Joint Hospital Surgical Grand Round Chiu Hiu Fung Jennifer Kwong Wah Hospital 25-1-2014 Chiu Hiu...
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Transcript of Joint Hospital Surgical Grand Round Chiu Hiu Fung Jennifer Kwong Wah Hospital 25-1-2014 Chiu Hiu...
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Joint Hospital Surgical Grand Round
Joint Hospital Surgical Grand Round
Chiu Hiu Fung JenniferKwong Wah Hospital
25-1-2014
Chiu Hiu Fung JenniferKwong Wah Hospital
25-1-2014
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Is Breast Conserving Treatment (BCT) feasible for Ipsilateral Breast Tumour Recurrence (IBTR)?
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Breast conserving surgery
BCT = wide local excision + radiotherapy
Well-established treatment modality for early breast cancer
Equal local control and disease-free survival compared to mastectomy
Superior psychosocial outcomes - improved body image and lifestyle score
National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial
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Definition of local recurrence
IBTR - recurrent tumour within the ipsilateral breast after lumpectomy + radiotherapy
Recurrence within 6 months of primary surgery - primary treatment failure
Local recurrence - recurrence after mastectomy ie skin / chest wall
True recurrence (TR) vs New primary (NP)
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Ipsilateral breast tumour recurrence (IBTR) rate after BCS + RT is 1-2% per year
In 1990s, IBTR rate after BCS (without RT) at 10 years: 19%
In 2000s, IBTR rate after BCS + RT at 10 years: 9%
NSABP B-17 and B-24 trials
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Risk factors for first recurrence:
Omission of radiotherapy
Young age
Involved margin
Multifocality
Extensive in-situ component
Lymphovascular invasion
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No standard classification of True Recurrence (TR) vs New Primary (NP)
Different classifications include:
tumour location
histological subtype
ER status
DNA flow cytometry
Gene expression profiling data
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True Recurrences: 44 - 78%
TR - shorter metastasis-free survival
mean time to disease recurrence -
37 months for TRs vs 55 months for NPs
Classification of ipsilateral breast tumor recurrence after breast-conserving therapy: New primary cancer allows a good prognosis. Nishimura S. Cancer 2005;12:112–117.
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True recurrence is a poor prognostic factor - agressive biology intrinsic to the tumour itself
Lower overall survival and disease-free survival compared to NP group
Hypothesis that TR and NP tumours are distinct entities with different survival prognoses requires further confirmation with pathology review and molecular analyses
Analysis of Ipsilateral Breast Tumor Recurrences after Breast-conserving Treatment Based on the Classification of True Recurrences and New Primary Tumors. Komoike Y. Breast Cancer. 2005;12(2):104-111.
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Treatment options for IBTR
Salvage mastectomy - gold standard of local treatment for IBTR
Second local recurrence rate: 10% (3-32%)
5 year disease free survival: 41-59%
5 year overall survival: 70% (58-84%)
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Is there any role for repeating BCS for IBTR?
Is it safe?
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<local treatment options for IBTR>
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Four different salvage options were analyzed:
(a) Salvage mastectomy alone
(b) Salvage mastectomy + re-irradiation
(c) 2nd BCS alone
(d) 2nd BCS + re-irradiation
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Methods of Re-irradiation
Conventional external beam re-irradiation
Interstitial brachytherapy
low dose rate, high dose rate, or pulsed dose rate
Intra-operative radiotherapy
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Salvage mastectomy alone for IBTR
Second local recurrence rate 10-15% (3 - 32%)
10 year disease free survival: 40-45% (61 - 84%)
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Second bcs without post-operative re-irradiation
Second local recurrence rate: 20% (7 - 32%)
10 year disease free survival: 60% (61 - 64%)Second BCS without re-irradiation is associated with more second local recurrence and less 10 year overall survival when compared to salvage mastectomy
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Second local recurrence rate: 2 - 26%
5 year overall survival: 75% (61 - 97%)
Second bcs with post-operative re-irradiation for IBTR
Grade 3-4 toxicity: 3 - 11%
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2nd local recurrence rate
5-year disease-free survival
(%)
5-year overall survival (%)
10-year overall survival (%)
Salvage mastectomy alone
10-15% 50% 60-65% -
Salvage mastectomy alone with post-op re-
irradiation2% 62% 59%
* distant metastasis rate
- 28%
Second breast-conserving surgery
alone
20% (7-32%)
78% - 50%
Second breast-conserving surgery with
re-irradiation
10%(0-26%)
60% 87% -
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Salvage mastectomy vs second BCS + Re-irradiation
Second local recurrence rate is similar (about 10%)
5 year overall survival is similar, mainly influenced by distant metastatic progression
Difficult to conduct a randomized controlled trial
Large number of patients will be needed as IBTR is a rare event
Patient may not accept randomization between salvage mastectomy and second BCT
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What are the risk factors for second local recurrence?
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Retrospective analysis
3155 patients with DCIS or IDC underwent breast conserving surgery from 1986 - 2010
132 developed IBTR (~3%)
46 underwent salvage mastectomy, remaining 86 received second BCS
8 patients that did not receive re-irradiation were excluded
Total of 78 patient with IBTR and were treated with second BCS + re-irradiation
17 of 78 patients experienced second IBTR
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Time >2 years
ER +ve
negative marginsage at diagnosis >40
yearsER +ve
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Low risk: DFI > 2 years, ER positive or unknown, negative margins, and age at initial diagnosis >=40
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Which type of patients are suitable for second BCS + re-irradiation?
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Controversial...
Time to recurrence >2 years
Positive ER status
? new primary tumors
Sizeable breasts
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Conclusion
Both salvage mastectomy and second BCS + re-irradiation are treatment options of IBTR
Still need further large scale studies to compare local recurrence rate and overall survival
To identify the group of patients who can benefit from second BCT
Develop newer radiation techniques to reduce re-irradiation toxicity
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References
Local treatment options for ipsilateral breast tumour recurrence. Hannoun-Levi JM. Cancer Treat Rev. 2013 Nov;39(7):737-41.
Analysis of Ipsilateral Breast Tumor Recurrences after Breast-conserving Treatment Based on the Classification of True Recurrences and New Primary Tumors. Komoike Y. Breast Cancer. 2005;12(2):104-111.
Repeat Lumpectomy for Ipsilateral Breast Tumor Recurrence after Breast-Conserving Treatment. Ishitobi M. Oncology. 2011;81:381-386
True Recurrence Versus New Primary: An Analysis of Ipsilateral Breast Tumor Recurrences After Breast-Conserving Therapy. V Panet-Raymond. International Journal of Radiation Oncology. 2011;81(2):409-41
Repeating Conservative Surgery after Ipsilateral Breast Tumor Reappearance: Criteria for Selecting the Best Candidates. Gentilini O. Ann Surg Oncol. 2012;19:3771-3776
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The End
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interstitial brachytherapy
Brachy: short-distance
Can be used alone or in combination with surgery, external beam RT and chemotherapy
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Intraoperative radiotherapy (IORT)
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IORT group: 1 dose 21 Gy during surgery
External RT group: 50 Gy in 25 fractions of 2 Gy + boost of 10 Gy in 5 fractions
5-year rate for IBTR 4.4% for IORT group; 0.4% for external RT
Same overall survival
Significantly fewer skin side-effects in IORT group (p=0.0002)
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Toxicity of irradiation
radiation dermatitis, fibrosis, telangiectasia
pericarditis, pericardial effusion, pneumonitis
From double surgery: asymmetry