Treatment of stage I and II adenocarcinoma of the breast by tumor excision and irradiation

/III. J. Radiarion Oncok~gy Biol. Phys.. Vol. 1. pp. I553- I559 Printed in the U.S.A. All rights reserved

036~3016/81/1 I I55347$02.00/0 Copyright 0 1981 Pergamon Press Ltd.

0 Rapid Communication TREATMENT

OF STAGE I AND II ADENOCARCINOMA OF THE BREAST BY TUMOR EXCISION AND IRRADIATION JOHN BEDWINEK, M.D.

Director

of Breast Service, Division of Radiation Oncology, * Mallinckrodt Institute of Radiology, University School of Medicine, 45 11 Forest Park, St. Louis, MO 63 108

Washington

In recent years there has been an increase in the number of women with breast cancer seeking an alternative to mastectomy. When seeing these patients in consultation, radiation oncologists should make an effort to enter them into one of the two current United States clinical trials involving breast-conserving surgery and irradiation. If a patient cannot or will not be entered into one of these trials, then her management should be based on careful consideration of the various factors involved in the selection of patients for breast-conserving surgery and irradiation, particularly tumor size, breast size and patient attitude. In addition to a discussion of these selection factors, this communication includes a description of the different tvues __ of breast-conserving surgery and the technical details involved in irradiating the intact breast. Breast cancer, Irradiation of breast cancer, Lumpectomy. INTRODUCTION In recent

years a number of articles have been published on the use of irradiation and breast conserving surgery as the primary treatment for Stage I and II adenocarcinoma of the breast.‘,6.8,9,‘0,‘3 Because of the good results in these reports and the public’s increasing awareness of the existence of an alternative to mastectomy, more and more women are seeking this alternative. Moreover, the trend toward earlier diagnosis has resulted in a higher proportion of women who are eligible for breast conserving surgery and irradiation. Since it is anticipated that these trends will continue, it is essential that radiation oncologists be fully aware of all aspects relating to the topic of alternatives to mastectomy. One very important issue is the question of whether the results of breast conserving surgery and irradiation are comparable to those obtained by mastectomy. Retrospective comparisons of patients treated by tumorectomy and irradiation with mastectomy series strongly suggest that, for early lesions, these two treatment methods produce similar results, both in terms of survival and localregional control. Retrospective comparisons, however, cannot prove comparability as solidly as prospective, randomized trials. It is this author”s opinion, therefore, that radiation oncologists should try to participate in one of the two prospective trials evaluating alternatives to mastectomy that are currently underway in the United States. One of these trials is being carried out under the

auspices of the National Cancer Institute. In this study, patients with Tl or T2 tumors are randomized to modified radical mastectomy or tumorectomy and axillary node dissection followed by irradiation to the breast and peripheral lymphatics. All patients with histologically positive nodes also receive adjuvant chemotherapy (adriamycin and cytoxan). Dr. Alan Lichter at the National Cancer Institute in Bethesda, Maryland should be contacted for more information regarding this trial. The other trial is being carried out by the National Surgical Adjuvant Breast Project. In this trial, which has been designated NSABP Protocol 06, patients with tumors 4 cm or less are randomized to one of three treatment arms: 1) total mastectomy plus axillary node dissection (modified radical mastectomy), 2) tumorectomy plus axillary node dissection or 3) tumorectomy plus axillary node dissection followed by irradiation to the breast. All patients with histologically positive axillary lymph nodes also receive adjuvant chemotherapy (L-PAM + 5FU). In addition to comparing tumorec‘tomy and irradiation to modified radical mastectomy this trial also addresses the very important question 01 whether irradiation is a necessary adjunct for all patients treated by tumorectomy. This is an extremely important clinical trial, and every effort should be made to enter patients into it. For more information regarding NSABP Fisher, or Mrs. Mary Protocol 06, contact Dr. Bernard Ketner

at the University

of Pittsburgh

(phone

412-624.

2671).

*The Division of Radiation Oncology is the radiation quality control center for the Southeastern Cancer Study Group. Acknowledgments-The author expresses his gratitude to Dr.

Luther Brady, Dr. William Spanos, and Dr. Jay Harris for their help in the preparation of this report. Accepted for publication 20 July I98 1. 1553

Radiation Oncology 0 Biology ??Physics

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November 1981, Volume 7, Number 11

If a patient cannot be entered into one of the above trials or refuses to participate, then her management should be based on the following considerations which fall into three general categories: 1) patient selection, 2) the types of breast conserving surgical procedures, and 3) the technical details of irradiating the intact breast. METHODS

AND MATERIALS

Patient selection Tumor size. Tumor size is an extremely important selection factor. The larger the tumor, the greater the likelihood of local recurrence. Retrospective reviews’.,6 of patients treated by tumorectomy and irradiation show a local-regional recurrence rate of less than 5% for T, tumors; this incidence is comparable to that seen for T, tumors treated by mastectomy.3,4 For T, lesions, the local-regional recurrence rate with tumor excision and irradiation is about IO%‘,6 and, again, this is similar to holds mastectomy series.3.4 Whether this comparability for both large and small T, lesions remains to be seen; hence, many radiation oncologists have made an arbitrary decision to exclude patients from tumorectomy and irradiation if the tumor size is greater than 3 cm. Breast size. Another selection factor is breast size. A breast that is very small relative to the size of the tumor may show an unacceptably large surgical defect when the entire tumor is excised. In such cases, the best option may be a modified radical mastectomy with subsequent reconstructive surgery. The opposite extreme, very large breasts, will also produce a poor cosmetic result. A very large and pendulous breast will tend to exhibit more fibrosis and retraction following 5,000 rad of irradiation than a moderate sized breast (Figure I). Since a moderate amount of fibrosis and retraction may be more acceptable to a woman than having no breast at all, large pendulous breasts are certainly not a contraindication to tumor excision and irradiation. However, a largebreasted patient and her referring physician should be forewarned of the retraction and fibrosis that may occur. Multiple breast masses. Patients with a second mass in the breast that cannot be excised along with the excision of the dominant mass should be considered for a mastectomy rather than tumor excision and irradiation. It is, therefore, important to obtain mammograms prior to tumor excision, not only to rule out undetected masses within the affected breast, but also to evaluate the contralateral breast. Mammography prior to tumor excision is particularly important in infiltrating lobular carcinoma because of the very high incidence of multifocal disease with this histologic sub-type.” Since this high incidence of multifocality pertains to both the ipsilateral and contralateral breast, the contralateral breast must be followed as closely as the treated breast. with physical examination every two months and mammography at least yearly. In some cases of infiltrating lobular carcinoma, in which the breasts are difficult to examine and in which the fear of a new primary in the contralateral

Fig. I. Example of the retraction produced in a large, pendulous breast six years following irradiation to 5000 rad in 25 fractions. breast is extremely great, bilateral mastectomy with subsequent reconstruction should be considered as an alternative to tumor excision and irradiation of only the symptomatic breast. Distant metastases. Patients with distant metastases should usually be excluded from definitive local irradiation. Therefore, a work-up appropriate to detect distant disease is mandatory on all patients prior to the institution of any definitive treatment. Patient attitude. An important selection factor is the attitude of the woman herself. Breast conserving surgery and irradiation should be limited to those women with a strong desire for breast preservation. Surgery,

There are a number of names for breast conserving surgery: wedge excision, segmental mastectomy, partial mastectomy, tylectomy, tumorectomy, and lumpectomy. Wedge excision, segmental mastectomy, and partial mastectomy are all more or less synonymous and imply resection of the tumor with a generous margin consisting of a segment or wedge of the breast (Figure 2A). This can range from a resection of a very modest amount of breast tissue up to a hemimastectomy. Tylectomy, tumorectomy and lumpectomy are synonymous and mean removal of just the tumor itself without a large segment of surrounding normal breast tissue (Figure 2B). Since the sole reason for performing tumor excision and irradiation in lieu of mastectomy is to leave the patient with two cosmetically acceptable breasts, tylec-

Treatment

of breast cancer with tumor excision and irradiation

1555

0 J. BEDWINEK

Fig. 3. Example of the poor cosmetic result that can be produced by segmental mastectomy. Better cosmesis is obtained by tumorectomy.

Fig. 2. A. Wedge excision, segmental mastectomy, or partial mastectomy. B. Tylectomy, tumorectomy, or lumpectomy, excisional biopsy. tomy is preferable to segmental mastectomy, for the latter may result in a large surgical defect that can impair the cosmetic result (Figure 3). This has been confirmed by the Harvard experience,’ which has shown that cosmetic results are optimum when the tumor is excised with only enough surrounding tissue to obtain a clear margin. The NSABP Protocol 06 recommends that attention be given to the direction of the incision. Cosmesis is best when excisions in the upper half of the breast are circumareolar and excisions in the lower half of the breast are radial (Figure 4). In addition to excision of the tumor, most patients should have either an axillary node sampling or an axillary node dissection. This is essential for premenopausal women, since the axillary nodal status will determine whether adjuvant chemotherapy should be given. Since a recent study of Bonadonna and Valagussa’ has suggested that adjuvant chemotherapy in full doses is

also beneficial in postmenopausal women, an axillary node sampling or dissection is also recommended for these women. The NSABP Protocol 06 recommends that the incision for the axillary surgery be separate from that used for the excision of the breast mass (Figure 5). It is very tempting to include the excision of an upper outer quadrant mass in the same incision used to reach the axillary lymph nodes. This, however, results in a long scar that can produce severe lateral deviation of the breast. The question of whether to perform a low axillary node sampling or a full axillary node dissection has not yet been settled. As a rule there is a higher incidence of breast and arm edema with a full axillary node dissection than with an axillary node sampling. On the other hand, some node “sampling” procedures can be vigorous enough to cause as high a likelihood of breast and arm edema as a full node dissection. Moreover, this probability is increased even further if the axillary node sampling

RECOMMENDED Mi

NON RECOMMENDED Mi

Fig. 4. NSABP recommendation for the direction of the incision used for tumorectomy. Courtesy of Dr. Bernard Fisher, chairman of the National Surgical Adjuvant Breast Project.

1556

Radiation Oncology 0 Biology 0 Physics

RECOMMENDED

NON RECOMMENDED

November 198 1,Volume 7, Number I I internal treated,

mammary and supraclavicular nodes should be but the low axilla can be excluded. If the axillary

lymph

nodes are histologically

lar fossa and internal treated

regardless

previously

positive,

mammary of

mentioned,

the

the supraclavicu-

lymph

location

nodes should

of

if the positive

the

be

lesion.

axillary

As

nodes came

from a axillary

dissection

of at least level 1 and lateral

level

then

low

II

nodes,

receive

irradiation.

sampling treated

the

axillary

If the axillary

of the low axillary whenever

nodes

surgery

need

nodes, the low axilla

the sampled

not

was only

a

must be

nodes are histologically

positive. I)OSP. If all gross disease has been removed, Fig. 5. NSABP recommendation for the incision used for the axillary node dissection. Courtesy of Dr. Bernard Fisher, chairman of the National Surgical Adjuvant Breast Project.

tumor

dose to the entire

breast

rad”: the daily fraction

5000 rad of irradiation surgically

violated

the low axillary

should

axilla.

size should be no less than 180 rad

contents

thorough just

dissection

beneath

positive.

of the axillary

the lateral

border

even if

This author

prefers a

lymphatics

up to and

of the pectoralis

should

if the excision

is performed,

need not be irradiated

excision

excision.

minor

margins

with

energy’ or with an external

and 1500-2000

rad

were not free or were in question.

This boost can be accomplished priate

The site of the

receive a boost of 1000 rad if the

tumor was excised with clear margins

be added to the already

If a full dissection

the nodes are histologically

tumor

nodes, for in this situation.

areas

than 5000

than 200 rad.

Boost to the .site of tumor positive

the total

lymphatic

should be no less than 4500 rad and no greater and no greater

turns up histologically

and

with electrons

an interstitial

photon

beam is usually

for this can cause the boost volume

of appro-

implant.’

Boosting

not acceptable,

to be too large and/or

muscle (level I nodes and the lateral portion of level I1 nodes). When this is done, the low axilla need not be

the dose to underlying

irradiated

and should extend down into the breast to approximately

regardless

of the status of the recovered

If the nodes from this procedure clavicular

fossa is irradiated;

the medial

level

supraclavicular

are positive,

the undissected

II nodes will

fall

within

nodes.

the supralevel I I I and

volume

should

include

two centimeters deep margin

lung to be too high. 2 cm all around

deep to the deep resection

cannot

be determined

the surgeon, then the boost volume

the standard

the pectoralis

field.

Wedges

tumor

excision

an optimum

requires

cosmetic

arc to be obtained. technique

Fields tumor

breast

attention

result and maximum

correct

all situations

the intact

meticulous

control

are several crucial

rectangular:

c,ompensating

Although

for irradiating technical

if

there

considerations

is no single breast,

there

that apply

to

excision

In the past, patients

and irradiation

treated

did not undergo

distribution

bc no greater

with

should extend down to

,filters.

arc usually

Although

breasts

are never square

conical.

For this

or

reason,

filter must be used to achieve a

of dose within

the breast. The varia-

with

an axil-

lary node dissection or sampling; therefore, it was necessary to give comprehensive irradiation to the breast and all three peripheral lymphatic areas. With a sampling or dissection of the axillary lymph nodes, it is possible to reduce the number of lymphatic areas to be treated

than I OR.

Bean1 energ)‘. The entire

breast should be treated

CO”” or with X ray energies of 4-6 MV. greater

and deserve mention.

to be treated.

uniform

If this

by consultation

tion in dose from the base of the breast to its apex should

local-regional

the intact

they

wedges or a compensating

following to detail

margin.

scar

muscle. or

come in all sizes and shapes, they Irradiation technique The technique of treating

The boost

the excision

may

with

Photon energies

than 6 MV should not be used, for these energies

result

in an underdose

to superficial

tissues just

beneath the skin surface. Hollcs. The skin of the breast is usually

not at risk for

recurrence following excision of a Tl or T2 tumor the skin of the chest wall following a mastectomy.

as is For

this reason. applying bolus to the entire breast is unnecessark, and even undesirable, since this practice can produce not only an unnecessarily brisk skin reaction, but also tclangiectasia and other late skin changes that

depending upon the location of the tumor and the histologic status of the axillary nodes. If the axillary lymph nodes are histologically negative in a woman with an outer quadrant lesion, the axilla. supraclavicular fossa. and internal mammary nodes need not be irradiated; onI> the breast is irradiated. If the axillary lymph nodes arc

scar may be bolused for 50-100% of the treatments. At the Harvard .loint Center”.h even the scar is not bolused.

histologically rant lesion.

Matching the supraclavicularfield with the tangential fields. A hot soot can exist iust beneath the skin surface

negative in a woman with then. in addition to breast

a medial quadirradiation. the

impare the cosmetic result.” Since the skin immediately adjacent to the excision scar may be at risk, the excision

Treatment of breast cancer with tumor excision and irradiation 0 J.

BEDWINEK

1557

A

Fig. 6. The hot spot beneath the skin surface at the junction of the supraclavicular field and tangential fields is caused by: A. Divergence of the tangential beams up into the supraclavicular field and B. Divergence of the supraclavicular beam down into the tangential field.

at the junction of the inferior border of the supraclavicular field and the superior border of the tangential fields. This hot spot is caused by divergence of the tangential beams up into the supraclavicular field and by divergence of the supraclavicular beam down into the tangential fields (Figure 6). The penumbral characteristics of C06’ are such that this matchline hot region is probably not intense enough or large enough to cause significant late problems. Evidence for this is the M.D. Anderson experi60% of their ence with C060.* Although approximately patients develop matchline fibrosis, this fibrosis can be detected only by palpation and does not significantly impair the cosmetic result (Spanos, W., oral communication, May 1981). On the other hand, the sharp beam of a linear accelerator and the “horns” at the edge of this beam will produce a marked increase in dose beneath the matchline if the divergence mentioned above is not corrected.14 This increase in dose may result in severe matchline fibrosis or rib fracture.5 When using a linear accelerator it is, therefore, important to eliminate the divergence of both the supraclavicular and tangential beams. The divergence of the tangential fields, can be eliminated by angling the tangential beams inferiorly so that the superior edge of these beams lines up perfectly with the inferior border of the supraclavicular field (Figure 7A). This inferior angulation of the tangential beams is

Fig. 7. A. Inferior angulation of the tangential beams eliminates their divergence into the supraclavicular field. B. Splitting the supraclavicular beam eliminates its divergence down into the tangential field.

easily accomplished by angling the foot of the treatment couch away from the radiation source. The inferior divergence of the supraclavicular beam can be eliminated by blocking off the inferior half of this beam so that the central non-diverging portion of the beam becomes the inferior border of this field (Figure 7B).

Alignment of the tangential beam with the chest wall contour.The anterior chest wall of most women

Tangential field collimator rotated to match chest wall contour \

I I

4

I

Fig. 8. Rotation of the collimator to make the tangential beam follow the sloping chest wall contour can produce nonalignment between the supraclavicular and tangential fields, thereby causing a cold area beneath the skin surface.

Radiation Oncology 0 Biology ??Physics

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November 198 1, Volume 7, Number 11

B

HANGING

BLOCK

ROTA’TI NG BEAM SPLITTER Fig. 9. The superior edge of the tangential

block” technique; or B.By avoiding collimator slopes downward

from

make the posterior this

downward

tangential

the mid

sloping

contour, rotated

8. This rotation

throws the superior

beam

vertical

matches

the

the inferior

so that

which

has been made perfectly

follow

beam

splitter.

of the

block” technique

to the neck.

edge of the tangential

beam is usually

off

chest

beams can be made to be perfectly vertical by means of the “hanging rotation with the use of a rotating beam splitter.

beam

the collimator as illustrated

To

in Figure

edge of the tangential it

no longer

edge of the supraclavicular

perfectly beam,

Triangular cold region can exist when a large amount of breast tissue underlies the tangential- I M matchline

This

developed

in which a vertical of the collimator the tangential

verticle

can be corrected

by the use of a by the “hanging

at the Harvard

block is affixed

Joint CenterI

to the superior

to block off the non-vertical beam (Figure

9A).

nique is that used at the Washington

B

portion

portion

An alternative University

Mallinc-

Cold triangle IS negligible when

only a small amount of breast tissue underlies the tangential- IM matchline

When not using a separate IM field, core should be taken to include IM nodes while not irradiating an excessive amount of lung

Fig. 10. A. A significantly large cold region exists when the IM-tangential matchline overlies a thick amount of breast tissue. B. This cold area may be negligible when the breast tissue beneath this matchline is thin. C. The lack of a separate IM field can result in the irradiation of an excessive volume of lung, particularly in large-chested patients.

of

tech-

Treatment of breast cancer with tumor excision and irradiation 0 J.

krodt Institute of Radiology. In this technique the posterior edge of the tangential beam is made to follow the chest wall contour by means of a rotating beam splitter rather than by rotation of the entire collimator (Figure 9B). In this way the superior edge of the tangential beam remains in the true vertical and matches perfectly the vertical inferior edge of the supraclavicular field. Matching the tangential field with the internal mammaryjeld. The match between the medial tangential field and the internal mammary field can be a problem when there is a significant amount of breast tissue beneath this match line. In this situation a cold spot can exist (Figure lOA); this cold spot may be negligible when

the breast

tissue

beneath

this matchline

1559

BEDWINEK

mammary nodes are to be included in the tangential fields, one must check the portal films to ensure that not too much lung is being irradiated. There is no good solution to this match-line problem in large-chested women who also have a significant amount of breast tissue beneath the tangential-internal mammary matchline. One must carefully consider the individual situation and choose among the following alternatives: ( 1) accepting the cold spot, (2) overlapping the medial tangential field with the internal mammary field, which may cause a hot spot, or (3) not using an internal mammary field, which can result in the irradiation of a large volume of lung.

is thin

10B). This can be avoided in small-chested patients by not using a separate internal mammary field (Figure IOC). When this is done, one needs to be sure that the internal mammary nodes are included in the tangential beams. Some authors have advocated the use of internal mammary node scintigraphy for this purpose.“,‘4 In large-chested women the lack of a separate internal mammary field can cause an excessive amount of lung to be irradiated (Figure 1OC); hence, whenever the internal (Figure

CONCLUSION This

discussion

has

touched

upon

only

a few of the

in treating the intact breast, and the solutions mentioned herein are certainly not the only solutions. When problems or questions arise, it is essential to seek advice from individuals at those institutions having a large experience with the technique of tumor excision and irradiation. technical

problems

encountered

REFERENCES I. Bedwinek, J.M., Perez, CA., Kramer, S., Brady, L.. Goodman, R., Grundy, G: Irradiation as the primary management of Stage I and II adenocarcinoma of the breast. Cancer Clin. Trials 3: 1l-1 8, 1980. 2. Bonadonna, G., Valagussa, P.: Dose-response effect of adjuvant chemotherapy in breast cancer. N. Engl. Med. 294: 405410,1976. 3. Dao, T.L., Nemoto, T.: The clinical significance of skin recurrence after radical mastectomy in women with cancer of the breast. Surg. Gyn. Obst. 447: 453, 1963. 4. Donegan, W.L., Perez-Mesa, CM.. Watson, F.R.: A biostatistical study of locally recurrent breast carcinoma. Surg. Gyn. Obst. 122: 529-540, 1966. 5. Harris, J.R., Levene, M.B., Svensson, G., Hellman, S.: Analysis of cosmetic results following primary radiation therapy for Stages I and II carcinoma of the breast. Int. J. Radiat. Oncol. Biol. Phys. 5: 257-261, 1979. 6. Hellman, S., Harris, J.R., Levene, M.B.: Radiation therapy of early carcinoma of the breast without mastectomy. Cancer 46: 988-994, 1980. 7. Levene, M.B.: Interstitial therapy of breast cancer. fntl. J. Radiat. Oncol. Biol. Phys. 2: 1157-l 161, 1977. 8. Montague, E.D., Guiterrez, A.E., Barker, J.L., Tapley, N.D., Fletcher, G.H.: Conservation surgery and irradiation

9.

IO.

I I.

12.

13.

14.

for the treatment of favorable breast cancer. Cancer 43: lO58-1061,1979. Peters, M.V.: Wedge resection with or without radiation in early breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 2: ll5l-1156,1977. Pierquin, B., Owen, R., Maylin, C., Otmezguine, Y., Raynal, M., Mueller, W., Harnoun, S.: Radical radiation therapy of breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 6: 17-24, 1980. Rose, C.M., Kaplan, W.D., Marck. A., Bloomer, W.D., Hellman, S.: Parasternal lymphscintigraphy: Implications for the treatment planning of internal mammary lymph nodes in breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 5: 1849-1853, 1979. Rosen, P.P., Braun, D.W. Jr., Kinne. D.E.: The clinical significance of preinvasive breast carcinoma. Cancer 46: 919-925.1980. Spitalier, J., Brandone, H., Ayme, Y., Amalric, R., Santamaria, F., Seigle, J.: Cesiumtherapy of breast cancer. A five-year report on 400 consecutive patients. Int. J. Radiat. Oncol. Biol. Phys. 2: 231-235, 1977. Svensson, G.K., Bjarngard, B.E., Larsen, R.D., Levene, M.B.: A modified three-field technique for breast treatment. Intl. J. Radiat. Oncol. Biol. Phys. 6: 689-694, 1980.