Abstract Introduction This study aims to report the outcome and toxicity of combined hyperthermia (HT) and radiation therapy (RT) in treatment of locally advanced or loco-regionally recurrent breast ...cancer. Patients and Methods Patients treated with HT and RT from January 1991 to December 2007 were reviewed. RT doses for previously irradiated patients were > 40 Gy and for RT naïve patients > 60 Gy, at 1.8–2 Gy/day. HT was planned for 2 sessions/week, immediately after RT, for a minimum of 20 min and for > 4 sessions. Superficial or interstitial applicators were used with temperature measured by superficial or interstitial thermistors based on target thickness. HT treatment was assessed by thermal equivalent dose (TED), > 42.5 °C and > 43 °C. Endpoints included treatment response, lack of local progression (local control), and survival. Results 127 patients received HT and RT to 167 sites. These included the intact breast (24.4%), chest wall/skin (67.7%), and breast/chest wall and nodes (7.9%). At a median follow-up of 13 months (mean 30 ± 38), improved overall survival was significantly associated with increasing RT dose (p < 0.0001), median TED 42.5 °C ≥ 200 min (p = 0.003), and local control (p = 0.0002). Local control at last follow-up was seen in 55.1% of patients. Complete response was significantly associated with median TED 42.5 °C ≥ 200 min (p = 0.002) and median TED 43 °C ≥ 100 min (p = 0.03). Conclusion HT and RT are effective for locally advanced or recurrent breast cancer in patients that have been historically difficult to treat by RT alone. Over 50% of patients achieved control of locoregional disease. Overall survival was improved with local control.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Our goals were to examine the impact of neoadjuvant chemoradiation for rectal cancer on surgical outcomes and to determine prognostic factors predicting improved survival. Methods ...Retrospective cohort of 56 male and 44 female patients. Results After preoperative chemoradiation, 73% of patients had sphincter-preserving surgery. The 5-year disease-free (DFS) and overall survival rates were 77% and 81%, respectively. Twenty-five percent of patients showed a complete pathologic response. T-level downstaging and pathologic T stage did not correlate with recurrence or survival rates. Pathologic nodal stage was associated with a significant difference in recurrence rates (N0 19%, N1 20%, and N2 75%, P = .038) and DFS (N0 /N1 vs. N2 , 79% vs. 25%, P = .002). Conclusion Neoadjuvant chemoradiation resulted in a high rate of sphincter preservation. Complete pathologic responses after surgery were frequent and although pathologic T stage after surgery did not affect recurrence rates, pathologic nodal response was associated with improved recurrence and survival rates.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To review the toxicity and clinical outcomes for patients who underwent repeat chest wall or breast irradiation (RT) after local recurrence.
Between 1993 and 2005, 81 patients underwent repeat RT of ...the breast or chest wall for locally recurrent breast cancer at eight institutions. The median dose of the first course of RT was 60 Gy and was 48 Gy for the second course. The median total radiation dose was 106 Gy (range, 74.4-137.5 Gy). At the second RT course, 20% received twice-daily RT, 54% were treated with concurrent hyperthermia, and 54% received concurrent chemotherapy.
The median follow-up from the second RT course was 12 months (range, 1-144 months). Four patients developed late Grade 3 or 4 toxicity. However, 25 patients had follow-up >20 months, and no late Grade 3 or 4 toxicities were noted. No treatment-related deaths occurred. The development of Grade 3 or 4 late toxicity was not associated with any repeat RT variables. The overall complete response rate was 57%. No repeat RT parameters were associated with an improved complete response rate, although a trend was noted for an improved complete response with the addition of hyperthermia that was close to reaching statistical significance (67% vs. 39%, p = 0.08). The 1-year local disease-free survival rate for patients with gross disease was 53% compared with 100% for those without gross disease (p < 0.0001).
The results of our study have shown that repeat RT of the chest wall for patients with locally recurrent breast cancer is feasible, because it is associated with acceptable acute and late morbidity and encouraging local response rates.
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GEOZS, IJS, NUK, OILJ, UL, UM, UPUK
To validate an in-house optimization program that uses adaptive simulated annealing (ASA) and gradient descent (GD) algorithms and investigate features of physical dose and generalized equivalent ...uniform dose (gEUD)-based objective functions in high-dose-rate (HDR) brachytherapy for cervical cancer.
Eight Syed/Neblett template-based cervical cancer HDR interstitial brachytherapy cases were used for this study. Brachytherapy treatment plans were first generated using inverse planning simulated annealing (IPSA). Using the same dwell positions designated in IPSA, plans were then optimized with both physical dose and gEUD-based objective functions, using both ASA and GD algorithms. Comparisons were made between plans both qualitatively and based on dose-volume parameters, evaluating each optimization method and objective function. A hybrid objective function was also designed and implemented in the in-house program.
The ASA plans are higher on bladder V75% and D2cc (p=0.034) and lower on rectum V75% and D2cc (p=0.034) than the IPSA plans. The ASA and GD plans are not significantly different. The gEUD-based plans have higher homogeneity index (p=0.034), lower overdose index (p=0.005), and lower rectum gEUD and normal tissue complication probability (p=0.005) than the physical dose-based plans. The hybrid function can produce a plan with dosimetric parameters between the physical dose-based and gEUD-based plans. The optimized plans with the same objective value and dose-volume histogram could have different dose distributions.
Our optimization program based on ASA and GD algorithms is flexible on objective functions, optimization parameters, and can generate optimized plans comparable with IPSA.
: The purpose of this study was to evaluate the risk factors associated with supraclavicular nodal failure (SCF) in patients with one to three positive axillary nodes treated with breast conserving ...surgery and axillary dissection without supraclavicular node radiation (S/C RT) to aid in the selection of patients for S/C RT. Two hundred two breast conservation patients with one to three positive axillary nodes on axillary dissection treated with breast irradiation without S/C RT and 20 patients with S/C RT between August 1985 and May 2002 were identified and retrospectively evaluated. The Kaplan–Meier method was used to determine SCF‐free and overall survival curves. Risk factors for SCF were examined. The median follow‐up from surgery was 72 months (range: 4–195). Nine of 202 patients (4%) failed in the ipsilateral breast, 4 (2%) in the ipsilateral supraclavicular lymph nodes, 4 (2%) in the ipsilateral axillary and/or internal mammary nodes and 30 (15%) distantly. The 5‐ and 10‐year SCF‐free survival was 97.92%. The overall survival at 5, 10, and 15 years was 91.35%, 75.58%, and 67.18%, respectively. SCFs were associated with high grade or ER negative cancers, but not with number of positive nodes. Two of the four SCFs were associated with distant metastases, and two with local failures. One patient with a SCF was salvaged and is disease‐free at 134 months. The overall low incidence of SCF in patients with one to three positive nodes treated with breast radiation alone after breast conserving surgery and adequate axillary dissection suggests that additional S/C RT is unnecessary in this cohort. When it occurs, supraclavicular nodal failure is often associated with distant metastases.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Identification of early-stage breast cancers has increased over the past 2 decades primarily because of mammographic screening. The general guidelines to management of breast cancer may not apply to ...the smallest of these tumors, as their metastatic potential may be smaller than larger tumors. Tumors < 5 mm (T1a) carry an excellent prognosis, despite a variety of treatment approaches. However, some patients' cancer returns. There appear to be some histologic features that can predict a higher risk of axillary metastases, and therefore, a higher risk of distant metastases. Controversy exists over the extent of treatment, as to whether less than conventional treatment, such as mastectomy, axillary evaluation, and breast-conserving surgery and radiation, can be done. T1a lesions associated with extensive ductal carcinoma in situ and T1a lesions in young patients should be treated with caution if less than conventional breast treatment is to be considered. In older patients with good histologic features, axillary assessment may not be necessary. Very wide excision alone may be appropriate for some patients, but partial breast irradiation is under study and may provide a reasonable compromise. Systemic therapy for node-negative patients is not recommended. Recurrences within the breast occur later in early-stage breast cancers than with extensive-stage breast cancers, requiring annual imaging and evaluation for many years.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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Background: Metastatic breast cancer (MBC) remains an incurable disease despite advances in treatment modalities. In 2008, Eastern Cooperative Oncology Group 2100 trial (E2100) ...results led to FDA approval for bevacizumab with paclitaxel in the initial treatment of HER2-negative MBC. The addition of bevacizumab to paclitaxel led to a gain of around 2.5 months of progression-free survival (PFS), no significant benefit on overall survival (OS), and increased toxicity. In November 2011, the FDA officially revoked approval of bevacizumab for HER2-negative MBC. However, both the European Medicines Agency (EMEA) and NCCN still endorse bevacizumab for this indication. One of the greatest challenges facing healthcare worldwide is reconciling incremental clinical benefits with exponentially rising costs. This study aimed to assess the cost-effectiveness of bevacizumab with paclitaxel for HER2-negative MBC. Methods: A Markov decision tree using Data 3.5 (TreeAge Software, Inc.) was created to do decision and cost-effectiveness analyses of using bevacizumab in combination with paclitaxel versus paclitaxel alone as first-line chemotherapy in HER2-negative MBC using efficacy and toxicity data from the E2100 study. Costs were obtained from the Center for Medicare Services Drug Payment Table and Physician Fee Schedule. The model was designed from the patient and payer perspectives and sensitivity analyses were run. Results: The marginal cost between paclitaxel alone versus bevacizumab and paclitaxel was 86K with a marginal efficacy of 0.369 quality-adjusted life-years and marginal cost effectiveness of 232,720.72 USD. The expected outcome value was 1.86 for bevacizumab and paclitaxel and 1.67 for paclitaxel alone. However, the combination was not cost effective and only a marginal survival advantage that was not significant was observed. Conclusions: This study demonstrates that, despite a significant PFS advantage, the addition of bevacizumab to paclitaxel is not cost-effective for patients with HER2-negative MBC. Such data could be informative to policymakers who consider the health economics and incremental cost-effectiveness of medical therapies.
Breast disease diagnosis and management is a quintessential example of a process requiring multidisciplinary coordination. European guidelines consider a coordinated team approach to be the standard ...of care. While the necessity of multidisciplinary coordination of breast healthcare is recognized in the US, its adoption in a practical sense has been fragmented and incomplete. Interdisciplinary communication and coordination has become the cornerstone of effective cancer care, but it is not supported financially or practically by a healthcare infrastructure that primarily focuses on the reimbursement of individual specialists for procedures and therapies rather than the process by which these therapies are optimally selected and integrated. Practical obstacles to interdisciplinary care are complicated by the heterogeneity of healthcare systems that must necessarily adapt to differences in population distribution, variability in access to care, availability of trained specialists, varied models of medical care delivery, and structure of insurance coverage. The American Society of Breast Disease (ASBD) is a multidisciplinary group that focuses on how interdisciplinary breast cancer care can be successfully delivered. Since much of quality improvement hinges on outcome measurement, metrics of quality interdisciplinary care are needed to assess how well we are doing in different healthcare venues. In November 2006, the ASBD held a colloquium entitled
Ensuring Optimal Interdisciplinary Breast Care in the United States
, the purpose of which was to develop a framework of quality indicators related to multidisciplinary and interdisciplinary care that can be used to assess the degree to which interdisciplinary communication and coordination is taking place.
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DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Twenty‐five patients with aggressive fibromatoses (desmoid tumors) have been treated or followed in the Department of Radiation Medicine at the Massachusetts General Hospital between 1972 and 1982. ...Seventeen patients were treated by radiation, 4 for primary and 13 for recurrent disease. Seven patients were treated in conjunction with surgery. Partial or complete regression was achieved in 76%, and 59% are without evidence of disease (NED) at 9 to 94 months follow‐up. Eight of ten patients treated primarily with radiation have achieved complete response without an attempt at resection (five) or have achieved stabilization (three) of their disease after some regression. Consistent complete control was seen with doses above 60 Gy. Periods to 27 months were required to observe complete responses. Only three failures within the radiation field were observed, two after low doses (22 and 24 Gy, respectively). Eight patients were seen after resection but with uncertain or histologically minimum positive margins, and were followed regularly and not treated. One patient has failed to date and is NED after resection. Radiation therapy is recommended in those situations where wide‐field resection without significant morbidity is not possible for gross local disease. If minimally positive margins exist after resection in a patient who may be followed carefully, frequent follow‐up and prompt treatment at recurrence may be an effective alternative to immediate radiation therapy.
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BFBNIB, FZAB, GIS, IJS, KILJ, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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