RESUMO
A previous randomized trial (CALGB 9344/Intergroup 0148) compared four cycles of adjuvant doxorubicin/cyclophosphamide (AC) to four cycles of AC plus four cycles of paclitaxel (AC + T) and demonstrated that the addition of paclitaxel improved locoregional control (LRC) in patients with node-positive breast cancer. However, it could not be determined whether it was the paclitaxel or the increased duration of chemotherapy that led to this improvement. The present study aimed to analyze whether the addition of paclitaxel to a doxorubicin-based regimen improves LRC in a cohort of patients who all received eight total cycles of chemotherapy. Five hundred eleven women with operable breast cancer were randomized on a single-institution prospective trial to receive 5-fluorouracil, doxorubicin, cyclophosphamide (FAC) × 8 cycles (n = 252) or FAC × 4 cycles plus paclitaxel × 4 cycles (TFAC) (n = 259). Rates of LRC and overall survival (OS) were analyzed. Median follow-up was 124 months (range 5-167 months). The 10-year LRC rate was 92.6 versus 93.1% in the FAC versus TFAC arms, respectively (P = 0.26). The LRC between treatment arms did not differ when analyzed by locoregional treatment group: breast conservation therapy (BCT), mastectomy alone (M), and mastectomy + radiation (M + RT). The 10-year LRC rates were 95.1% (FAC) versus 91.2% (TFAC) after BCT (P = 0.98), 89.5% (FAC) versus 93.4% (TFAC) after M (P = 0.24), and 94.7% (FAC) versus 96.5% (TFAC) after M + RT (P = 0.59). Additionally, there was no difference in OS between the treatment arms, with 10-year OS rates of 78.4% (FAC) versus 81.7% (TFAC) (P = 0.93). The addition of paclitaxel to a doxorubicin-based regimen had no impact on LRC, regardless of the type of local therapy received. Historically inferior LRC with AC chemotherapy alone versus AC + T may have been due to an inadequate duration of systemic therapy and not due to the absence of paclitaxel.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Ciclofosfamida/administração & dosagem , Doxorrubicina/administração & dosagem , Feminino , Fluoruracila/administração & dosagem , Seguimentos , Humanos , Mastectomia , Pessoa de Meia-Idade , Paclitaxel/administração & dosagem , Estudos Prospectivos , Taxa de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To determine the anatomic distribution of gross supraclavicular nodes within the supraclavicular fossa using 2-deoxy-2-[F-18] fluoro-d-glucose (FDG) positron emission tomography/computed tomography (PET/CT) scans, and to evaluate likely coverage of specific regions of the supraclavicular fossa using standard radiation fields. METHODS AND MATERIALS: We identified 33 patients with advanced or metastatic breast cancer who had a PET/CT scan demonstrating hypermetabolic supraclavicular lymph nodes in 2005. The locations of the involved lymph nodes were mapped onto a single CT set of images of the supraclavicular fossa. These lymph nodes were also mapped onto the treatment-planning CT dataset of 4 patients treated in our institution (2 patients with biopsy-proven supraclavicular nodes and 2 patients with clinically negative supraclavicular nodes). RESULTS: We were able to determine the distribution of 52 supraclavicular lymph nodes in 32 patients. Of 32 patients, 28 (87%) had a history of metastatic disease, and 2 patients had isolated nodal recurrences. Five patients had supraclavicular nodes posterior to the vertebral body transverse process, and several lymph nodes were in close proximity to the medial field border, raising the possibility of geographic miss in these areas. CONCLUSIONS: In patients with locally advanced disease, increased coverage of the supraclavicular fossa medially and posteriorly may be warranted.
Assuntos
Neoplasias da Mama/diagnóstico por imagem , Linfonodos/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Clavícula , Feminino , Fluordesoxiglucose F18 , Humanos , Metástase Linfática/diagnóstico por imagem , Pessoa de Meia-Idade , Tomografia por Emissão de Pósitrons/métodos , Compostos Radiofarmacêuticos , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
PURPOSE: The aims of this study were to determine outcomes for patients with inflammatory breast cancer (IBC) treated with multimodality therapy, to identify factors associated with locoregional recurrence, and to determine which patients may benefit from radiation dose escalation. METHODS AND MATERIALS: We retrospectively reviewed 256 consecutive patients with nonmetastatic IBC treated at our institution between 1977 and 2004. RESULTS: The 192 patients who were able to complete the planned course of chemotherapy, mastectomy, and postmastectomy radiation had significantly better outcomes than the 64 patients who did not. The respective 5-year outcome rates were: locoregional control (84% vs. 51%), distant metastasis-free survival (47% vs. 20%), and overall survival (51% vs. 24%) (p < 0.0001 for all comparisons). Univariate factors significantly associated with locoregional control in the patients who completed plan treatment were response to neoadjuvant chemotherapy, surgical margin status, number of involved lymph nodes, and use of taxanes. Increasing the total chest-wall dose of postmastectomy radiation from 60 Gy to 66 Gy significantly improved locoregional control for patients who experienced less than a partial response to chemotherapy, patients with positive, close, or unknown margins, and patients <45 years of age. CONCLUSIONS: Patients with IBC who are able to complete treatment with chemotherapy, mastectomy, and postmastectomy radiation have a high probability of locoregional control. Escalation of postmastectomy radiation dose to 66 Gy appears to benefit patients with disease that responds poorly to chemotherapy, those with positive, close, or unknown margin status, and those <45 years of age.
Assuntos
Adenocarcinoma/terapia , Neoplasias da Mama/terapia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/secundário , Adulto , Idoso , Análise de Variância , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Terapia Combinada/métodos , Intervalo Livre de Doença , Feminino , Humanos , Metástase Linfática/patologia , Mastectomia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia , Lesões por Radiação/patologia , Dosagem Radioterapêutica , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: For patients with Stage II breast cancer with one to three positive lymph nodes, controversy exists about whether radiation as a component of treatment provides a survival benefit. METHODS AND MATERIALS: We analyzed data from patients with Stage II breast cancer with one to three positive lymph nodes diagnosed from 1988-2002 in the Surveillance, Epidemiology, and End Results registry and compared the outcome of 12,693 patients treated with breast-conservation therapy with radiation (BCT + XRT) with the 18,902 patients treated with mastectomy without radiation (MRM w/o XRT). RESULTS: Patients treated with BCT + XRT were younger, were more likely to be treated in recent years of the study period, more commonly had T1 primary tumors, and had fewer involved nodes compared with those treated with MRM w/o XRT (p < 0.001 for all differences). The 15-year breast cancer-specific survival rate for the BCT + XRT group was 80% vs. 72% for the MRM w/o XRT group (p < 0.001). Cox regression analysis showed that MRM w/o XRT was associated with a hazard ratio for breast cancer death of 1.19 (p < 0.001) and for overall death of 1.25 (p < 0.001). The survival benefit in the BCT + XRT group was not limited to subgroups with high-risk disease features. CONCLUSIONS: Radiation use was independently associated with improved survival for patients with Stage II breast cancer with one to three positive lymph nodes. Because multivariate analyses of retrospective data cannot account for all potential biases, these data require confirmation in randomized clinical trials.
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Neoplasias da Mama/mortalidade , Neoplasias da Mama/terapia , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/prevenção & controle , Radioterapia/mortalidade , Medição de Risco/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Axila , Estudos de Coortes , Feminino , Humanos , Linfonodos , Metástase Linfática , Pessoa de Meia-Idade , Prevalência , Prognóstico , Sistema de Registros/estatística & dados numéricos , Fatores de Risco , Análise de Sobrevida , Taxa de Sobrevida , Texas/epidemiologia , Resultado do TratamentoRESUMO
PURPOSE: Postmastectomy radiotherapy (PMRT) improves locoregional control (LRC) in patients with high-risk features after mastectomy. Young age continues to evolve as a potentially important risk factor. The objective of this study was to assess the benefits of PMRT in patients <35 years old treated with doxorubicin-based neoadjuvant chemotherapy for Stage II-III breast cancer. PATIENTS AND METHODS: We retrospectively analyzed 107 consecutive breast cancer patients <35 years old with Stage IIA-IIIC disease treated at our institution with doxorubicin-based neoadjuvant chemotherapy and mastectomy, with or without PMRT. The treatment groups were compared in terms of LRC and overall survival. RESULTS: Despite more advanced disease stages, the patients who received PMRT (n = 80) had greater rates of LRC (5-year rate, 88% vs. 63%, p = 0.001) and better overall survival (5-year rate, 67% vs. 48%, p = 0.03) than patients who did not receive PMRT (n = 27). CONCLUSION: Among breast cancer patients <35 years old at diagnosis, the use of PMRT after doxorubicin-based neoadjuvant chemotherapy and mastectomy led to a statistically greater rate of LRC and overall survival compared with patients without PMRT. The benefit seen for PMRT in young patients provides valuable data to better tailor adjuvant, age-specific treatment decisions after mastectomy.
Assuntos
Neoplasias da Mama/radioterapia , Mastectomia , Adulto , Fatores Etários , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante , Doxorrubicina/uso terapêutico , Feminino , Humanos , Metástase Linfática , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Estadiamento de Neoplasias , Estudos Retrospectivos , Análise de SobrevidaRESUMO
BACKGROUND: The purpose of this study was to determine whether the use of optimized CT treatment planning offered better coverage of axillary level III (LIII)/supraclavicular (SC) targets than the empirically derived dose prescription that are commonly used. MATERIALS/METHODS: Thirty-two consecutive breast cancer patients who underwent CT treatment planning of a SC field were evaluated. Each patient was categorized according to body mass index (BMI) classes: normal, overweight, or obese. The SC and LIII nodal beds were contoured, and four treatment plans for each patient were generated. Three of the plans used empiric dose prescriptions, and these were compared with a CT-optimized plan. Each plan was evaluated by two criteria: whether 98% of target volume receive >90% of prescribed dose and whether < 5% of the irradiated volume received 105% of prescribed dose. RESULTS: The mean depth of SC and LIII were 3.2 cm (range, 1.4-6.7 cm) and 3.1 (range, 1.7-5.8 cm). The depth of these targets varied according across BMI classes (p = 0.01). Among the four sets of plans, the CT-optimized plans were the most successful at achieving both of the dosimetry objectives for every BMI class (normal BMI, p = .003; overweight BMI, p < .0001; obese BMI, p < .001). CONCLUSIONS: Across all BMI classes, routine radiation prescriptions did not optimally cover intended targets for every patient. Optimized CT-based treatment planning generated the most successful plans; therefore, we recommend the use of routine CT simulation and treatment planning of SC fields in breast cancer.
Assuntos
Índice de Massa Corporal , Neoplasias da Mama/radioterapia , Irradiação Linfática/métodos , Planejamento da Radioterapia Assistida por Computador/métodos , Tomografia Computadorizada por Raios X , Axila , Neoplasias da Mama/classificação , Neoplasias da Mama/diagnóstico por imagem , Clavícula , Feminino , Humanos , Obesidade/classificação , Sobrepeso/classificação , Dosagem RadioterapêuticaRESUMO
PURPOSE: The aim of this study was to investigate the role of postmastectomy radiation therapy in women with breast cancer who achieved a pathologic complete response (pCR) to neoadjuvant chemotherapy. METHODS AND MATERIALS: We retrospectively identified 226 patients treated at our institution who achieved a pCR at surgery after receiving neoadjuvant chemotherapy. Of these, the 106 patients without inflammatory breast cancer who were treated with mastectomy were analyzed. The patients' clinical stages at diagnosis were I in 2%, II in 31%, IIIA in 30%, IIIB in 25%, and IIIC in 11% (American Joint Committee on Cancer 2003 system). Of the patients, 92% received anthracycline-based chemotherapy, and 38% also received a taxane. A total of 72 patients received postmastectomy radiation therapy, and 34 did not. The actuarial rates of local-regional recurrence (LRR) and survival of the two groups were compared using the log-rank test. RESULTS: The median follow-up of surviving patients was 62 months. Use of radiation therapy did not affect the 10-year rates of LRR for patients with Stage I or II disease (the 10-year LRR rates were 0% for both groups). However, the 10-year LRR rate for patients with Stage III disease was significantly improved with radiation therapy (7.3% +/- 3.5% with vs. 33.3% +/- 15.7% without; p = 0.040). Within this cohort, use of radiation therapy was also associated with improved disease-specific and overall survival. CONCLUSION: Postmastectomy radiation therapy provides a significant clinical benefit for breast cancer patients who present with clinical Stage III disease and achieve a pCR after neoadjuvant chemotherapy.
Assuntos
Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/radioterapia , Adulto , Idoso , Análise de Variância , Antineoplásicos/uso terapêutico , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante , Feminino , Humanos , Mastectomia , Pessoa de Meia-Idade , Terapia Neoadjuvante , Estudos Retrospectivos , Análise de Sobrevida , Resultado do TratamentoRESUMO
PURPOSE: To evaluate the locoregional efficacy of multimodality treatment for breast cancer patients who present with ipsilateral supraclavicular (SCV) disease without systemic metastases. METHODS: We retrospectively reviewed the data from 71 patients with ipsilateral SCV involvement at presentation. SCV involvement in 16 patients (23%) was diagnosed by ultrasound examination only, without palpable disease. All patients were treated with curative intent using neoadjuvant chemotherapy, mastectomy or breast-conserving surgery (BCT), and radiotherapy. RESULTS: The 5-year SCV control, locoregional control (LRC), disease-free survival, and overall survival rate was 90%, 77%, 30%, and 47%, respectively. Patients with persistent SCV disease after neoadjuvant chemotherapy by physical examination had a lower rate of LRC (64% vs. 86%, p = 0.026), as did those with persistent SCV disease by ultrasound examination (66% vs. 96%, p = 0.007). Of those with a complete response of SCV disease by physical examination after neoadjuvant chemotherapy, those with persistently abnormal ultrasound findings had significantly worse disease-free survival (0% vs. 55%, p = 0.03). BCT was not associated with lower rates of LRC (82% for BCT vs. 76% for mastectomy, p = 0.80). CONCLUSION: Radiotherapy achieved excellent LRC after surgery for patients with ipsilateral SCV metastases who achieved a complete response of the SCV disease after neoadjuvant chemotherapy. For patients who achieved a complete response of the SCV disease by physical examination, ultrasonography of the SCV fossa may help assess the risk of disease recurrence. SCV involvement should not be considered a contraindication for BCT.
Assuntos
Neoplasias da Mama/terapia , Terapia Neoadjuvante/métodos , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante/métodos , Feminino , Seguimentos , Humanos , Metástase Linfática , Pessoa de Meia-Idade , Estadiamento de Neoplasias/métodos , Radioterapia Adjuvante , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Static multileaf collimated field-in-field forward-planned intensity-modulated radiation treatment (FiF-IMRT) has been shown to improve dose homogeneity compared to conventional wedged fields. However, a direct comparison of the scattered dose to the contralateral breast resulting from wedged and FiF-IMRT plans remains to be documented. METHODS: The contralateral scattered breast dose was measured in a custom-designed anthropomorphic breast phantom in which 108 thermoluminescent dosimeters (TLDs) were volumetrically placed every 1-2cm. The target phantom breast was treated to a dose of 50Gy using three dose compensation techniques: No medial wedge and a 30-degree lateral wedge (M0-L30), 15-degree lateral and medial wedges (M15-L15), and FiF-IMRT. TLD measurements were compared using analysis of variance. RESULTS: For FiF-IMRT, the mean doses to the medial and lateral quadrants of the contralateral breast were 112cGy (range 65-226cGy) and 40cGy (range 18-91 cGy), respectively. The contralateral breast doses with FiF-IMRT were on average 65% and 82% of the doses obtained with the M15-L15 and M0-L30 techniques, respectively (p<0.001). Compared to the M15-L15 technique, the maximum dose reduction obtained with FiF-IMRT was 115cGy (range 13-115cGy). CONCLUSIONS: The dose to the contralateral breast is significantly reduced with FiF-IMRT compared to wedge-compensated techniques. Although long-term follow-up is needed to establish the clinical relevance of this finding, these results, along with the previously reported improvement in ipsilateral dose homogeneity, support the use of FiF-IMRT if resources permit.
Assuntos
Neoplasias da Mama/radioterapia , Imagens de Fantasmas , Planejamento da Radioterapia Assistida por Computador , Radioterapia de Intensidade Modulada , Feminino , Humanos , Dosagem Radioterapêutica , Espalhamento de Radiação , Dosimetria TermoluminescenteRESUMO
PURPOSE: We previously developed a prognostic index that stratified patients treated with breast conservation therapy (BCT) after neoadjuvant chemotherapy into groups with different risks for local-regional recurrence (LRR). The purpose of this study was to compare the rates of LRR as a function of prognostic index score for patients treated with BCT or mastectomy plus radiation after neoadjuvant chemotherapy. METHODS: We retrospectively analyzed 815 patients treated with neoadjuvant chemotherapy, surgery, and radiation. Patients were assigned an index score from 0 to 4 and given 1 point for the presence of each factor: clinical N2 to N3 disease, lymphovascular invasion, pathologic size>2 cm, and multifocal residual disease. RESULTS: The 10-year LRR rates were very low and similar between the mastectomy and BCT groups for patients with an index score of 0 or 1. For patients with a score of 2, LRR trended lower for those treated with mastectomy vs. BCT (12% vs. 28%, p=0.28). For patients with a score of 3 to 4, LRR was significantly lower for those treated with mastectomy vs. BCT (19% vs. 61%, p=0.009). CONCLUSIONS: This analysis suggests that BCT can provide excellent local-regional treatment for the vast majority of patients after neoadjuvant chemotherapy. For the few patients with a score of 3 to 4, LRR was >60% after BCT and was <20% with mastectomy. If these findings are confirmed in larger randomized studies, the prognostic index may be useful in helping to select the type of surgical treatment for patients treated with neoadjuvant chemotherapy, surgery, and radiation.
Assuntos
Neoplasias da Mama/cirurgia , Mastectomia/métodos , Recidiva Local de Neoplasia , Adulto , Idoso , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Neoplasias da Mama/radioterapia , Quimioterapia Adjuvante , Feminino , Humanos , Mastectomia Segmentar , Pessoa de Meia-Idade , Terapia Neoadjuvante , Neoplasia Residual , Prognóstico , Radioterapia Adjuvante , Estudos Retrospectivos , Medição de RiscoRESUMO
PURPOSE: The aim of this study was to investigate whether patients <35 years old have similar risk of locoregional recurrence after breast conservation therapy compared with patients 35 to 40 years old. METHODS AND MATERIALS: We retrospectively reviewed records of 196 consecutive patients < or =40 years old who received breast conservation therapy (BCT) from 1987 to 2000 for breast cancer and compared outcomes between patients <35 years old with patients 35 to 40 years old. The majority of patients received neoadjuvant chemotherapy as part of their treatment. Multivariate analysis was performed to assess risk factors for locoregional recurrence. RESULTS: After a median follow-up of 64 months, 22 locoregional recurrences (LRR) were observed. Twenty patients developed locoregional recurrence as their first site of relapse. Two patients had bone-only metastases before their locoregional recurrence. On multivariate analysis, age <35 years was associated with a statistically significant increased risk of locoregional recurrence. The 5-year rate of locoregional control was 87.9% in patients <35 years old compared with 91.7% in patients 35 to 40 years old (p = 0.042). CONCLUSIONS: Our finding supports an increased risk of locoregional recurrence as a function of younger age after breast conservation therapy, even among young patients 40 years old and younger.
Assuntos
Fatores Etários , Neoplasias da Mama/etiologia , Recidiva Local de Neoplasia/etiologia , Adulto , Análise de Variância , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante , Terapia Combinada/métodos , Doxorrubicina/administração & dosagem , Feminino , Humanos , Mastectomia Segmentar , Recidiva Local de Neoplasia/mortalidade , Estadiamento de Neoplasias , Receptores de Estrogênio/análise , Análise de Regressão , Estudos Retrospectivos , Análise de SobrevidaRESUMO
Intensity-modulated radiation therapy (IMRT) has been gaining increasing popularity among practicing physicians in the U.S., but the extent to which radiation oncology residents are taught the principles of this technology and are trained to use IMRT remains unknown. In this paper, we assessed the current level of resident education in IMRT in the United States. Chief residents at all 77 accredited radiation oncology programs were sent a 13-question survey addressing formal didactics and hands-on experience in IMRT. The survey assessed the frequency, subject, and format of IMRT didactics. Questions also addressed the number of IMRT patients and anatomical sites treated, resident involvement in the IMRT process, and the intent of IMRT use. Finally, residents were asked for their opinions on their IMRT education. Sixty-one surveys (79%) were completed. Overall, forty-three respondents (71%) reported receiving formal IMRT didactics, with nearly one-third reporting extensive didactics (> or = 3 lectures/seminars et cetera per year). The most common didactic formats were lectures (95%) and journal clubs (63%), most commonly supervised by physicists (98%). Involvement by physicians and radiobiologists were reported by 63% and 7% of respondents, respectively. Overall, 87% of respondents had hands-on IMRT training, with nearly one-half having treated > 25 patients. The most common sites treated were head and neck (94%) and prostate (81%). Involvement in all aspects of the IMRT process was common, particularly target and tissue delineation (98%) and plan evaluation (93%). Most respondents (79%) with hands-on experience reported receiving formal didactics. However, nearly one-third received no or only minimal formal didactics. The percentage of respondents desiring increased IMRT didactics and hands-on experience were 70% and 47%, respectively. Our results suggest that the great majority of radiation oncology residents in the United States are currently exposed to didactics and hands-on training in IMRT. Areas of potential improvement include increased involvement of physicians and radiobiologists in formal IMRT didactics.
Assuntos
Internato e Residência/normas , Neoplasias/radioterapia , Radioterapia (Especialidade)/educação , Planejamento da Radioterapia Assistida por Computador/estatística & dados numéricos , Radioterapia Conformacional/estatística & dados numéricos , Pesquisas sobre Atenção à Saúde , Humanos , Competência Profissional , Inquéritos e Questionários , Estados UnidosRESUMO
PURPOSE: To determine the efficacy of an emulsion containing hyaluronic acid to reduce the development of ≥ Grade 2 radiation dermatitis after adjuvant breast radiation compared with best supportive care. METHODS AND MATERIALS: Women with breast cancer who had undergone lumpectomy and were to receive whole-breast radiotherapy to 50 Gy with a 10- to 16-Gy surgical bed boost were enrolled in a prospective randomized trial to compare the effectiveness of a hyaluronic acid-based gel (RadiaPlex) and a petrolatum-based gel (Aquaphor) for preventing the development of dermatitis. Each patient was randomly assigned to use hyaluronic acid gel on the medial half or the lateral half of the irradiated breast and to use the control gel on the other half. Dermatitis was graded weekly according to the Common Terminology Criteria v3.0 by the treating physician, who was blinded as to which gel was used on which area of the breast. The primary endpoint was development of ≥ Grade 2 dermatitis. RESULTS: The study closed early on the basis of a recommendation from the Data and Safety Monitoring Board after 74 of the planned 92 patients were enrolled. Breast skin treated with the hyaluronic acid gel developed a significantly higher rate of ≥ Grade 2 dermatitis than did skin treated with petrolatum gel: 61.5% (40/65) vs. 47.7% (31/65) (p = 0.027). Only one patient developed Grade 3 dermatitis using either gel. A higher proportion of patients had worse dermatitis in the breast segment treated with hyaluronic acid gel than in that treated with petrolatum gel at the end of radiotherapy (42% vs. 14%, p = 0.003). CONCLUSION: We found no benefit from the use of a topical hyaluronic acid-based gel for reducing the development of ≥ Grade 2 dermatitis after adjuvant radiotherapy for breast cancer. Additional studies are needed to determine the efficacy of hyaluronic acid-based gel in controlling radiation dermatitis symptoms after they develop.
Assuntos
Neoplasias da Mama/radioterapia , Emolientes/administração & dosagem , Ácido Hialurônico/administração & dosagem , Vaselina/administração & dosagem , Protetores contra Radiação/administração & dosagem , Radiodermite/prevenção & controle , Administração Tópica , Adulto , Idoso , Mama/anatomia & histologia , Neoplasias da Mama/cirurgia , Término Precoce de Ensaios Clínicos , Feminino , Humanos , Mastectomia Segmentar , Pessoa de Meia-Idade , Tamanho do Órgão , Radiodermite/patologia , Radioterapia Adjuvante/efeitos adversos , Método Simples-Cego , Falha de TratamentoRESUMO
PURPOSE: To examine the outcome of patients who developed an isolated locoregional recurrence (LRR) involving the supraclavicular fossa (SCV) after initial treatment with modified radical mastectomy and chemotherapy. METHODS AND MATERIALS: Records from 140 breast cancer patients treated on five prospective trials with mastectomy and doxorubicin-based chemotherapy, with or without radiation, who developed a LRR were reviewed. Kaplan-Meier survival times were calculated using date of LRR as time zero. RESULTS: The median follow-up after LRR was 2.9 years (N = 140; interquartile range, 1.3-6.6 years). In all, 47 of 140 patients (34%) had an SCV component to their LRR. These patients had lower 3-y distant metastasis-free survival (40% vs. 54%, p = 0.003) and overall survival (49% vs. 69%, p = 0.04) than patients without an SCV component. Multivariate analysis revealed that LRR involving an SCV component (hazard ratio, 1.96, p = 0.004) and patients with lymphovascular space invasion in their primary tumors (hazard ratio, 1.65, p = 0.029) were independently associated with a poor distant metastasis-free survival. However, among 23 patients with isolated SCV recurrence, Overall survival was not statistically significantly different between isolated chest wall recurrence and isolated SCV recurrence. Patients with isolated SCV recurrence displayed a median follow-up of 3.3 years (IR, 1.2-5.2). Only 6 LRR of 23 patients were treated with aggressive local therapy, including surgery, chemotherapy, and radiation (alone or in combination). CONCLUSIONS: Although breast cancer recurrence with SCV involvement carries a high risk of distant metastasis and death, among women with recurrence limited to the SCV alone, overall survival after isolated SCV recurrence can be long (25% >5 years).
Assuntos
Antibióticos Antineoplásicos/uso terapêutico , Neoplasias da Mama , Doxorrubicina/uso terapêutico , Mastectomia , Recidiva Local de Neoplasia , Adulto , Idoso , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Clavícula , Terapia Combinada/métodos , Terapia Combinada/mortalidade , Feminino , Seguimentos , Humanos , Metástase Linfática , Mastectomia/mortalidade , Pessoa de Meia-Idade , Análise Multivariada , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Resultado do TratamentoRESUMO
BACKGROUND: Young age is an independent risk factor for local-regional recurrence after mastectomy in patients with T1/T2 tumors with zero or one to three positive lymph nodes. The authors evaluated the current incidence and management of local-regional recurrence after immediate breast reconstruction in patients with T1/T2 tumors and zero to three positive lymph nodes who did not receive postmastectomy radiotherapy. METHODS: Clinical and pathologic factors were identified for 495 patients with T1/T2 tumors and zero to three positive lymph nodes who were treated with mastectomy and immediate breast reconstruction between 1997 and 2002 and did not receive primary systemic chemotherapy or postmastectomy radiation therapy. RESULTS: Autologous tissue-based reconstruction was performed in 70 percent of patients, and 30 percent had tissue expander placement. At a median follow-up of 7.5 years, local-regional recurrence had occurred in 16 patients (3.2 percent). Independent predictors of local-regional recurrence were age 40 years or less, estrogen receptor-negative tumors, and T2 (versus T1) tumors (p < 0.05). Multimodality therapy was utilized for all 16 patients with local-regional recurrence. Nine patients (56.3 percent) who had an isolated local-regional recurrence had a 100 percent local control rate and were treated with curative intent. The 10-year overall survival rate for patients with an isolated local-regional recurrence (87.5 percent) was not significantly different from that for patients without a local-regional recurrence (90.3 percent; p = 0.234). CONCLUSIONS: Routine use of postmastectomy radiation therapy in this heterogeneous patient population should be discouraged to allow more patients to undergo immediate breast reconstruction and ease the burden on plastic surgeons who have had to confront the problems of reconstruction in the face of perioperative radiation in an ever-increasing number of patients.
Assuntos
Neoplasias da Mama/cirurgia , Mamoplastia/efeitos adversos , Mastectomia/métodos , Recidiva Local de Neoplasia/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/patologia , Terapia Combinada , Feminino , Seguimentos , Humanos , Incidência , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologiaRESUMO
PURPOSE: The purpose of this study was to determine local-regional recurrence (LRR) risk according to whether postmastectomy radiation therapy (PMRT) was used to treat breast cancer patients with clinical T3N0 disease who received neoadjuvant chemotherapy (NAC) and mastectomy. METHODS AND MATERIALS: Clinicopathology data from 162 patients with clinical T3N0 breast cancer who received NAC and underwent mastectomy were retrospectively reviewed. A total of 119 patients received PMRT, and 43 patients did not. The median number of axillary lymph nodes (LNs) dissected was 15. Actuarial rates were calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS: At a median follow-up of 75 months, 15 of 162 patients developed LRR. For all patients, the 5-year LRR rate was 9% (95% confidence interval [CI], 4%-14%). The 5-year LRR rate for those who received PMRT was 4% (95% CI, 1%-9%) vs. 24% (95% CI, 10%-39%) for those who did not receive PMRT (p <0.001). A significantly higher proportion of irradiated patients had pathology involved LNs and were ≤40 years old. Among patients who had pathology involved LNs, the LRR rate was lower in those who received PMRT (p <0.001). A similar trend was observed for those who did not have pathology involved LN disease. Among nonirradiated patients, the appearance of pathologic LN disease after NAC was the only clinicopathologic factor examined that significantly correlated with the risk of LRR. CONCLUSIONS: Breast cancer patients with clinical T3N0 disease treated with NAC and mastectomy but without PMRT had a significant risk of LRR, even when there was no pathologic evidence of LN involvement present after NAC. PMRT was effective in reducing the LRR rate. We suggest PMRT should be considered for patients with clinical T3N0 disease.
Assuntos
Neoplasias da Mama/radioterapia , Recidiva Local de Neoplasia , Adulto , Fatores Etários , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Axila , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Neoplasias da Mama/prevenção & controle , Neoplasias da Mama/cirurgia , Quimioterapia Adjuvante/métodos , Feminino , Humanos , Excisão de Linfonodo/métodos , Mastectomia , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias , Estudos Retrospectivos , Medição de Risco , Carga TumoralRESUMO
PURPOSE: To determine the rate of locoregional recurrence (LRR) associated with modern tri-modality therapy. METHODS: We retrospectively reviewed data from 291 consecutive PMRT patients treated from 1999 to 2001. These patients were compared to an historical group of 313 patients treated from 1979 to 1988 who had fluoroscopic simulation and contour-generated 2D planning. 1999-2001 spans the adoption of CT simulators for breast radiation therapy and a comparison was made between patients simulated before and after the implementation of CT simulation. Five-year actuarial rates for LRR, distal metastasis (DM), and overall survival (OS) between the pre and post CT simulation cohorts were compared as well. RESULTS: Compared to a 2D planned historic control, the combined contemporary patients had improved outcomes at 5years for all endpoints studied; LRR 3.0% vs. 11.5%, DM 29.2% vs. 39.2%, and OS 79.2% vs. 70.6% (p=0.0004, 0.0052, 0.0012, respectively). Significant factors in a multivariate analysis for LRR were: advanced T-stage (RR=2.14, CI=1.11-4.11, p=0.023), and percent positive nodes (RR=1.01, CI=1.00-1.02, p=0.012). The comparison of the pre and post CT-simulated PMRT patients (1999-2001) found no significant difference in any endpoint. CONCLUSIONS: The rate of locoregional control for PMRT patients treated with modern radiotherapy is outstanding and has improved significantly compared to historical controls.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias da Mama/terapia , Mastectomia Radical Modificada/métodos , Recidiva Local de Neoplasia/epidemiologia , Adulto , Idoso , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Terapia Combinada , Doxorrubicina/administração & dosagem , Feminino , Humanos , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
PURPOSE: To investigate the incidence and local control of internal mammary lymph node metastases (IMN+) in patients with clinical N2 or N3 locally advanced breast cancer. METHODS AND MATERIALS: We retrospectively reviewed the records of 809 breast cancer patients diagnosed with advanced nodal disease (clinical N2-3) who received radiation treatment at our institution from January 2000 December 2006. Patients were considered IMN+ on the basis of imaging studies. RESULTS: We identified 112 of 809 patients who presented with IMN+ disease (13.8%) detected on ultrasound, computed tomography (CT), positron emission tomography/CT (PET/CT), and/or magnetic resonance imaging (MRI) studies. All 112 patients with IMN+ disease received anthracycline and taxane-based chemotherapy. Neoadjuvant chemotherapy (NCT) resulted in a complete response (CR) on imaging studies of IMN disease in 72.1% of patients. Excluding 16 patients with progressive disease, 96 patients received adjuvant radiation to the breast or the chest wall and the regional lymphatics including the IMN chain with a median dose of 60 Gy if the internal mammary lymph nodes normalized after chemotherapy and 66 Gy if they did not. The median follow-up of surviving patients was 41 months (8-118 months). For the 96 patients able to complete curative therapy, the actuarial 5-year IMN control rate, locoregional control, overall survival, and disease-free survival were 89%, 80%, 76%, and 56%. CONCLUSION: Over ten percent of patients with advanced nodal disease will have IMN metastases on imaging studies. Multimodality therapy including IMN irradiation achieves excellent rates of control in the IMN region and a DFS of more than 50% after curative treatment.
Assuntos
Neoplasias da Mama/radioterapia , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Mama , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Carcinoma Ductal de Mama/tratamento farmacológico , Carcinoma Ductal de Mama/mortalidade , Carcinoma Ductal de Mama/radioterapia , Carcinoma Ductal de Mama/secundário , Carcinoma Lobular/tratamento farmacológico , Carcinoma Lobular/mortalidade , Carcinoma Lobular/radioterapia , Carcinoma Lobular/secundário , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Metástase Linfática , Pessoa de Meia-Idade , Terapia Neoadjuvante/métodos , Dosagem Radioterapêutica , Indução de Remissão , Estudos RetrospectivosRESUMO
BACKGROUND: Single-institution data suggest that treatment with radiation and axillary lymph node dissection (ALND) may be an appropriate alternative to mastectomy for T0N+ breast cancer. Population-based multi-institutional data supporting this approach are lacking. METHODS: The cause-specific survival (CSS) and overall survival (OS) of women with T0N+M0 ductal, lobular, or mixed breast cancer in the Surveillance, Epidemiology, and End Results database from 1983 to 2006 were analyzed. Groups were defined as: 1) no ALND, mastectomy, or RT (observation); 2) ALND only; 3) mastectomy plus ALND with or without postmastectomy radiation (Mast); and 4) breast-conserving therapy (BCT) with ALND and radiation (BCT). RESULTS: In total, 750 of 770,030 patients with breast cancer had T0N+M0 disease (incidence, 0.10%), and 596 of those patients underwent ALND (79.5%). Patients who underwent Mast or BCT (n = 470) had a 10-year OS rate of 64.9% compared with 58.5% for patients who underwent ALND only (n = 126; P = .02) and 47.5% for patients who underwent observation only (n = 94; P = .04). The 10-year CSS rate was 75.7% for patients who underwent BCT versus 73.9% for patients who underwent Mast (P = .55). In multivariate analysis of CSS for patients who underwent Mast or BCT, the following factors were correlated with an unfavorable outcome: positive estrogen receptor status (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.24-0.96; P = .04), >/=10 positive lymph nodes (HR, 5.7; 95%CI, 2.4-13.4; P = .01), and <10 resected lymph nodes (HR, 42.9; 95%CI, 1.2-7.1; P = .02). Mast did not improve CSS compared with BCT (HR, 1.09; 95%CI, 0.57-2.1; P = .79). CONCLUSIONS: Definitive locoregional treatment with either Mast or BCT improved the outcome of patients with T0N+breast cancer, and no difference in survival was observed between the treatments. Cancer 2010. (c) 2010 American Cancer Society.
Assuntos
Neoplasias da Mama/diagnóstico , Adulto , Idoso , Axila , Neoplasias da Mama/epidemiologia , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Neoplasias da Mama/terapia , Terapia Combinada , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Mastectomia , Pessoa de Meia-Idade , Neoplasias Hormônio-Dependentes/epidemiologia , Vigilância da População , Radioterapia Adjuvante , Programa de SEER , Resultado do TratamentoRESUMO
PURPOSE: To compare interobserver variations in delineating the whole breast for treatment planning using two contouring methods. METHODS AND MATERIALS: Autosegmented contours were generated by a deformable image registration-based breast segmentation method (DEF-SEG) by mapping the whole breast clinical target volume (CTVwb) from a template case to a new patient case. Eight breast radiation oncologists modified the autosegmented contours as necessary to achieve a clinically appropriate CTVwb and then recontoured the same case from scratch for comparison. The times to complete each approach, as well as the interobserver variations, were analyzed. The template case was also mapped to 10 breast cancer patients with a body mass index of 19.1-35.9 kg/m(2). The three-dimensional surface-to-surface distances and volume overlapping analyses were computed to quantify contour variations. RESULTS: The median time to edit the DEF-SEG-generated CTVwb was 12.9 min (range, 3.4-35.9) compared with 18.6 min (range, 8.9-45.2) to contour the CTVwb from scratch (30% faster, p = 0.028). The mean surface-to-surface distance was noticeably reduced from 1.6 mm among the contours generated from scratch to 1.0 mm using the DEF-SEG method (p = 0.047). The deformed contours in 10 patients achieved 94% volume overlap before correction and required editing of 5% (range, 1-10%) of the contoured volume. CONCLUSION: Significant interobserver variations suggested a lack of consensus regarding the CTVwb, even among breast cancer specialists. Using the DEF-SEG method produced more consistent results and required less time. The DEF-SEG method can be successfully applied to patients with different body mass indexes.