RESUMEN
We compared simulator images of medial tangential fields taken in two positions: (1) with the ipsilateral arm abducted, holding a 'L-bar' armrest and (2) with both arms extended above the head in a forearm support. The average maximum heart distance as well as the central lung distance decreased significantly by 3.4 (SE 0.9) and 4.7 (SE 1.1) mm, respectively, when the new forearm support was used. The estimated normal tissue complication probability for excess cardiac mortality decreased by on average 3.1% (SE 1.3%). For some patients, a greater amount of the axilla was included in the field. We recommend the use of the forearm support during breast cancer treatment with tangential fields to decrease the amount of heart and lung inside the fields.
Asunto(s)
Neoplasias de la Mama/radioterapia , Traumatismos por Radiación/prevención & control , Protección Radiológica , Antebrazo , Corazón , Humanos , Pulmón , Protección Radiológica/instrumentación , Protección Radiológica/métodosRESUMEN
PURPOSE: To determine the intra- and interobserver variation in delineation of the target volume of breast tumors on computed tomography (CT) scans in order to perform conformal radiotherapy. MATERIALS AND METHODS: The clinical target volume (CTV) of the breast was delineated in CT slices by four radiation oncologists on our clinically used delineation system. The palpable glandular breast tissue was marked with a lead wire on 6 patients before CT scanning, whereas 4 patients were scanned without a lead wire. The CTV was drawn by each observer on three separate occasions. Planning target volumes (PTVs) were constructed by expanding the CTV by 7 mm in each direction, except toward the skin. The deviation in the PTV extent from the average extent was quantified in each orthogonal direction for each patient to find a possible directional dependence in the observer variations. In addition, the standard deviation of the intra- and interobserver variation in the PTV volume was quantified. For each patient, the common volumes delineated by all observers and the smallest volume encompassing all PTVs were also calculated. RESULTS: The patient-averaged deviations in PTV extent were larger in the posterior (42 mm), cranial (28 mm), and medial (24 mm) directions than in the anterior (6 mm), caudal (15 mm), and lateral (8 mm) directions. The mean intraobserver variation in volume percentage (5.5%, 1 SD) was much smaller than the interobserver variation (17.5%, 1 SD). The average ratio between the common and encompassing volume for the four observers separately was 0.82, 0.74, 0.82, and 0.80. A much lower combined average ratio of 0.43 was found because of the large interobserver variations. For the observer who placed the lead wire, the intraobserver variation in volume was decreased by a factor of 4 on scans made with a lead wire in comparison to scans made without a lead wire. For the other observers, no improvement was seen. Based on these results, an improved delineation protocol was designed. CONCLUSIONS: Intra- and especially interobserver variation in the delineation of breast target volume on CT scans can be rather large. A detailed delineation protocol making use of CT scans with lead wires placed on the skin around the palpable breast by the delineating observer reduces the intraobserver variation. To reduce the interobserver variation, better imaging techniques and pathology studies relating glandular breast tissue to imaging may be needed to provide more information on the extent of the clinical target volume.
Asunto(s)
Neoplasias de la Mama/diagnóstico por imagen , Mamografía/métodos , Variaciones Dependientes del Observador , Tomografía Computarizada por Rayos X , Neoplasias de la Mama/patología , Neoplasias de la Mama/radioterapia , Femenino , Humanos , Mamografía/instrumentación , Radioterapia Conformacional , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND AND PURPOSE: The standard linear source breast implant of our institution was compared with alternative linear source implant geometries and a stepping source implant, to evaluate the possibility of minimizing the treated volume. Normalization to a higher isodose than the conventional 85% of the mean central dose (MCD) was investigated for the stepping source implant to reduce the thickness of the treated volume and to increase dose uniformity. The purpose of this study was to develop an implant geometry yielding a high conformity and a more uniform dose distribution over the target volume. MATERIALS AND METHODS: The dose distributions of four implant geometries were compared for a planning target volume (PTV) of 48 cm(3). Implants #1 (standard) and #2 had linear sources arranged in a triangular pattern of equal lengths and lengths adapted to the shape of the PTV. Implants #3 and #4 were squared pattern arranged implants with linear sources and a stepping source with geometric optimized dwell times. The active lengths were adapted to the shape of the PTV. Using implant #4 for PTVs of different volumes, the reference dose (RD) was normalized to 85 and 91% of the MCD. RESULTS: Comparing implants #2, #3, and #4 with #1, the treated volume (V(100)) encompassed by the reference isodose was reduced by 22, 35, and 37%, respectively. The volumes receiving a dose of at least 125% (V(125)) of the reference dose was reduced by 16, 30, and 30%, respectively. The conformation number increased being 0.30, 0.39, 0.47, and 0.48 for implants #1, #2, #3, and #4, respectively. The average reduction of V(125) when the dose was normalized to 91% compared with 85% of the MCD was 18%. CONCLUSIONS: A conformal treatment to a PTV could be best achieved with a geometrically optimized stepping source plan with needles arranged in a squared pattern. Reduction of high dose volumes within the implant was obtained by normalizing the RD to 91% instead of 85% of the MCD.
Asunto(s)
Braquiterapia/métodos , Neoplasias de la Mama/radioterapia , Planificación de la Radioterapia Asistida por Computador/métodos , Neoplasias de la Mama/patología , Relación Dosis-Respuesta en la Radiación , Femenino , Humanos , Dosificación Radioterapéutica , Radioterapia Conformacional/métodosRESUMEN
PURPOSE: To find an irradiation technique for locoregional irradiation of breast cancer patients which, compared with a standard technique, improves the dose distribution to the internal mammary-medial supraclavicular (IM-MS) lymph nodes. The improved technique is intended to minimize the lung dose and reduce the dose to the heart. METHODS AND MATERIALS: The standard technique consists of an anterior mixed electron/photon IM-MS field. In the improved technique, an oblique electron and an oblique asymmetric photon field are combined to irradiate the IM lymph nodes. To irradiate the MS lymph nodes, a combination of an anterior electron and an anterior asymmetric photon field is used. For both the standard and the improved technique, tangential photon fields are used to irradiate the breast. Three-dimensional (3D) treatment planning was performed for 8 patients with various breast sizes for these two techniques. Dose-volume histograms (DVHs) and normal tissue complication probabilities (NTCPs) were compared for both techniques. The field dimensions and energy of the standard technique were determined at simulation, whereas for the improved technique the fields were designed by CT-based treatment planning. RESULTS: The dose in the breast planning target volume was essentially the same for both techniques. For the improved technique, combined with 3D localization information, an improvement in the IM-MS planning target coverage is seen. The volume within the 95% isodose surface was on average 25% (range, 0-64%) and 74% (range, 43-90%) for the standard and improved technique, respectively. The heart generally receives less dose with the improved technique. However, sometimes a small but acceptable increase in lung dose is found. CONCLUSION: The improved technique, combined with localization information of the IM-MS lymph nodes, greatly improves the dose distribution in the planning target volume for a large group of patients without significantly increasing the dose to organs at risk.
Asunto(s)
Neoplasias de la Mama/radioterapia , Irradiación Linfática/métodos , Planificación de la Radioterapia Asistida por Computador/métodos , Neoplasias de la Mama/patología , Femenino , Corazón , Humanos , Pulmón , Fenómenos Físicos , Física , Dosificación Radioterapéutica , Radioterapia Conformacional , Valores de Referencia , Estudios Retrospectivos , Médula Espinal , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: To assess for locoregional irradiation of breast cancer patients, the dependence of cardiac (cardiac mortality) and lung (radiation pneumonitis) complications on treatment technique and individual patient anatomy. MATERIALS AND METHODS: Three-dimensional treatment planning was performed for 30 patients with left-sided breast cancer and various breast sizes. Two locoregional techniques (Techniques A and B) and a tangential field technique, including only the breast in the target volume, were planned and evaluated for each patient. In both locoregional techniques tangential photon fields were used to irradiate the breast. The internal mammary (IM)-medial supraclavicular (MS) lymph nodes were treated with an anterior mixed electron/photon field (Technique A) or with an obliquely incident mixed electron/photon IM field and an anterior electron/photon MS field (Technique B). The optimal IM and MS electron field dimensions and energies were chosen on the basis of the IM-MS lymph node target volume as delineated on CT-slices. The position of the tangential fields was adapted to match the IM-MS fields. Dose-volume histograms (DVHs) and normal tissue complication probabilities (NTCPs) for the heart and lung were compared for the three techniques. In the beam's eye view of the medial tangential fields the maximum distance of the heart contour to the posterior field border was measured; this value was scored as the Maximum Heart Distance. RESULTS: The lymph node target volume receiving more than 85% of the prescribed dose was on average 99% for both locoregional irradiation techniques. The breast PTV receiving more than 95% of the prescribed dose was generally smaller using Technique A (mean: 90%, range: 69-99%) than using Technique B (mean: 98%, range: 82-100%) or for the tangential field technique (mean: 98%, range: 91-100%). NTCP values for excess cardiac mortality due to acute myocardial ischemia varied considerably between patients, with minimum and maximum values of 0.1 and 7.5% (Technique A), 0.1 and 5.8% (Technique B) and 0.0 and 6.1% (tangential tech.). The NTCP values were on average significantly higher (P<0.001) by 1.7% (Technique A) and 1.0% (Technique B) when locoregional breast irradiation was given, compared with irradiation of the left breast only. The NTCP values for the tangential field technique could be estimated using the Maximum Heart Distance. NTCP values for radiation pneumonitis were very low for all techniques; between 0.0 and 1.0%. CONCLUSIONS: Technique B results in a good coverage of the breast and locoregional lymph nodes, while Technique A sometimes results in an underdosage of part of the target volume. Both techniques result in a higher probability of heart complications compared with tangential irradiation of the breast only. Irradiation toxicity for the lung is low in all techniques. The Maximum Heart Distance is a simple and useful parameter to estimate the NTCP values for cardiac mortality for tangential breast irradiation.
Asunto(s)
Neoplasias de la Mama/radioterapia , Corazón/efectos de la radiación , Pulmón/efectos de la radiación , Radioterapia/efectos adversos , Femenino , Humanos , Probabilidad , Estudios RetrospectivosRESUMEN
BACKGROUND: The objective of the current study was to evaluate the effectiveness and morbidity of primary axillary radiotherapy in breast-conserving therapy for postmenopausal, clinically axillary lymph node negative patients with early stage breast carcinoma. METHODS: Between 1983-1997, 105 patients with clinically negative axillary lymph nodes and breast carcinoma were treated with wide local excision followed by radiotherapy to the breast, and axillary and supraclavicular lymph node areas. Adjuvant treatment with tamoxifen was given to 75 patients. The median follow-up of patients still alive was 41 months (range, 8-137 months). Fifty-five patients with no evidence of disease at last follow-up were examined prospectively with respect to late functional damage. RESULTS: The mean age of the patients was 64 years. Three patients developed a local recurrence. No isolated axillary lymph node recurrence was observed. In two patients, axillary recurrence was accompanied by distant metastases. The 5-year disease free interval and the overall survival were 82% (standard error [SE], 6%) and 83% (SE, 6%), respectively. In five patients, arm edema was reported and impaired shoulder function was reported in seven patients. Prospectively scored, arm edema was reported subjectively by the patient in 4% and objectively measured in 11% of cases. Impaired shoulder function was reported subjectively in 35% and objectively measured in 17% of cases. No brachial plexus neuropathy was noted. CONCLUSIONS: Primary axillary radiotherapy for postmenopausal women with clinically lymph node negative, early stage breast carcinoma was found to result in low axillary lymph node recurrence rates with only limited late complications. Therefore, primary axillary radiotherapy should be considered as axillary treatment in selected patients as an alternative to axillary lymph node dissection.
Asunto(s)
Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Carcinoma Ductal de Mama/radioterapia , Carcinoma Lobular/radioterapia , Ganglios Linfáticos , Irradiación Linfática , Anciano , Antineoplásicos Hormonales/uso terapéutico , Axila , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/mortalidad , Carcinoma Ductal de Mama/tratamiento farmacológico , Carcinoma Ductal de Mama/mortalidad , Carcinoma Ductal de Mama/cirugía , Carcinoma Lobular/tratamiento farmacológico , Carcinoma Lobular/mortalidad , Carcinoma Lobular/cirugía , Quimioterapia Adyuvante , Terapia Combinada , Supervivencia sin Enfermedad , Femenino , Humanos , Persona de Mediana Edad , Tamoxifeno/uso terapéutico , Factores de TiempoRESUMEN
PURPOSE: To evaluate both qualitative and quantitative scoring methods for the cosmetic result after breast-conserving therapy (BCT), and to compare the usefulness and reliability of these methods. METHODS AND MATERIALS: In EORTC trial 22881/10882, stage I and II breast cancer patients were treated with tumorectomy and axillary dissection. A total of 5318 patients were randomized between no boost and a boost of 16 Gy following whole-breast irradiation of 50 Gy. The cosmetic result was assessed for 731 patients in two ways. A panel scored the qualitative appearance of the breast using photographs taken after surgery and 3 years later. Digitizer measurements of the displacement of the nipple were also made using these photographs in order to calculate the breast retraction assessment (BRA). The cosmetic results after 3-year follow-up were used to analyze the correlation between the panel evaluation and digitizer measurements. RESULTS: For the panel evaluation the intraobserver agreement for the global cosmetic score as measured by the simple Kappa statistic was 0.42, considered moderate agreement. The multiple Kappa statistic for interobserver agreement for the global cosmetic score was 0.28, considered fair agreement. The specific cosmetic items scored by the panel were all significantly related to the global cosmetic score; breast size and shape influenced the global score most. For the digitizer measurements, the standard deviation from the average value of 30.0 mm was 2.3 mm (7.7%) for the intraobserver variability and 2.6 mm (8.7%) for the interobserver variability. The two methods were significantly, though moderately, correlated; some items scored by the panel were only correlated to the digitizer measurements if the tumor was not located in the inferior quadrant of the breast. CONCLUSIONS: The intra- and interobserver variability of the digitizer evaluation of cosmesis was smaller than that of the panel evaluation. However, there are some treatment sequelae, such as disturbing scars and skin changes, that can not be evaluated by BRA measurements. Therefore, the methods of cosmetic evaluation used in a study must be chosen in a way that balances reliability and comprehensiveness.
Asunto(s)
Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Mama , Estética , Adulto , Anciano , Mama/anatomía & histología , Mama/patología , Neoplasias de la Mama/patología , Femenino , Humanos , Modelos Logísticos , Persona de Mediana Edad , Estadificación de Neoplasias , Variaciones Dependientes del Observador , Periodo Posoperatorio , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: The purpose of the current study was to evaluate the locoregional recurrence rate after treatment of patients with operable breast carcinoma with a modification of the Halsted radical mastectomy and the selective use of radiotherapy and to identify risk factors for locoregional recurrence. METHODS: Between 1979-1987, 691 consecutive patients underwent mastectomy after a negative biopsy of the axillary apical lymph nodes. The median age of the patients was 59 years (range, 26-89 years). The clinical tumor size was < 2 cm in 72 patients, 2-5 cm in 387 patients, and >5 cm in 169 patients; 16 patients had a T4 tumor. Surgery was comprised of a modification of the Halsted radical mastectomy, including at least part of the pectoralis major muscle and the entire pectoralis minor muscle, in 573 patients; 303 patients had positive axillary lymph nodes. Adjuvant radiotherapy to the chest wall and regional lymph nodes was given to 74 patients, whereas an additional 414 patients underwent irradiation to the internal mammary and medial supraclavicular lymph nodes. The median follow-up was 91 months. RESULTS: The actuarial overall survival rate was 82% at 5 years and 63% at 10 years. The 10-year chest wall and regional lymph node control rates, including patients with prior distant failures, were 95% and 94%, respectively. The only two significant prognostic factors for locoregional recurrence on multivariate analysis were lymph node status and pathologic tumor size. CONCLUSIONS: Excellent locoregional control can be achieved with a modified technique of radical mastectomy in patients with negative apical biopsy and the selective use of comprehensive radiotherapy. These results may serve as a reference outcome for comparison with other locoregional treatment strategies.
Asunto(s)
Neoplasias de la Mama/cirugía , Mastectomía Radical Modificada , Recurrencia Local de Neoplasia/epidemiología , Radioterapia Adyuvante , Adulto , Anciano , Anciano de 80 o más Años , Antineoplásicos Hormonales/uso terapéutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Biopsia , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/patología , Neoplasias de la Mama/radioterapia , Quimioterapia Adyuvante , Terapia Combinada , Supervivencia sin Enfermedad , Femenino , Humanos , Tablas de Vida , Metástasis Linfática/prevención & control , Persona de Mediana Edad , Recurrencia Local de Neoplasia/tratamiento farmacológico , Recurrencia Local de Neoplasia/prevención & control , Estadificación de Neoplasias , Países Bajos/epidemiología , Estudios Retrospectivos , Riesgo , Análisis de Supervivencia , Tasa de Supervivencia , Neoplasias Torácicas/epidemiología , Neoplasias Torácicas/secundario , Resultado del TratamientoRESUMEN
In two recent randomized clinical trials from Denmark and Canada the usefulness of radiotherapy was evaluated in premenopausal patients with breast cancer who had been operated and in whom the findings indicated a poor prognosis. Over 2000 patients participated. After follow-up periods of 10 and 15 years, respectively, addition of locoregional therapy to mastectomy and chemotherapy with cyclophosphamide, methotrexate and fluorouracil (CMF) was found to result in better locoregional control and a better disease-free survival. These studies also demonstrated, for the first time, that the overall survival was increased after postoperative radiotherapy. In view of these findings, the indication for postoperative locoregional radiotherapy in breast cancer in the Netherlands should be reconsidered.
Asunto(s)
Neoplasias de la Mama/terapia , Cuidados Posoperatorios/normas , Radioterapia Adyuvante/métodos , Adulto , Anciano , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Quimioterapia Adyuvante , Terapia Combinada/métodos , Supervivencia sin Enfermedad , Femenino , Guías como Asunto/normas , Humanos , Mastectomía , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Países Bajos , PremenopausiaRESUMEN
BACKGROUND: Uncontrolled studies suggest that high-dose chemotherapy is beneficial in patients with breast cancer and multiple metastases to the axillary lymph nodes. Many physicians accept this treatment as standard care. We aimed to assess adjuvant high-dose chemotherapy in breast cancer in a phase II randomised trial. METHODS: 97 women aged younger than 60 years, who had breast cancer with extensive axillary-node metastases (confirmed by a tumour-positive infraclavicular lymph-node biopsy), received three courses of up-front chemotherapy (FE120C). This regimen consisted of cyclophosphamide 500 mg/m2, epirubicin 120 mg/m2, and 5-fluorouracil 500 mg/m2 once weekly for 3 weeks. After surgery, stable patients or those who responded to chemotherapy were randomly assigned conventional therapy (fourth course of FE120C, followed by radiation therapy and 2 years of tamoxifen [40 patients]) or high-dose therapy (identical treatment but an additional high-dose regimen and peripheral-blood progenitor-cell [PBPC] support after the fourth FE120C course [41 patients]). This high-dose regimen comprised cyclophosphamide 6 g/m2, thiotepa 480 mg/m2, and carboplatin 1600 mg/m2. The primary endpoint was overall and disease-free survival. All analyses were by intention to treat. FINDINGS: No patients died from toxic effects of chemotherapy. With a median follow-up of 49 (range 21-76) months, the 4-year overall and relapse-free survivals for all 97 patients were 75% and 54%, respectively. There was no significant difference in survival between the patients on conventional therapy and those on high-dose therapy. INTERPRETATION: High-dose therapy is associated with substantial cost and acute toxic effects, but also has potentially irreversible long-term effects. Until the benefit of this therapy is substantiated by large-scale phase III trials, high-dose chemotherapy should not be used in the adjuvant treatment of breast cancer, apart from in randomised studies.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama/cirugía , Trasplante de Células Madre Hematopoyéticas , Metástasis Linfática/patología , Antibióticos Antineoplásicos/administración & dosificación , Antimetabolitos Antineoplásicos/administración & dosificación , Antineoplásicos/administración & dosificación , Antineoplásicos Alquilantes/administración & dosificación , Antineoplásicos Hormonales/administración & dosificación , Protocolos de Quimioterapia Combinada Antineoplásica/administración & dosificación , Axila , Neoplasias de la Mama/patología , Carboplatino/administración & dosificación , Quimioterapia Adyuvante , Ciclofosfamida/administración & dosificación , Supervivencia sin Enfermedad , Esquema de Medicación , Epirrubicina/administración & dosificación , Antagonistas de Estrógenos/administración & dosificación , Femenino , Fluorouracilo/administración & dosificación , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Radioterapia Adyuvante , Tasa de Supervivencia , Tamoxifeno/administración & dosificación , Tiotepa/administración & dosificaciónRESUMEN
High-dose chemotherapy with autologous bone marrow and/or peripheral blood stem cell (PBSC) support is increasingly employed in the adjuvant treatment of high-risk breast cancer. Subsequent radiotherapy has been reported to be associated with morbidity and mortality resulting from pulmonary toxicity. In addition, the course of radiation therapy may be hampered by excess myelosuppression. The aim of this study was to investigate the contribution to radiation-induced toxicity of a high-dose chemotherapy regimen (CTC) that incorporates cyclophosphamide, thiotepa and carboplatin, in patients with high-risk breast cancer. In two randomised single institution studies, 70 consecutive patients received anthracycline-containing adjuvant chemotherapy (FEC: 5-fluorouracil, epirubicin and cyclophosphamide) followed by radiotherapy to achieve maximal local control. Of these patients, 34 received high-dose CTC with autologous PBSC support. All patients tolerated the full radiation dose in the planned time schedule. Radiation pneumonitis was observed in 5 patients (7%), 4 of whom had undergone high-dose chemotherapy (P = 0.38). All 5 responded favourably to prednisone. Fatal toxicities were not observed. Myelosuppression did not require interruption or untimely discontinuation of the radiotherapy, although significant reductions in median nadir platelet counts and haemoglobin levels were observed in patients who had received high-dose chemotherapy (P = 0.0001). The median nadir of WBC counts was mildly but significantly decreased during radiotherapy (P = 0.01). Red blood cell or platelet transfusions were rarely indicated. Adequate radiotherapy for breast cancer can be safely administered after high-dose CTC with autologous PBSC support. Radiation-induced myelotoxicity is clearly enhanced following CTC, but this is of little clinical significance. Radiation pneumonitis after high-dose therapy may occur more often in patients with a history of lung disease or after a relatively high radiation dose to the chest wall. Other high-dose regimens, particularly those incorporating drugs with known pulmonary toxicity (such as BCNU), may predispose patients to radiation pneumonitis.
Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/radioterapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/radioterapia , Adulto , Carboplatino , Quimioterapia Adyuvante , Ciclofosfamida , Femenino , Estudios de Seguimiento , Pruebas Hematológicas , Trasplante de Células Madre Hematopoyéticas , Humanos , Metástasis Linfática , Persona de Mediana Edad , Faringitis/patología , Neumonitis por Radiación/tratamiento farmacológico , Neumonitis por Radiación/fisiopatología , Enfermedades de la Piel/patología , TiotepaRESUMEN
To evaluate the prognostic significance of the axillary apex biopsy and its impact on clinical practice, a retrospective analysis was performed in 875 patients with clinically operable breast cancer who underwent this procedure from 1977 to 1985 (165 TNM stage I; 512 TNM stage II; 198 TNM stage IIIA). Apex biopsy is performed as a staging procedure. Apex biopsy positive patients are treated by radiotherapy alone, while apex biopsy negative patients are treated with breast conserving therapy or mastectomy, both including complete axillary dissection. The apex biopsy was tumour positive in 4% of TNM stage I patients; 17% of stage II patients and 40% of stage IIIA patients. Among patients with clinically node-negative disease, the apex biopsy was positive in 12%; in patients with palpable suspected lymph nodes this figure was 45%. Actuarial 8 y survival rates for patients with stage I, II and III disease and a negative apex biopsy were 83, 70 and 50%, respectively. The corresponding figures for patients with a positive apex biopsy were 60, 28 and 14%. In a multivariate analysis, a positive apex biopsy, clinical N classification and T classification were independent prognostic factors for survival (P < 0.0001). We conclude that a positive apex biopsy is rare in clinical stage I breast cancer, and that in patients with TNM stage II and III disease the procedure is an important tool to assess prognosis pre-operatively.
Asunto(s)
Biopsia/métodos , Neoplasias de la Mama/patología , Metástasis Linfática/patología , Axila , Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Femenino , Estudios de Seguimiento , Humanos , Mastectomía , Estadificación de Neoplasias , Pronóstico , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
PURPOSE: To analyze factors involved in the development of fibrosis in the boost area after breast conservation therapy (BCT) in patients treated with continuous low dose rate iridium implants following 50 Gy whole breast irradiation. METHODS AND MATERIALS: Fibrosis was estimated by palpation in 404 patients by four physicians. The median follow-up (FUP) duration was 70 months (range 30-133 months). Original implant data were used for reconstruction and dose-volume calculations. The total dose of the external whole breast irradiation and iridium implants was expressed in Normalized Total Dose (NTD): the total dose given in fractions of 2 Gy, which is biologically equivalent to the actual dose given according to the linear-quadratic model, using an alpha/beta value of 2 Gy, and 1.5 h for the recovery half-life of sublethal damage repair. To identify predictors of fibrosis we used a proportional odds model in a polychotomous logistic regression analysis. RESULTS: Seven independent factors were identified that were related to the severity of fibrosis: age, duration of FUP, clinical T-size, photon beam energy, NTD level, implant volume, and adjuvant chemotherapy. From the proportional odds model, a volume exponent could be estimated (0.16 +/- 0.04) that enabled us to determine dose-effect relations for different volumes. A 10-fold higher risk of fibrosis was seen when the total dose was above 79 Gy as compared with doses lower than 70 Gy. A fourfold increase in risk of fibrosis was seen for each 100 cm3 increase in irradiated boost volume. The use of adjuvant chemotherapy resulted in a twofold increase in the risk of fibrosis (dose modifying factor approximately 1.08). The application of Co-60 beams had a similar effect. The relative odds for the other factors were smaller (1.4 for each 10 years of older age, and 1.2 for clinical T-size over 20 mm). The FUP-period had a nonlinear effect: relative odds 2.2 at 6 years, 3.6 at 7-8 years, and 2.8 at 9-11 years. The dose rate (mean 0.57, range 0.26-0.89 Gy/h) had no influence on the development of fibrosis and there was no correlation between dose rate and irradiated volume. CONCLUSIONS: To optimize cosmetic results after BCT, both the total dose and the irradiated volume should be kept as low as possible. Minimum effective dose levels still have to be established. The boost volume can be minimized by more conformal brachytherapy techniques and optimal localization. It may be worthwhile to take adjuvant chemotherapy into account in decisions on boost dose levels.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Braquiterapia/métodos , Neoplasias de la Mama/terapia , Traumatismos por Radiación/prevención & control , Radioterapia/métodos , Adulto , Anciano , Braquiterapia/efectos adversos , Neoplasias de la Mama/patología , Cisplatino/administración & dosificación , Terapia Combinada , Femenino , Fibrosis , Fluorouracilo/administración & dosificación , Estudios de Seguimiento , Humanos , Radioisótopos de Iridio/uso terapéutico , Escisión del Ganglio Linfático , Mastectomía , Metotrexato/administración & dosificación , Persona de Mediana Edad , Probabilidad , Traumatismos por Radiación/patología , Radioterapia/efectos adversos , Dosificación Radioterapéutica , Análisis de RegresiónRESUMEN
We investigated the feasibility of breast conserving treatment (BCT) in patients with large (T2, T3) breast cancers, by combining preoperative radiotherapy and tissue replacement after wide excision by a myosubcutaneous flap transposition. The treatment consisted of 50 Gy whole breast irradiation followed by a 15-25 Gy iridium implant to the primary tumour with 2 cm margins. Four weeks after completion of the radiotherapy, wide excision of the original tumour area with a 1 cm margin and an axillary dissection was performed. In the same session the breast was reconstructed with an ipsilateral latissimus dorsi transposition flap. The treatment results in the first 6 patients are encouraging with respect to treatment toxicity and cosmetic outcome. The clinical tumour response after radiotherapy was difficult to evaluate. However, microscopic evaluation showed residual tumour in all specimens with (focal) involvement of the surgical margins in two. With a minimum follow-up of over 2.5 years no tumour recurrences in the breast have occurred.
Asunto(s)
Neoplasias de la Mama/cirugía , Colgajos Quirúrgicos , Braquiterapia , Mama/patología , Mama/cirugía , Neoplasias de la Mama/patología , Neoplasias de la Mama/radioterapia , Terapia Combinada , Estudios de Factibilidad , Femenino , Humanos , Metástasis Linfática , Persona de Mediana Edad , Proyectos Piloto , Cuidados PreoperatoriosRESUMEN
To evaluate the efficacy of radiotherapy without surgery, treatment results in patients treated for locally advanced breast cancer (n = 209) and those selected by positive axillary apex biopsy (n = 289) in the period between 1977 and 1985 have been analysed retrospectively. Treatment consisted of primary irradiation to the breast and regional lymph nodes followed by a boost to the primary breast tumour and palpable regional disease to a mean normalised total dose (NTD) of 64.7 Gy with a range of 33.4-93 Gy (2 Gy fractions, alpha/beta = 5 Gy). Adjuvant systemic treatment was given in 30% of the locally advanced and in 40% of the apex positive patients. Thirty percent of the apex positive patients had an excisional biopsy of the breast tumour. By multivariate analysis a prognostic index is constructed for locoregional control, overall survival and distant disease-free interval. Primary tumour size and clinical nodal status are independent prognostic factors for locoregional control. Based on the prognostic index for local control four different groups can be identified with 5 year local control rates varying from 47 to 86%. Patients treated with adjuvant chemotherapy and patients irradiated to a NTD of 60 Gy or more had significantly better local control. For overall survival primary tumour size, clinical nodal size and age are independent prognostic factors. Patients irradiated to a NTD above 60 Gy had significantly better results. Survival according to the prognostic index for survival varies between 20 and 50% at 5 years for the four groups subdivided according to the index for survival. Primary tumour size, clinical node size and age are independent prognostic factors for distant disease-free interval. Patients treated with adjuvant hormonal therapy had significantly better results. In the four groups subdivided according to the prognostic index for distant disease-free interval results vary from 17 to 30% at 5 years.
Asunto(s)
Neoplasias de la Mama/radioterapia , Radioisótopos de Cobalto/uso terapéutico , Teleterapia por Radioisótopo , Radioterapia de Alta Energía , Axila , Biopsia , Neoplasias de la Mama/mortalidad , Neoplasias de la Mama/patología , Femenino , Humanos , Ganglios Linfáticos/patología , Metástasis Linfática , Análisis Multivariante , Países Bajos/epidemiología , Pronóstico , Estudios Retrospectivos , Análisis de Supervivencia , Tasa de SupervivenciaRESUMEN
Treatments results in breast conserving therapy show considerable variation with local breast control rates from 1 to 13% at 5 years of follow-up. This wide variation and reports on prognostic factors (e.g. age, extensive ductal carcinoma in situ component and margin involvement) having an adverse effect on local control raise questions about the safety of this treatment. An attempt is made to identify surgical and pathological factors which make modifications in the radiotherapeutic treatment necessary in order to reach the perfect balance between good local control and optimal cosmetic results. For this purpose, the literature is reviewed including three randomized trials on this subject (Milan, NSABP-06 and EORTC 10801) and those studies providing sufficient data on most of the mentioned prognostic factors. Looking at the treatment characteristics of the above mentioned studies, a considerable variation is observed with regard to surgical margins, the boost dose and the application of adjuvant systemic treatment. Microscopic margin evaluation and identification of extensive in situ component (EIC) is performed in about half of these studies and the implications of these findings are very different. Although a number of authors perform multivariate analyses, this is rarely done on a complete set of variables. This results in different treatment results and conflicting data on prognostic factors. There is no agreement on one single prognostic factor and best results in terms of local control are seen in those centres combining a very wide excision with a moderate boost or a less wide excision with a high boost.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/patología , Neoplasias de la Mama/cirugía , Femenino , Humanos , Mastectomía Segmentaria , Estadificación de Neoplasias , Planificación de Atención al Paciente , Pronóstico , Factores de TiempoRESUMEN
The way in which local recurrence after breast conserving treatment for invasive carcinoma became apparent, is reported in 44 patients. All patients were followed by regular physical examination and annual mammography. In 36 patients first suspicion of local recurrence was heralded by clinical signs and symptoms, presented between two scheduled routine visits in 12 patients, and at the time of a routine visit in 14 patients. Routine physical examination by surgeon or radiotherapist revealed local recurrence in 10 patients. Local recurrence was detected only by mammography in eight patients. Mammography confirmed the clinical suspicion in seven patients. The remaining 23 patients with clinical overt recurrence showed no signs of recurrent tumour on the mammographs performed after first clinical suspicion. Fine needle aspiration (FNA) cytology confirmed the clinical suspicion in 35 of the 38 tested patients. In our experience, regular physical examination is the mainstay for the detection of local recurrence after breast conserving therapy. Mammography was of limited value but proved more valuable for the early detection of recurrent tumour outside the primary tumour area. Fine needle aspiration cytology is a helpful tool in confirming the diagnosis of local recurrence.
Asunto(s)
Neoplasias de la Mama/diagnóstico , Mamografía , Recurrencia Local de Neoplasia/diagnóstico , Examen Físico , Adulto , Anciano , Biopsia con Aguja , Neoplasias de la Mama/radioterapia , Neoplasias de la Mama/cirugía , Femenino , Humanos , Persona de Mediana Edad , Recurrencia Local de Neoplasia/radioterapia , Recurrencia Local de Neoplasia/cirugía , Factores de TiempoRESUMEN
To investigate possible contraindications for breast-conserving therapy (BCT) a retrospective clinicopathological study was carried out in 585 patients treated conservatively in The Netherlands Cancer Institute from 1979 to 1984. The local recurrence rate in the breast was 2% at 6 years and was similar in stages I and II breast cancer. Invasive cancer with extensive ductal carcinoma in situ (DCIS) component appeared to be the only main prognostic factor when local failure in the breast was considered. A multivariate analysis revealed that tumor size, microscopically incomplete excision of the primary tumor and age did not have a significant influence on local control alone, when this was corrected for extensive DCIS. When breast and axillary recurrences were taken together, age and extensive DCIS component appeared to be two independent prognostic factors according to a multivariate analysis. Especially patients younger than 40 years with an extensive DCIS component had a higher locoregional recurrence rate.
Asunto(s)
Neoplasias de la Mama/patología , Mama/patología , Carcinoma in Situ/patología , Carcinoma Intraductal no Infiltrante/patología , Recurrencia Local de Neoplasia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Axila , Neoplasias de la Mama/terapia , Carcinoma in Situ/terapia , Carcinoma Intraductal no Infiltrante/terapia , Terapia Combinada , Femenino , Humanos , Escisión del Ganglio Linfático , Mastectomía/métodos , Pronóstico , Dosificación Radioterapéutica , Estudios Retrospectivos , Estadística como AsuntoRESUMEN
Fifty-eight patients conservatively treated for T1 breast cancers are analyzed for cosmetic outcome; 17 had concomitant adjuvant combination chemotherapy (cyclophosphamide, adriamycin, 5 fluorouracil). The results are evaluated by clinical criteria and a quantitative measurement by use of light field projection at 33 months median follow-up. Surgery consisted of lumpectomy and axillary dissection; radiotherapy was given to the breast only except for additional internal mammary irradiation in central and medial lesions. (50 Gy whole breast, 64 Gy electron/photon boost). Questionnaires are used for inquiry on patient experience: 88% of the patients experienced a good to excellent cosmetic outcome. According to the panel only 64% show a good to excellent cosmesis. Panel-scores on asymmetry are compared with quantitative measurements. More esophagitis and probably a higher degree of fibrosis in the boost area is found in the chemotherapy group. No differences in cosmetic outcome, complication rates, and patient experiences are seen. Results are compared with published data.