Primer consenso español sobre el uso de la radioterapia intraoperatoria en el cáncer de mama. Conclusiones del panel de expertos / First Spanish consensus on the use of intraoperative radiotherapy in breast cancer. Conclusions of the expert panel

Introducción: la publicación de ensayos aleatorizados con resultados a largo plazo ha demostrado que la radioterapia intraoperatoria (RIO) en cáncer de mama en estadio precoz puede ser una alternativa terapéutica en casos bien seleccionados. En el presente trabajo se presentan los resultados del Primer Consenso de Radioterapia Intraoperatoria en Cáncer de Mama realizado de manera multidisciplinar en España. Material y método: se hizo una revisión sistemática de la literatura y se invitó a todos los oncólogos radioterápicos y cirujanos expertos en RIO en cáncer de mama de España a participar en el consenso. Se aplico la siguiente metodología en 2 fases: a) la creación de un grupo de trabajo y la revisión de la evidencia; b) la realización de la encuesta y generación de recomendaciones consensuadas. Resultados: han participado un total 95,65% de los centros que actualmente utilizan esta técnica en cáncer de mama y que fueron invitados. Los expertos estuvieron de acuerdo en el uso de RIO exclusiva en cáncer de mama en aquellas pacientes mayores de 60 años y por encima de 50 años posmenopáusicas, con carcinoma ductal infiltrante o subtipos histológicos favorables, sin invasión linfovascular, tumores menores o iguales a 25 mm, márgenes de resección libres y receptores hormonales positivos. La utilización de RIO como rescate de recidiva local después de la irradiación externa alcanzó un nivel de consenso muy fuerte. Conclusión: el presente consenso pretende establecer las guías respecto a las indicaciones de RIO exclusiva o como sobreimpresión anticipada y ser una ayuda para la toma conjunta de decisiones. (AU)

Introduction: The publication of randomized trials with long-term results has demonstrated that intraoperative radiation therapy (IORT) in early-stage breast cancer can be a therapeutic alternative for well-selected cases. This paper present work presents the results of the first multidisciplinary consensus on IORT in breast cancer carried out in Spain. Materials and methods: A systematic literature review was conducted, and all radiation oncologists and surgeons with expertise in IORT for breast cancer in Spain were invited to participate in the consensus. The following methodology was employed in two phases: a) creation of a working group and review of the evidence; b) conduct of the survey and generation of consensus recommendations. Results: A total of 95.65% of the invited centers currently utilizing this technique in breast cancer participated. The experts agreed on the use of exclusive intraoperative radiation therapy in breast cancer for patients above 60 years of age and above 50 years postmenopausal, with invasive ductal carcinoma or favorable histological subtypes, no lymphovascular invasion, tumors less than or equal to 25 mm, clear surgical margins, and positive hormone receptor. The use of IORT as salvage surgery for local recurrence after external irradiation achieved a very strong consensus level. Conclusion: The present consensus aims to establish guidelines regarding the indications for exclusive IORT or as an early boost, and to serve as an aid for joint decision-making. (AU)

Tumor Bed Boost Radiotherapy in the Conservative Treatment of Breast Cancer: A Review of Intra-Operative Techniques and Outcomes.

Conservative surgery is the preferred treatment in the management of breast cancer followed by adjuvant whole-breast irradiation. Since the tumor bed is the main site of relapse, boost doses are conveniently administered according to risk factors for local relapse to increase the efficacy of the treatment. The benefit of a radiation boost is well established and it can be performed by several techniques like brachytherapy, external radiation or intraoperative radiotherapy. Greater precision in localizing the tumor cavity, immediacy and increased biological response are the main advantages of intraoperative boost irradiation. This modality of treatment can be performed by means of mobile electron accelerators or low-photon X-ray devices. There is a lot of research and some published series analyzing the results of the use of an intraoperative boost as an adjuvant treatment, after neoadjuvant systemic therapy and in combination with some reconstructive surgeries. This review discusses advantages of intraoperative radiotherapy and presents the main results of a boost in terms of local control, survival, tolerance and cosmesis.

In vivo dosimetry in low-voltage IORT breast treatments with XR-RV3 radiochromic film.

PURPOSE: The objectives of the study were to establish a procedure for in vivo film-based dosimetry for intraoperative radiotherapy (IORT), evaluate the typical doses delivered to organs at risk, and verify the dose prescription. MATERIALS AND METHODS: In vivo dose measurements were studied using XR-RV3 radiochromic films in 30 patients with breast cancer undergoing IORT using the Axxent® device (Xoft Inc.). The stability of the radiochromic films in the energy ranges used was verified by taking measurements at different depths. The stability of the scanner response was tested, and 5 different calibration curves were constructed for different beam qualities. Six pieces of film were placed in each of the 30 patients. All the pieces were correctly sterilized and checked to ensure that the process did not affect the outcome. All calibration and dose measurements were analyzed using the Radiochromic.com software application. RESULTS: The doses were measured for 30 patients. The doses in contact with the applicator (prescription zone) were 19.8 ± 0.9 Gy. In the skin areas, the doses were as follows: 1-2 cm from the applicator, 1.86 ± 0.77 Gy; 2-5 cm, 0.73 ± 0.14 Gy; and greater than 5 cm, 0.28 ± 0.17 Gy. The dose delivered to the pectoral muscle (tungsten shielding disc) was 0.51 ± 0.27 Gy. CONCLUSIONS: The study demonstrated the viability of XR-RV3 films for in vivo dose measurement in the dose and energy ranges applied in a complex procedure, such as breast IORT. The doses in organs at risk were far below the tolerances for cases such as those studied.

Cirugía oncoplástica y radioterapia intraoperatoria en el cáncer de mama / Oncoplastic surgery and intraoperative radiotherapy in breast cancer

Objetivo: Estudio prospectivo de pacientes con cáncer de mama precoz tratadas con cirugía conservadora oncoplástica y radioterapia intraoperatoria con intención de dosis única o monoterapia. Material y método: Veintitrés pacientes intervenidas entre junio de 2016 y agosto de 2018, que han cumplido criterios de administración de radioterapia intraoperatoria establecidos por nuestro comité multidisciplinar de tumores de mama (carcinoma ductal infiltrante<3cm, unifocal, con axila clínica y radiológicamente negativa, receptores hormonales positivos y HER2 negativo) y han sido candidatas a cirugía oncoplástica. Resultados: Tras el estudio anatomopatológico, todas las piezas de resección tenían márgenes libres y 16 pacientes seguían cumpliendo criterios de radioterapia intraoperatoria como monoterapia. En 7 pacientes se precisó administrar radioterapia glandular externa por no cumplir alguno de los criterios. Conclusiones: La cirugía oncoplástica asociada a radioterapia intraoperatoria es una evolución en el tratamiento del cáncer de mama precoz en un importante número de nuestras pacientes. Presenta un alto grado de satisfacción y una menor percepción de la enfermedad por parte de las pacientes

Objective: Prospective study of patients with early breast cancer treated with oncoplastic conservative surgery and intraoperative radiotherapy with single-dose intent or monotherapy. Material and method: We included 23 patients who underwent surgery between June 2016 and August 2018 and who met the criteria for administration of intraoperative radiotherapy established by our multidisciplinary committee of breast tumours (infiltrating ductal carcinoma<3cm, unifocal, with a clinically and radiologically negative axilla, hormone receptor-positive and HER2-negative) and who were candidates for oncoplastic surgery. Results: After pathological study, all the surgical specimens had free margins and 16 patients continued to meet the intraoperative radiotherapy criteria for monotherapy. In 7 patients who did not meet any of the criteria, external glandular radiotherapy was administered. Conclusions: Oncoplastic surgery associated with intraoperative radiotherapy is a development in the treatment of early breast cancer in a significant number of patients. It produces a high degree of satisfaction and a lower disease perception among patients

Cross-Situational Self-Consistency in Nine Cultures: The Importance of Separating Influences of Social Norms and Distinctive Dispositions.

We assessed self-consistency (expressing similar traits in different situations) by having undergraduates in the United States ( n = 230), Australia ( n = 220), Canada ( n = 240), Ecuador ( n = 101), Mexico ( n = 209), Venezuela ( n = 209), Japan ( n = 178), Malaysia ( n = 254), and the Philippines ( n = 241) report the traits they expressed in four different social situations. Self-consistency was positively associated with age, well-being, living in Latin America, and not living in Japan; however, each of these variables showed a unique pattern of associations with various psychologically distinct sources of raw self-consistency, including cross-situationally consistent social norms and injunctions. For example, low consistency between injunctive norms and trait expressions fully explained the low self-consistency in Japan. In accord with trait theory, after removing normative and injunctive sources of consistency, there remained robust distinctive noninjunctive self-consistency (reflecting individuating personality dispositions) in every country, including Japan. The results highlight how clarifying the determinants and implications of self-consistency requires differentiating its distinctive, injunctive, and noninjunctive components.

A four-culture study of self-enhancement and adjustment using the social relations model: do alternative conceptualizations and indices make a difference?

In the self-enhancement literature, 2 major controversies remain--whether self-enhancement is a cultural universal and whether it is healthy or maladaptive. Use of the social relations model (SRM; Kenny, 1994) might facilitate resolution of these controversies. We applied the SRM with a round-robin design in both friend and family contexts in 4 diverse cultures: the United States (n = 399), Mexico (n = 413), Venezuela (n = 290), and China (n = 222). Results obtained with social comparison, self-insight, and SRM conceptualizations and indices of self-enhancement were compared for both agentic traits (i.e., egoistic bias) and communal traits (i.e., moralistic bias). Conclusions regarding cultural differences in the prevalence of self-enhancement vs. self-effacement tendencies, and the relationship between self-enhancement and adjustment, varied depending on the index of self-enhancement used. For example, consistent with cultural psychology perspectives, Chinese showed a greater tendency to self-efface than self-enhance using social comparison and self-insight indices, particularly on communal traits in the friend context. However, no cultural differences were observed when perceiver and target effects were controlled using the SRM indices. In all cultures, self-enhancement indices were moderately consistent across friend and family contexts, suggesting traitlike tendencies. To a similar extent in all 4 cultures, self-enhancement tendencies, as measured by the SRM indices, were moderately related to self-rated adjustment, but unrelated, or less so, to observer-rated adjustment.

Culture, Method, and the Content of Self-Concepts: Testing Trait, Individual-Self-Primacy, and Cultural Psychology Perspectives.

Three theoretical perspectives on cultural universals and differences in the content of self-concepts were tested in individualistic (United States, n = 178; Australia, n = 112) and collectivistic (Mexico, n = 157; Philippines, n = 138) cultures, using three methods of self-concept assessment. Support was found for both trait perspectives and the individual-self-primacy hypothesis. In contrast, support for cultural psychology hypotheses was limited because traits and other personal attributes were not more salient, or social attributes less salient, in individualistic cultures than collectivistic cultures. The salience of some aspects of self-concept depended on the method of assessment, calling into question conclusions based on monomethod studies.

Measuring individual and cultural differences in implicit trait theories.

A new measure of implicit theories or beliefs regarding the traitedness versus contextuality of behavior was developed and tested across cultures. In Studies 1 (N = 266) and 2 (N = 266), these implicit beliefs dimensions were reliably measured and replicated across U.S. college student samples and validity evidence was provided. In Study 3, their structure replicated well across an individualistic culture (the United States; N = 249) and a collectivistic culture (Mexico; N = 268). Implicit trait and contextual beliefs overlapped only modestly with implicit entity theory beliefs and were predicted by self-construals in ways that generally supported cultural psychology hypotheses. Implicit trait beliefs were fairly strongly endorsed in both cultures, suggesting that such beliefs may be universally held.