer follow-up is needed. Author Disclosure: R.J. Kimple, None; C.I. Sartor, None; D.T. Moore, None; W.M. Chiu, None; L. Esler, None; N. KlauberDeMore, None; D.W. Ollila, None.
2019
The Impact of a Boost on Outcomes after Breast-conserving Surgery and Radiation 1
C. Murphy , T. Li2, P. Anderson2, N. Nicolaou2, G. Freedman2 1
Temple University School of Medicine, Philadelphia, PA, 2Fox Chase Cancer Center, Philadelphia, PA
Purpose/Objective(s): Randomized studies have demonstrated the effectiveness of a boost after receiving whole breast radiation for breast cancer. We examine local control and cosmetic outcomes with specific attention to factors relating to the boost. Materials/Methods: 3186 women underwent whole-breast radiation for breast cancer from 1970 to 2008. Eligibility included lumpectomy, Tis-T2, and receiving a boost. Exclusion criteria included mastectomy, men, T3-T4, or Stage IV disease. The primary endpoints were local control, cosmesis rated by the patient when available or by the physician, and fibrosis on physician breast exam. Assessments were made during physician visits approximately every 6 months for 5 years and then annually. In univariate analysis, Kaplan-Meier method was used to estimate the 5 and 10 yr actuarial rates of the endpoints. In multivariate analysis (MVA), the Cox proportional hazard model was used to look for independent predictors of the endpoints. Factors analyzed included patient age, tumor size, boost, and total dose, tumor location, boost cut-out size, energy of boost, whole breast treatment technique, and energy, and use of systemic therapy. Results: The median follow-up was 78 months (range 1-305). Of 3186 patients, 3087 had an electron boost and 99 had a photon boost. Boost energy was 6-10 MeV in 31%, 12-16 MeV in 51%, and 18-21 MeV in 18%. Boost size was 4-6 cm in 33%, 7-8 cm in 41%, . 8 cm in 11%, and unknown in 15%. Boost dose was \10 Gy in 9%, 11-16 Gy in 59%, and .16 Gy in 32%. The median age is 58 years (range 20-91). 2567 patients were available for cosmetic assessment. Crude cosmetic result at last follow-up was excellent in 54%, good in 41%, and fair/poor in 5%. The 10-year actuarial rate of having an excellent cosmesis was 66%. On MVA, independent predictors of an excellent cosmetic result were use of electron boost, lower electron energy, use of adjuvant systemic therapy, and whole breast IMRT. 269 of 3186 patients developed fibrosis. The actuarial incidence of fibrosis was 11% at 5 years and 17% at 10 years. On MVA, independent predictors of increased fibrosis were larger cup size and higher boost energy. The use of IMRT was an independent predictor of decreased fibrosis. The 10-year actuarial local failure was 6.3%. There was no significant difference in local control by boost method, cut-out size, dose, or energy. Conclusions: Excellent cosmesis after a boost was associated with lower electron energy and use of electrons, while higher energy or photon boost in patients with larger cup size was associated with increased incidence of fibrosis. However, because local control was high and the incidence of fair/poor cosmesis was low, patient anatomy should ultimately determine the choice of boost parameters. Author Disclosure: C. Murphy, None; T. Li, None; P. Anderson, None; N. Nicolaou, None; G. Freedman, None.
2020
Triple-negative and Her-2 Positive Predict Higher Locoregional Recurrence in Node Positive Breast Cancer Patients Treated with Mastectomy
S. Wang, Y. Li, Y. Song, W. Wang, J. Jin, Y. Liu, X. Liu, Z. Yu Cancer Hospital, Chinese Academy of Medical Science, Beijing, China Purpose/Objective(s): To evaluate the prognostic value of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor 2 (Her2) in node-positive breast cancer patients treated with mastectomy.
S189
2018
Three Year Local Control following Single Dose Intraoperative Radiotherapy for Early Stage Breast Cancer
R. J. Kimple, C. I. Sartor, D. T. Moore, W. M. Chiu, L. Esler, N. Klauber-DeMore, D. W. Ollila University of North Carolina, Chapel Hill, NC Purpose/Objective(s): To determine the feasibility of obtaining an acceptable cosmetic outcome and local control rate using partial breast irradiation with a single fraction of intraoperative radiotherapy (IORT) targeting the tumor in situ. Materials/Methods: In 2003, we initiated a Phase II trial of IORT delivered partial breast irradiation for women with early stage breast cancer. Women age 48 or older with ultrasound-visible tumors \3 cm and clinically negative lymph nodes were eligible. Following sentinel lymph node procedure, skin flaps were raised to retract the breast skin from the field and 1500 cGy was delivered using an electron irradiator (Mobetron, IntraOP Medical Corp, Sunnyvale, CA). The target volume included the tumor, a 1.5-2 cm radial margin, and a 1 cm deep margin. Tumor excision followed IORT. Whole breast radiation or re-excision was performed if pre-specified criteria were met. Patients who received whole breast radiation or mastectomy were excluded from these analyses. The primary endpoints, cosmetic outcome and grade III/IV toxicity, were assessed by a physician. Ipsilateral breast recurrence, a secondary endpoint, was classified as true/marginal, elsewhere, or regional. Kaplan-Meier methods were used to estimate all survival functions. Results: From March 2003 to July 2007, 71 women were enrolled and underwent subsequent IORT with an average follow-up of 2.8 years (median 2.6). Seven patients underwent subsequent mastectomy and 11 received whole breast radiation. Of 53 evaluable patients, the age range was 48-92 (mean 64) with a mean follow-up of 2.6 years (median 2.6). ER-positive disease was seen in 79% of patients, while 15% were triple negative (i.e., negative for ER, PR, and HER2). Grade 1, 2, and 3 tumors were seen in 38%, 38%, and 24% of patients, respectively. Pathologic evaluation revealed 4% of patients had pT1a tumors, 22% had pT1b, 57% had pT1c, and 17% had pT2. Two women experienced pathologically confirmed ipsilateral breast failures: a true/marginal failure at 5.8 months and an elsewhere failure at 13.4 months, for a three-year local control rate of 51/53 (96%; 95% CI: 85% - 99%). Three year adjusted overall survival for patients treated with only IORT was 91%, and breast cancer-specific survival was 100%. Physician assessment of cosmetic outcome at the 2 year follow-up visit was available for 27/53 patients; all had good or excellent cosmetic outcomes. Finally, grade 1 toxicities were seen in 2/53 patients (4%; exact 95% CI: 0% -13%). No grade 2, 3, or 4 toxicities or serious adverse events have been seen to date. Conclusions: Intraoperative radiotherapy delivered to an in situ tumor is feasible for selected patients. Three-year local control and breast cancer-specific survival are acceptable, but longer follow-up is needed. Author Disclosure: R.J. Kimple, None; C.I. Sartor, None; D.T. Moore, None; W.M. Chiu, None; L. Esler, None; N. KlauberDeMore, None; D.W. Ollila, None.
2019
The Impact of a Boost on Outcomes after Breast-conserving Surgery and Radiation 1
C. Murphy , T. Li2, P. Anderson2, N. Nicolaou2, G. Freedman2 1
Temple University School of Medicine, Philadelphia, PA, 2Fox Chase Cancer Center, Philadelphia, PA
Purpose/Objective(s): Randomized studies have demonstrated the effectiveness of a boost after receiving whole breast radiation for breast cancer. We examine local control and cosmetic outcomes with specific attention to factors relating to the boost. Materials/Methods: 3186 women underwent whole-breast radiation for breast cancer from 1970 to 2008. Eligibility included lumpectomy, Tis-T2, and receiving a boost. Exclusion criteria included mastectomy, men, T3-T4, or Stage IV disease. The primary endpoints were local control, cosmesis rated by the patient when available or by the physician, and fibrosis on physician breast exam. Assessments were made during physician visits approximately every 6 months for 5 years and then annually. In univariate analysis, Kaplan-Meier method was used to estimate the 5 and 10 yr actuarial rates of the endpoints. In multivariate analysis (MVA), the Cox proportional hazard model was used to look for independent predictors of the endpoints. Factors analyzed included patient age, tumor size, boost, and total dose, tumor location, boost cut-out size, energy of boost, whole breast treatment technique, and energy, and use of systemic therapy. Results: The median follow-up was 78 months (range 1-305). Of 3186 patients, 3087 had an electron boost and 99 had a photon boost. Boost energy was 6-10 MeV in 31%, 12-16 MeV in 51%, and 18-21 MeV in 18%. Boost size was 4-6 cm in 33%, 7-8 cm in 41%, . 8 cm in 11%, and unknown in 15%. Boost dose was \10 Gy in 9%, 11-16 Gy in 59%, and .16 Gy in 32%. The median age is 58 years (range 20-91). 2567 patients were available for cosmetic assessment. Crude cosmetic result at last follow-up was excellent in 54%, good in 41%, and fair/poor in 5%. The 10-year actuarial rate of having an excellent cosmesis was 66%. On MVA, independent predictors of an excellent cosmetic result were use of electron boost, lower electron energy, use of adjuvant systemic therapy, and whole breast IMRT. 269 of 3186 patients developed fibrosis. The actuarial incidence of fibrosis was 11% at 5 years and 17% at 10 years. On MVA, independent predictors of increased fibrosis were larger cup size and higher boost energy. The use of IMRT was an independent predictor of decreased fibrosis. The 10-year actuarial local failure was 6.3%. There was no significant difference in local control by boost method, cut-out size, dose, or energy. Conclusions: Excellent cosmesis after a boost was associated with lower electron energy and use of electrons, while higher energy or photon boost in patients with larger cup size was associated with increased incidence of fibrosis. However, because local control was high and the incidence of fair/poor cosmesis was low, patient anatomy should ultimately determine the choice of boost parameters. Author Disclosure: C. Murphy, None; T. Li, None; P. Anderson, None; N. Nicolaou, None; G. Freedman, None.
2020
Triple-negative and Her-2 Positive Predict Higher Locoregional Recurrence in Node Positive Breast Cancer Patients Treated with Mastectomy
S. Wang, Y. Li, Y. Song, W. Wang, J. Jin, Y. Liu, X. Liu, Z. Yu Cancer Hospital, Chinese Academy of Medical Science, Beijing, China Purpose/Objective(s): To evaluate the prognostic value of estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor 2 (Her2) in node-positive breast cancer patients treated with mastectomy.
S189