Preoperative Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Preliminary Results of a Prospective, Phase 2 Trial.

PURPOSE: To assess the feasibility of utilizing 3-dimensional conformal accelerated partial-breast irradiation (APBI) in the preoperative setting followed by standard breast-conserving therapy. PATIENTS AND METHODS: This was a prospective trial testing the feasibility of preoperative APBI followed by lumpectomy for patients with early-stage invasive ductal breast cancer. Eligible patients had T1-T2 (<3 cm), N0 tumors. Patients received 38.5 Gy in 3.85-Gy fractions delivered twice daily. Surgery was performed >21 days after radiation therapy. Adjuvant therapy was given as per standard of care. RESULTS: Twenty-seven patients completed treatment. With a median follow-up of 3.6 years (range, 0.5-5 years), there have been no local or regional failures. A complete pathologic response according to hematoxylin and eosin stains was seen in 4 patients (15%). There were 4 grade 3 seromas. Patient-reported cosmetic outcome was rated as good to excellent in 79% of patients after treatment. CONCLUSIONS: Preoperative 3-dimensional conformal radiation therapy-APBI is feasible and well tolerated in select patients with early-stage breast cancer, with no reported local recurrences and good to excellent cosmetic results. The pathologic response rates associated with this nonablative APBI dose regimen are particularly encouraging and support further exploration of this paradigm.

Effect of reduction mammoplasty on acute radiation side effects and use of lumpectomy cavity boosts.

PURPOSE: Reduction mammoplasty (RM) during breast-conserving surgery is popular among women with large-volume breasts because it reduces redundant breast folds and may decrease skin-related morbidity from radiation therapy. However, RM may obscure the lumpectomy cavity (LC) and pose challenges to administering an LC boost, potentially affecting local control. We investigated the impact of RM on acute side effects and use of LC boosts. METHODS AND MATERIALS: The records of 645 consecutive women treated with whole-breast irradiation at an urban university and 2 community practices between January 2012 and December 2014 were reviewed on an institutional review board-approved study. The primary endpoint was grade ≥3 radiation dermatitis; the secondary endpoint was use of LC boost. Student 2-sample t tests, Pearson χ2 tests, Fisher exact tests, and univariate and multivariable logistic regression analyses were performed. RESULTS: Forty-three (7%) RMs were performed in 650 treated breasts. No significant differences in grade 3 toxicities were identified among RM and non-RM patients. LC boost was delivered to 474 breasts. Fewer (16/43) RM patients received LC boosts compared with non-RM patients (458/607), P = .0001. RM patients were more likely to have neoadjuvant chemotherapy, stage III or multifocal disease, higher body mass index, larger planning treatment volumes, and conventional fractionation (P < .05). CONCLUSIONS: RM was associated with decreased use of LC boost without significant differences in acute toxicities. Further investigation to delineate LCs in patients undergoing RM or identify alternative strategies for delivering LC dose is needed.

Characteristics associated with the initiation of radiation therapy after breast-conserving surgery among African American and white women diagnosed with early-stage breast cancer in Maryland, 2000-2006.

PURPOSE: Socioeconomic status appears to be an important independent barrier to breast cancer care, irrespective of insurance inequalities. Receiving radiation therapy (RT) reduces local recurrence and mortality in patients receiving breast-conserving surgery (BCS). We investigated racial and socioeconomic determinants of RT initiation after BCS in Maryland. METHODS: Maryland Cancer Registry breast cancer data for the diagnosis years 2000 through 2006 were analyzed for characteristics associated with receipt of RT after BCS. We used generalized regression models to estimate RT initiation among low-income patients, adjusting for racial, demographic, and clinical covariates. RESULTS: Low-income women were more likely to be African American; older; uninsured or to use Medicare, Medicaid, or Maryland breast cancer insurance; and have tumors that were estrogen receptor and progesterone-receptor negative. Among low-income women, those at risk of not initiating RT after BCS were more likely to be African American, be older than 80 years of age, and have tumors >2 cm. CONCLUSIONS: Socioeconomic disparities were identified in the initiation of RT after BCS in Maryland from 2000 to 2006. In addition, racial disparities in RT after BCS were apparent for women diagnosed from 2000 to 2003. Additional research is needed to investigate uptake of prescribed treatments after BCS and develop strategies for reducing barriers to obtaining treatments among patients at risk for incomplete cancer care.

Can axillary dissection be avoided in patients with sentinel lymph node metastasis?

BACKGROUND: Who should undergo a completion dissection following identification of a +sentinel lymph node (SLN) is controversial. METHODS: The records of 1,133 patients who underwent SLN mapping were reviewed. The association between patient, tumor, and treatment characteristics and the presence of +SLNs and +nonSLNs was analyzed using two-way tables of frequency counts and Pearson chi2 test. Possible predictors of +SLNs and +nonSLNs were analyzed using simple and multiple logistic regression. RESULTS: One thousand one hundred forty-eight SLN procedures were performed. 367 procedures (32%) yielded +SLNs. For patients with a +SLN, on multiple logistic regression analysis LVSI, increasing numbers of +SLNs, decreasing numbers of negative SLNs, and increasing size of the largest SLN metastasis were statistically significantly associated with increased likelihood of nonSLN involvement. No subgroup was identified that did not have a significant rate of nonSLN involvement on completion axillary dissection, except those who had a large number of negative SLNs (> or =3) and small size of the largest SLN metastasis (<10 mm). CONCLUSIONS: A definitive answer to the question of who needs a completion axillary dissection awaits the results of ongoing trials. In the interim, our data does not support eliminating dissection for any subgroup of patients with +SLNs.

Sentinel lymph node positivity of patients with ductal carcinoma in situ or microinvasive breast cancer.

PURPOSE: The purpose of this study was to determine the rates of sentinel lymph node (SLN) positivity in patients with a final diagnosis of ductal carcinoma in situ (DCIS) or microinvasive breast cancer (MIC). METHODS: One hundred thirty patients underwent SLN mapping from 1998 to 2003 for DCIS or MIC. RESULTS: One hundred nine patients with DCIS and 21 with MIC underwent SLN mapping. One patient with bilateral DCIS underwent 2 SLN procedures; therefore, the results of 131 SLN procedures are included. On hematoxylin and eosin (H&E) staining, 4 of 110 patients (3.6%) with DCIS had positive SLNs. Four additional patients had positive SLNs by IHC staining only (3.6%). Two of 8 patients underwent completion axillary dissection, and neither had additional involved nodes on completion axillary dissection. One of the 21 patients with MIC had positive SLNs by hematoxylin and eosin (H&E) (4.8%), and another had an involved SLN by IHC staining (4.8%). The patient with the positive SLN by H&E had 1 additional node on completion axillary dissection. CONCLUSION: Rates of SLN positivity for patients with DCIS are modest, even in a high-risk population, and there is continuing uncertainty about its clinical importance.