Radiotherapy Utilization for Patients Over Age 60 With Early Stage Breast Cancer.

Introduction: Recent studies have questioned the relative benefit of radiotherapy (RT) for older patients with favorable breast cancer given the lack of survival benefit and marginal local control benefit. Despite the 2004 National Comprehensive Cancer Network (NCCN) guidelines advocating for the option of hormonal therapy alone, trends in utilization rates of RT in this group are not well-documented. We analyzed our institutional experience with implementation of the guidelines over time.

Indications for Postmastectomy Radiation After Neoadjuvant Chemotherapy in ypN0 and ypN1-3 Axillary Node-Positive Women.

Introduction: Downstaging with neoadjuvant chemotherapy (NAC) might obscure indications for postmastectomy radiation (PMRT). The degree of downstaging that results in local-regional recurrence (LRR) rates low enough to omit PMRT remains controversial. We examined the rate of LRR in women who received NAC who underwent mastectomy without PMRT.

Complications After Total Skin-Sparing Mastectomy and Expander-Implant Reconstruction: Effects of Radiation Therapy on the Stages of Reconstruction.

Background: Many patients undergoing total-skin sparing mastectomy (TSSM) and 2-staged expander-implant (TE-I) reconstruction require postmastectomy radiation therapy (PMRT). Additionally, many patients undergoing TSSM for recurrent cancer have a history of lumpectomy and radiation therapy (XRT). Few studies have looked at the impact of XRT on the stages of TE-I reconstruction.

An Innovative Risk-Reducing Approach to Postmastectomy Radiation Delivery after Autologous Breast Reconstruction.

Introduction: Postmastectomy radiation therapy (PMRT) has known deleterious side effects in immediate autologous breast reconstruction. However, plastic surgeons are rarely involved in PMRT planning. Our institution has adopted a custom bolus approach for all patients receiving PMRT.

Evaluation of Heart Dose for Left-Sided Breast Cancer Patients Over an 11-Year Period Spanning the Transition From 2-Dimensional to 3-Dimensional Planning.

Introduction/background: We evaluated heart dose from left breast radiotherapy with 2-dimensional (2D) versus 3-dimensional (3D) plans.

Patients And Methods: Treatment plans from patients treated with standard fractionation for left breast cancer from 2003 to 2013 were reviewed, with patients grouped into 3 cohorts: 2003 to 2004 ("2D", with computed tomography scans for dose calculation but fields defined using simulation films; n = 29), 2005 to 2006 ("2D-post," after several influential articles on heart dose were published; n = 31), and 2007 to 2013 ("3D"; n = 256). All patients were treated with free-breathing technique.

Endocrine Therapy for Hormone Receptor-Positive Metastatic Breast Cancer: American Society of Clinical Oncology Guideline.

Purpose: To develop recommendations about endocrine therapy for women with hormone receptor (HR) -positive metastatic breast cancer (MBC).

Methods: The American Society of Clinical Oncology convened an Expert Panel to conduct a systematic review of evidence from 2008 through 2015 to create recommendations informed by that evidence. Outcomes of interest included sequencing of hormonal agents, hormonal agents compared with chemotherapy, targeted biologic therapy, and treatment of premenopausal women.

Sentinel Lymph Node Mapping in Post-Mastectomy Chest Wall Recurrences: Influence on Radiation Treatment Fields and Outcome.

Background And Objectives: Invasive chest wall recurrences (CWR) following mastectomy are typically treated with surgical excision, radiation therapy (RT) to the chest wall and supraclavicular (SCV) region, and appropriate systemic therapy. Repeat axillary surgery is not routinely performed if the axilla is clinically negative. We evaluated sentinel node biopsy (SNB) in patients with an isolated invasive CWR, for identification and biopsy rates, non-axillary drainage, and clinical implications for radiation fields and outcome.

The Impact of Radiation Therapy, Lymph Node Dissection, and Hormonal Therapy on Outcomes of Tissue Expander-Implant Exchange in Prosthetic Breast Reconstruction.

Background: Total skin-sparing mastectomy, with preservation of the nipple-areola complex, must account for adjuvant medical and surgical treatments for cancer. The authors assessed risk factors for complications after second-stage tissue expander-implant exchange.

Methods: The authors reviewed all institutional total skin-sparing mastectomy cases that had completed tissue expander-implant exchange with at least 3 months of follow-up.

Rates of Reconstruction Failure in Patients Undergoing Immediate Reconstruction With Tissue Expanders and/or Implants and Postmastectomy Radiation Therapy.

Objectives: Mastectomy rates for breast cancer have increased, with a parallel increase in immediate reconstruction. For some women, tissue expander and implant (TE/I) reconstruction is the preferred or sole option. This retrospective study examined the rate of TE/I reconstruction failure (ie, removal of the TE or I with the inability to replace it resulting in no final reconstruction or autologous tissue reconstruction) in patients receiving postmastectomy radiation therapy (PMRT).

Gene expression profiling to predict the risk of locoregional recurrence in breast cancer: a pooled analysis.

The 70-gene signature (MammaPrint) has been developed to predict the risk of distant metastases in breast cancer and select those patients who may benefit from adjuvant treatment. Given the strong association between locoregional and distant recurrence, we hypothesize that the 70-gene signature will also be able to predict the risk of locoregional recurrence (LRR). 1,053 breast cancer patients primarily treated with breast-conserving treatment or mastectomy at the Netherlands Cancer Institute between 1984 and 2006 were included.

Practice patterns in the delivery of radiation therapy after mastectomy among the University of California Athena Breast Health Network.

Background: Practice patterns vary with the planning and delivery of PMRT. In our investigation we examined practice patterns in the use of chest wall bolus and a boost among the Athena Breast Health Network (Athena).

Materials And Methods: Athena is a collaboration among the 5 University of California Medical Centers that aims to integrate clinical care and research.

Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes.

Background: Radiation therapy is increasingly used in breast cancer therapy. With total skin-sparing mastectomy and nipple/areola complex preservation, defining the risks of various treatment regimens for morbidity is important, in the setting of immediate prosthetic reconstruction. The authors assessed the effects of premastectomy and postmastectomy radiation therapy on outcomes in total skin-sparing mastectomy and immediate prosthetic reconstruction.

Risk of positive nonsentinel nodes in women with 1-2 positive sentinel nodes related to age and molecular subtype approximated by receptor status.

We examine risk of positive nonsentinel axillary nodes (NSN) and ≥4 positive nodes in patients with 1-2 positive sentinel nodes (SN) by age and tumor subtype approximated by ER, PR, and Her2 receptor status. Review of two institutional databases demonstrated 284 women undergoing breast conservation between 1997 and 2008 for T1-2 tumors and 1 (229) or 2 (55) positive SN followed by completion dissection. The median number of SN and total axillary nodes removed were 2 (range 1-10) and 14 (range 6-37), respectively.

Impact of total skin-sparing mastectomy incision type on reconstructive complications following radiation therapy.

Background: Postoperative complications after total skin-sparing mastectomy and expander-implant reconstruction can negatively impact outcomes, particularly in the setting of postmastectomy radiation therapy. The authors studied whether rates of ischemic complications after postmastectomy radiation therapy are impacted by the total skin-sparing mastectomy incision.

Methods: The authors queried a prospectively collected database of patients undergoing total skin-sparing mastectomy and immediate two-stage expander-implant reconstruction.

Effect of Bra Use during Radiotherapy for Large-Breasted Women: Acute Toxicity and Treated Heart and Lung Volumes.

Purpose: Large breast size presents special problems during radiation simulation, planning and patient treatment, including increased skin toxicity, in women undergoing breast-conserving surgery and radiotherapy (BCT). We report our experience using a bra during radiation in large-breasted women and its effect on acute toxicity and heart and lung dosimetry.

Materials And Methods: From 2001 to 2006, 246 consecutive large-breasted women (bra size ≥ 38 and/or ≥ D cup) were treated with BCT using either 3D conformal (3D-CRT) or Intensity Modulated Radiation (IMRT).

Survival after lumpectomy and mastectomy for early stage invasive breast cancer: the effect of age and hormone receptor status.

Background: Randomized clinical trials (RCT) have demonstrated equivalent survival for breast-conserving therapy with radiation (BCT) and mastectomy for early-stage breast cancer. A large, population-based series of women who underwent BCT or mastectomy was studied to observe whether outcomes of RCT were achieved in the general population, and whether survival differed by surgery type when stratified by age and hormone receptor (HR) status.

Methods: Information was obtained regarding all women diagnosed in the state of California with stage I or II breast cancer between 1990 and 2004, who were treated with either BCT or mastectomy and followed for vital status through December 2009.

Effect of bra use during radiation therapy for large-breasted women: Acute toxicity and treated heart and lung volumes.

Purpose: Large breast size presents special problems during radiation simulation, planning, and patient treatment, including increased skin toxicity, in women undergoing breast-conserving surgery and radiation therapy (BCT). We report our experience using a bra during radiation in large-breasted women and its effect on acute toxicity and heart and lung dosimetry.

Methods And Materials: From 2001 to 2006, 246 consecutive large-breasted women (bra size ≥38 or ≥D cup) were treated with BCT using either 3-dimensional conformal radiation therapy (3DCRT) or intensity modulated radiation therapy (IMRT).

Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure.

Background: Increased rates of complications can occur when postmastectomy radiation therapy is required after immediate expander-implant breast reconstruction. The sequence and timing of tissue expansion and implant exchange with regard to postmastectomy radiation therapy may impact complication rates.

Methods: A prospectively maintained database of patients undergoing mastectomy and immediate reconstruction was queried for patients who underwent postmastectomy radiation therapy.

Role of postmastectomy radiation after neoadjuvant chemotherapy in stage II-III breast cancer.

Purpose: To identify a cohort of women treated with neoadjuvant chemotherapy and mastectomy for whom postmastectomy radiation therapy (PMRT) may be omitted according to the projected risk of local-regional failure (LRF).

Methods And Materials: Seven breast cancer physicians from the University of California cancer centers created 14 hypothetical clinical case scenarios, identified, reviewed, and abstracted the available literature (MEDLINE and Cochrane databases), and formulated evidence tables with endpoints of LRF, disease-free survival, and overall survival. Using the American College of Radiology appropriateness criteria methodology, appropriateness ratings for postmastectomy radiation were assigned for each scenario.

Is radiation indicated in patients with ductal carcinoma in situ and close or positive mastectomy margins?

Purpose: Resection margin status is one of the most significant factors for local recurrence in patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery with or without radiation. However, its impact on chest wall recurrence in patients treated with mastectomy is unknown. The purpose of this study was to determine chest wall recurrence rates in women with DCIS and close (<5 mm) or positive mastectomy margins in order to evaluate the potential role of radiation therapy.

Application of screening principles to the reconstructed breast.

A significant number of women choose mastectomy for the treatment of early and locally advanced breast cancer. Advances in reconstruction techniques and greater awareness of options have led to an increased use of immediate breast reconstruction, which has resulted in uncertainty for the management of surveillance for local recurrence. In this article, we review mastectomy and reconstruction trends and how these techniques affect the frequency and location of local recurrence.

Comparison between hybrid direct aperture optimized intensity-modulated radiotherapy and forward planning intensity-modulated radiotherapy for whole breast irradiation.

Purpose: To investigate the planning efficiency and dosimetric characteristics of hybrid direct aperture optimized (hDAO) intensity-modulated radiotherapy (IMRT) compared with forward planning (FP)-IMRT for whole breast irradiation with two tangential beams.

Methods And Materials: A total of 15 patients with left-sided breast cancer, categorized with three different breast volumes, were selected for this study. All patients were treated with FP plans to 50 Gy in 25 fractions.

Low complication rates are achievable after postmastectomy breast reconstruction and radiation therapy.

Purpose: To report our institution's experience of complications and cosmetic results among patients who underwent modified radical mastectomy followed by reconstruction and radiation therapy (RT).

Methods And Materials: Between 1987 and 2002, 85 patients with breast cancer underwent modified radical mastectomy, breast reconstruction, and postoperative RT. Reconstruction consisted of tissue expander/implant (TE/I) in 50 patients and an autologous transverse rectus abdominis myocutaneous (TRAM) flap in 35 patients.

Standard for breast conservation therapy in the management of invasive breast carcinoma.

Multidisciplinary guidelines for management of invasive breast carcinoma from the American College of Radiology, the American College of Surgeons, the College of American Pathology, and the Society of Surgical Oncology have been updated to reflect the continuing advances in the diagnosis and treatment of invasive breast cancer. The guidelines provide a framework for clinical decision-making for patients with invasive breast carcinoma based on review of relevant literature and include information on patient selection and evaluation, technical aspects of surgical treatment, techniques of irradiation, and follow-up care.