Single-institution Comparison of
Accelerated Partial Breast Irradiation and Whole Breast Irradiation in Breast
Cancer Patients with Unfavorable Parameters by the American Society for
Radiation Oncology Guidelines
Kazuhiko
Sato, Yoshio Mizuno, Hiromi Fuchikami, Masahiro Kato, Takahiro Shimo, Jun
Kubota, Naoko Takeda, Yuko Inoue, Hiroshi Seto, Tomohiko Okawa
Kazuhiko Sato, Yoshio Mizuno, Hiromi Fuchikami, Naoko
Takeda, Department of
Breast Oncology, Tokyo-West Tokushukai Hospital, 3-1-1 Matsubara, Akishima,
Tokyo, 196-0003, Japan
Masahiro Kato, Takahiro Shimo, Jun Kubota, Department of Radiation Oncology,
Tokyo-West Tokushukai Hospital, 3-1-1 Matsubara, Akishima, Tokyo, 196-0003,
Japan
Naoko Takeda, Yuko Inoue, Inoue Ladies Clinic, 1-26-9 Fujimi, Tachikawa, Tokyo,
190-0013, Japan
Hiroshi Seto, Seto Hospital, 8-6 Kanayama, Tokorozawa, Saitama,
359-1128, Japan
Tomohiko Okawa, Health Evaluation Center, Utsunomiya Memorial Hospital,
1-3-16 Odori, Utsunomiya, Tochigi, 320-0811, Japan
Correspondence to: Kazuhiko Sato, Department of Breast Oncology,
Tokyo-West Tokushukai Hospital, 3-1-1 Matsubara, Akishima, Tokyo, 196-0003,
Japan.
Email: kazsato.boc@gmail.com
Telephone: +81-42-500-4433
Fax: +81-42-500-4434
Received: March 29, 2014
Revised: April 22, 2014
Accepted: April 28, 2014
Published online: June 18, 2014
ABSTRACT
AIM: The American Society for Radiation Oncology (ASTRO) issued guidelines
regarding patients that were suitable for accelerated partial breast
irradiation (APBI) following breast-conserving surgery (BCS) as an alternative
to whole breast irradiation (WBI). However, the suitability criteria may not be
based on updated data concerning the risk of ipsilateral breast tumor
recurrence (IBTR) with APBI. We reviewed the experience of APBI and WBI in
patients that would be characterized in the unfavorable categories based on the
ASTRO guidelines.
METHODS: Patients in both APBI and WBI cohorts were
categorized into one of the three groups based on the ASTRO guidelines on ABPI:
suitable, cautionary, or unsuitable. Consecutive patients who underwent BCS
followed by APBI or WBI were examined to compare and determine patterns of
treatment failures.
RESULTS: Since November 2007, 203 patients receiving APBI and
132 receiving WBI were analyzed. Mean follow-up was longer than 3 years. In the
APBI cohort (17 suitable, 87 cautionary, and 99 unsuitable patients), IBTR or
regional recurrence was observed in 1 (5.9%), 1 (1.1%), and 3 (3.0%) patient,
respectively. In the WBI cohort (14 suitable, 30 cautionary, and 88 unsuitable
patients), IBTR or regional recurrence was observed in 0 (0%), 1 (3.3%), and 4
(4.5%) patients, respectively. When APBI patients were stratified according to
the ASTRO category, there was no statistically significant difference in the
local control rates.
CONCLUSIONS: The clinical efficacy of APBI was comparable
with that of WBI for local control after BCS in patients considered cautionary
or unsuitable for APBI following the ASTRO guidelines.
© 2014 ACT. All rights reserved.
Key words: Breast Cancer; Accelerated Partial
Breast Irradiation; Whole Breast Irradiation; Ipsilateral Breast Tumor
Recurrence; The American Society for Radiation Oncology guidelines
Sato K, Mizuno Y,
Fuchikami H, Kato M, Shimo T, Kubota J, Takeda N, Inoue Y, Seto H, Okawa T. Single-institution
Comparison of Accelerated Partial Breast Irradiation and Whole Breast
Irradiation in Breast Cancer Patients with Unfavorable Parameters by the
American Society for Radiation Oncology Guidelines. Journal of Tumor 2014;
2(6): 148-152 Available from: URL:
http://www.ghrnet.org/index.php/JT/article/view/731
INTRODUCTION
Breast-conserving
surgery (BCS) followed by whole breast irradiation (WBI) has been established
as an acceptable alternative to mastectomy for patients with early-stage breast
cancer[1,2]. However, it takes 5-6 weeks of frequent visits to the
radiation centers; therefore, at least 25% or more patients fail to receive
sufficient radiation after BCS[3,4]. Accelerated partial breast
irradiation (APBI) allows the delivery of radiation therapy after BCS in 1 week
or less via several techniques, which offer decreased overall treatment time
and several theoretical advantages over WBI.
The efficacy and feasibility
of APBI as an alternative to WBI have been evaluated in many phase II and III
trials[5-9], which showed that APBI with proper patient selection
and quality assurance yields similar results to those achieved with standard
WBI. Therefore, APBI is increasingly being used with a 10-fold increase between
2002 and 2007[10], and in recent years more than 30,000 patients
have been treated worldwide outside of clinical trials[11].
With the increased use of
APBI, evidence-based guidelines are necessary to guide physicians regarding
appropriate patient evaluation and selection. In the United States, several
professional societies including the American Brachytherapy Society and the
American Society of Breast Surgeons base these recommendations primarily on
patient age, tumor size, and margin status. In 2009, the American Society for
Radiation Oncology (ASTRO) Health Services Research Committee developed a
consensus statement regarding patient selection criteria to identify suitable
candidates and best practices for the off-protocol use of APBI before the
availability of results from randomized clinical trials[11]. These
guidelines proposed 3 groups of APBI appropriateness: “suitable,” “cautionary,”
and “unsuitable,” based on patient characteristics and clinical and
pathological factors.
In our institution, since
October 2008 we have initiated a prospective observational study on APBI using
multicatheter brachytherapy after BCS. Data regarding the long-term efficacy of
this technique indicated some instances of local recurrence and a low rate of
adverse events[12-14]. We started APBI immediately following lumpectomy
with simultaneous multicatheter insertion during primary surgery. Therefore, we
could not follow the ASTRO guidelines that require candidates to be selected
without the final pathology, which is similar to intraoperative radiotherapy
technique.
In this study, we reviewed
our single-institution experience of APBI in patients selected using our wider
enrollment criteria than the ASTRO suitable group to determine whether the
ASTRO guidelines are useful in patients with breast cancer in Japan.
METHODS
APBI with multicatheter brachytherapy
and WBI techniques after BCS
A prospective
observational study has been conducted to evaluate the efficacy of APBI using
multicatheter brachytherapy in patients with breast cancer. The following are
criteria for the inclusion: patient age≥40 years, pathologically proven breast cancer, unifocal
disease, tumor diameter≤3.0 cm, and negative margins and sentinel node metastasis by frozen
section analysis. Neoadjuvant chemotherapy was not allowed. A written informed
consent was obtained, and the institutional review board of our hospital approved
the study.
The technique of
multicatheter brachytherapy with APBI was previously reported[12]. The
procedure involves the insertion of applicators and the subsequent delivery of
doses of radiation simulated by preoperative computed tomography (CT) using the
Nucletron PLATO treatment planning system (Version UPS: 11.3; Nucletron Trading
BV, Veenendaal, The Netherlands). The planning target volume was determined as
the lumpectomy cavity defined by hemoclips plus 20-mm. Dose distribution
analysis using dose-volume histograms was performed based on postoperative CT. The
dose for APBI was 32 Gy in 8 twice-daily fractions with a minimum 6 hour
interval.
For WBI, patients received a
total dose of 50 Gy in fractions of 2 Gy delivered to the entire breast. Patients
with risk factors, such as positive margins and young age, also received a
10-Gy boost to the tumor bed. The combination of regional nodal irradiation
(RNI) with WBI after BCS was performed in patients with≥4 positive nodes. The follow-up after treatment was planned
as follows: clinical examination every 3-4 months, an annual mammography, and
contrast-enhanced breast magnetic resonance imaging (MRI) were performed every
year to detect ipsilateral breast tumor recurrence (IBTR) and regional nodal
failure for the first 5 years.
Classification by ASTRO guidelines
First, the
distribution of suitable, cautionary, and unsuitable patients between the APBI
and WBI treatment groups was evaluated. Patients in the APBI and WBI cohorts
were categorized into one of the 3 groups (suitable, cautionary or unsuitable)
using the criteria outlined in the ASTRO guidelines on APBI. There were no
patients referred for BRCA 1/2 testing. The suitable, cautionary, and
unsuitable patients in the APBI with WBI cohorts were compared to determine
patterns of breast cancer treatment failures. IBTR was classified into
“tumor-bed recurrence” and “treatment failure elsewhere” based on the location
of the tumor. Tumor-bed recurrence was considered as a true recurrence located
within or immediately adjacent to the lumpectomy cavity. Treatment failure
elsewhere was generally regarded as a new primary cancer located several
centimeters from the cavity.
Statistics
The chi-square test
was used to analyze associations among categorical variables with treatment
groups. Student’s unpaired t test was used to analyze differences between 2
sample means of continuous variables. A p value <0.05 was considered
to indicate statistical significance. Statview 5.0 (SAS Institute Inc. Cary, NC, USA) was used to
perform statistical analyses.
RESULTS
ASTRO guidelines assignments
A total of 343
consecutive patients who underwent BCS followed by radiotherapy from November
2007 to September 2013 were analyzed, and a prospective multicatheter
brachytherapy study was initiated in October 2008. Patients who received
neoadjuvant chemotherapy were excluded from the study.
All patients eligible for
our observational study were offered the option of APBI after BCS. They were
informed of the experimental nature of the treatment. Patients who have not met
the eligibility criteria declined WBI but were willing to receive APBI were
included in the study. A consort diagram is shown in figure 1, and table 1
lists the clinical, pathological, and treatment-related characteristics of ABPI
and WBI groups. The mean age of the APBI patients (56.0 years) was
significantly higher than that of the WBI patients (51.2 years, p<0.05).
The mean follow-up was 36.6 months for APBI and 42.7 months for the WBI cohort,
which was statistically different (p<0.05). APBI patients were less
likely to be node-negative (87.7% vs 75.8%, respectively; not
significant). A total of 170 patients (83.7%) in the APBI cohort and 85 (64.4%)
in the WBI cohort met the enrollment criteria for the registry study, which was
moderately different but not significant.
When the ASTRO guidelines
were used to segregate these patients into the 3 groups, the distributions were
as follows: in the APBI cohort, 17 (8.4%), 87 (42.9%), and 99 (48.7%) patients
were suitable, cautionary, and unsuitable, respectively, compared with 14
(10.6%), 30 (22.7%), and 88 (66.7%) in the WBI cohort, respectively. Therefore,
186 APBI patients (91.6%) and 118 WBI patients (89.4%) were regarded as
cautionary or unsuitable for APBI therapy based on the ASTRO guidelines (Table
2).
Clinical outcomes by ASTRO guidelines
Next, locoregional
and distant recurrence between the 2 treatment cohorts were examined among the
3 different ASTRO categories. In the suitable group, there were no IBTR
patients in either the APBI or WBI cohort, and regional-only recurrence was
observed in only 1 patient (5.9%) in the APBI cohort (Table 3). In the
cautionary group, there was 1 patient with regional-only recurrence (1.1%) in
the APBI cohort, and 1 IBTR patient (3.3%) in the WBI cohort. There was 1
patient with distant recurrence (3.3%) only in the WBI cohort (Table 3). In the
unsuitable group, there were 2 IBTR patients (2.0%) in the APBI cohort, and 3
(3.4%) in the WBI cohort. Although there were no obvious differences in
locoregional recurrence in the APBI and WBI cohorts, there were 4 patients
(4.5%) with distant recurrence only in the WBI cohort (Table 5).
DISCUSSION
Breast cancer is the
most common cancer in Japan[15]. After the introduction of mammography
to screen patients for breast cancer, the number of patients who underwent BCS
had been increasing, and this procedure has been the most common treatment for
breast cancer since 2003[16,17]. Data from the Early Breast Cancer
Trialists’ Collaborative Group (EBCTCG) demonstrated not only a significant
reduction in local recurrence but also an overall survival benefit with the use
of adjuvant radiation therapy after BCS[18,19]. Nevertheless,
15%-30% of patients who undergo BCS refuse WBI[20-25] primarily due
to the long-term daily visits that are required to the radiation centers. In
fact, 20% of patients who underwent BCS in Japan did not receive WBI[26],
especially if they had complete pathologically negative margins. Our
institution is located far from a metropolitan area; therefore, patients take a
long time to travel for receiving radiation therapy. We started our registry
program to introduce APBI particularly for patients living further from our
institution, and almost all BCS patients received adjuvant radiation therapy. Therefore,
we were able to enroll a large number of patients from a variety of backgrounds
into this study. This is one of the first observational studies from Asia to
demonstrate acceptable clinical outcomes of APBI for patients with unfavorable
features based on the ASTRO guidelines.
Older patients exhibited a
lower risk of IBTR than younger patients when treated with WBI[27,28]
or MammoSite[29], and the EBCTCG reported that WBI did not improve
survival for women aged≥60 years[18]. Therefore, the ASTRO guidelines have accepted
APBI as an alternative to WBI for these older patients. However, the incidence
of breast cancer peaks between the ages of 45 and 49 years in Japan, whereas
there is a continuous increase in the number of patients until 75-79 years in
the United States[15]. Therefore, the indication of a suitable age
group based on the ASTRO criteria could be too strict to allow Japanese
patients to be considered for APBI. Most recent single-institution and registry
studies examining patients treated with APBI stratified according to the ASTRO
category revealed no statistically significant difference in the IBTR rates
between the suitable, cautionary, and unsuitable groups[30], and we
need the guideline updates based on available APBI data.
There were 2 IBTR patients
in the APBI cohort in our study. Although 1 patient did not match our
enrollment criteria, APBI was performed for compassionate reasons. She received
a second conserving surgery and remained in a disease-free condition. In the
second patient, IBTR was identified using breast MRI during the 1 year
follow-up period. Compared with the previous breast MRI, another focus near the
primary lesion which had been recognized as benign cyst was revealed as
mucinous carcinoma. Therefore, we treated her with nipple-sparing mastectomy,
and she also remained disease free. It is essential that all mammographically
occult breast cancer is detected to improve patient selection for APBI. Although
the ASTRO task force does not support the routine use of MRI in an APBI
setting, MRI should be strongly considered for proper patient selection from
this case.
This study demonstrated that
the clinical efficacy of APBI for local control after BCS was comparable with
WBI in ASTRO-defined cautionary and unsuitable patients with breast cancer in
Japan after approximately 3 years of follow-up. The limitations of this study
were that it was not randomized, was based on only a small number of patients,
and covered only a short follow-up period. The application of APBI,
particularly in patients considered to be unfavorable based on the ASTRO
guidelines, should still be carefully approached until mature phase III trial
data are available.
List of abbreviations
BCS:
breast-conserving surgery
WBI: whole breast
irradiation
APBI: accelerated
partial breast irradiation
ASTRO: American
Society for Radiation Oncology
CT: computed
tomography
RNI: regional nodal
irradiation
MRI: magnetic
resonance imaging
IBTR: ipsilateral
breast tumor recurrence
EBCTCG: Early Breast
Cancer Trialists' Collaborative Group
ACKNOWLEDGMENTS
The authors would
like to thank Enago (www.enago.jp) for the English language review. This study
was presented in part at the global breast cancer conference 2013. Authors’
contributions: KS is the principle investigator who prepared and wrote the
manuscript. KS and TO designed the study. YM, HF, and NT performed the surgery
and MK, TS, and JK performed the radiation therapy. YI and HS participated in
data collection. All authors have read and approved the final manuscript.
CONFLICT
OF INTERESTS
There are no
conflicts of interest with regard to the present study.
REFERENCES
1 Fisher B,
Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N.
Twenty-year follow-up of a randomized trial comparing total mastectomy,
lumpectomy, and lumpectomy plus irradiation for the treatment of invasive
breast cancer. N Engl J Med 2002; 347: 1233-1241
2 Veronesi U1,
Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E.
Twenty-year follow-up of a randomized study comparing breast-conserving surgery
with radical mastectomy for early breast cancer. N Engl J Med 2002; 347:1227–1232
3 Hershman DL, Buono D,
McBride RB, Tsai WY, Joseph KA, Grann VR, et al. Surgeon characteristics and
receipt of adjuvant radiotherapy in women with breast cancer. J Natl Cancer
Inst 2008; 100: 199-206
4 Voti L, Richardson LC,
Reis I, Fleming LE, Mackinnon J, Coebergh JW. The effect of race/ethnicity and
insurance in the administration of standard therapy for local breast cancer in
Florida. Breast Cancer Res Treat 2006; 95: 89-95
5 Polgár C, Sulyok Z,
Fodor J, Orosz Z, Major T, Takácsi-Nagy Z, Mangel LC, Somogyi A, Kásler M,
Németh G. Sole brachytherapy of the tumor bed after conservative surgery for T1
breast cancer: five-year results of a phase I-II study and initial findings of
a randomized phase III trial. J Surg Oncol 2002; 80:121-128
6 Polgár C, Major
T, Fodor J, Németh G, Orosz Z, Sulyok Z, Udvarhelyi N, Somogyi A, Takácsi-Nagy
Z, Lövey K, Agoston P, Kásler M. High-dose-rate brachytherapy alone versus
whole breast radiotherapy with or without tumor bed boost after
breast-conserving surgery: seven-year results of a comparative study. Int J
Radiat Oncol Biol Phys 2004; 60:1173-1181
7 Veronesi U1, Orecchia
R, Luini A, Galimberti V, Zurrida S, Intra M, Veronesi P, Arnone P, Leonardi
MC, Ciocca M, Lazzari R, Caldarella P, Rotmensz N, Sangalli C, Sances D,
Maisonneuve P. Intraoperative radiotherapy during breast conserving surgery: a
study on 1,822 cases treated with electrons. Breast Cancer Res Treat
2010; 124:141-151
8 Vaidya JS,
Joseph DJ, Tobias JS, Bulsara M, Wenz F, Saunders C, Alvarado M, Flyger HL,
Massarut S, Eiermann W, Keshtgar M, Dewar J, Kraus-Tiefenbacher U, Sütterlin M,
Esserman L, Holtveg HM, Roncadin M, Pigorsch S, Metaxas M, Falzon M, Matthews
A, Corica T, Williams NR, Baum M. Targeted intraoperative radiotherapy versus
whole breast radiotherapy for breast cancer (TARGIT-A trial): an international,
prospective, randomised, non-inferiority phase 3 trial. Lancet 2010; 376:
91-102
9 Polgár C, Fodor
J, Major T, Németh G, Lövey K, Orosz Z, Sulyok Z, Takácsi-Nagy Z, Kásler M. Breast-conserving
treatment with partial or whole breast irradiation for low-risk invasive breast
carcinoma--5-year results of a randomized trial. Int J Radiat Oncol Biol
Phys 2007; 69: 694-702.
10 Husain ZA1, Mahmood U,
Hanlon A, Neuner G, Buras R, Tkaczuk K, Feigenberg SJ. Accelerated partial
breast irradiation via brachytherapy: A patterns-of-care analysis with ASTRO
consensus groupings. Brachytherapy 2011; 10: 479-485
11 Smith BD, Arthur DW,
Buchholz TA, Haffty BG, Hahn CA, Hardenbergh PH, Julian TB, Marks LB, Todor DA,
Vicini FA, Whelan TJ, White J, Wo JY, Harris JR. Accelerated partial breast
irradiation consensus statement from the American Society for Radiation
Oncology (ASTRO). Int J Radiat Oncol Biol Phys 2009; 74: 987-1001
12 Sato K, Mizuno Y, Kato M, Shimo T, Kubota J, Takeda N, Inoue Y, Seto
H, Okawa T. Intraoperative open-cavity implant for accelerated partial breast
irradiation using high-dose rate multicatheter brachytherapy in Japanese breast
cancer patients: A single-institution registry study. J Cancer Ther 2012;
3: 822-830
13 Sato K, Mizuno Y, Fuchikami
H, Kato M, Shimo T, Kubota J, et al. Individualized case–control study of
accelerated partial breast irradiation by multicatheter intertstitial
brachytherapy in Japanese patients with breast cancer. Cancer Clin Onco2013;
2:127-135
14 Sato K, Mizuno Y, Fuchikami H,
Kato M, Shimo T, Kubota J, Takeda
N, Inoue Y, Seto H, Okawa T. Sentinel-node-driven personalized radiation
techniques ranging from partial breast irradiation to regional nodal radiation
after breast-conserving surgery. J Cancer Ther 2013; 4: 49-55
15 Saika K, Sobue T. Epidemiology
of breast cancer in Japan and the US. JMAJ 2009; 52: 39-44
16 Sonoo H, Noguchi S. Results of
questionnaire survey on breast cancer surgery in Japan 2004-2006. Breast
Cancer 2008; 15: 3-4
17 Park Y, Kitahara T,
Takagi R, Kato R. Current status of therapy for breast cancer worldwide and in
Japan. World J Clin Oncol 2011; 2:125-134
18 Clarke M1, Collins R, Darby S,
Davies C, Elphinstone P, Evans E, Godwin J, Gray R, Hicks C, James S, MacKinnon
E, McGale P, McHugh T, Peto R, Taylor C, Wang Y; Early Breast Cancer Trialists’
Collaborative Group (EBCTCG). Early Breast Cancer Trialists’ Collaborative
Group (EBCTCG). Effects of radiotherapy and of differences in the extent of
surgery for early breast cancer on local recurrence and 15-year survival: An overview
of the randomised trials. Lancet 2005; 366: 2087-2106
19 Early Breast Cancer Trialists’
Collaborative Group (EBCTCG), Darby S, McGale P, Correa C, Taylor C, Arriagada
R, Clarke M, Cutter D, Davies C, Ewertz M, Godwin J, Gray R, Pierce L, Whelan
T, Wang Y, Peto R. Effect of radiotherapy after breast-conserving surgery on
10-year recurrence and 15-year breast cancer death: Meta-analysis of individual
patient data for 10,801 women in 17 randomised trials. Lancet 2011; 378:
1707-1716
20 Farrow DC, Hunt WC, Samet JM. Geographic variation
in the treatment of localized breast cancer. N Engl J Med 1992; 326:1097-1101
21 Lazovich DA, White E, Thomas DB, Moe RE. Underutilization of breast-conserving
surgery and radiation therapy among women with stage I or II breast cancer. JAMA
1991; 266: 3433-3438
22 Mann BA, Samet JM, Hunt WC,
Key CR, Goodwin JM, Goodwin JS. Changing treatment of breast cancer in New
Mexico from 1969 through 1985. JAMA 1988; 259: 3413-3417
23 Ballard-Barbash R, Potosky
AL, Harlan LC, Nayfield SG, Kessler LG. Factors associated with surgical and
radiation therapy for early stage breast cancer in older women. J Natl
Cancer Inst 1996, 88: 716-726
24 Athas WF,
Adams-Cameron M, Hunt WC, Amir-Fazli A, Key CR. Travel distance to radiation
therapy and receipt of radiotherapy following breast-conserving surgery. J
Natl Cancer Inst 2000, 92: 269-271
25 Schroen AT, Brenin DR, Kelly
MD, Knaus WA, Slingluff CL Jr. Impact of patient distance to radiation therapy
on mastectomy use in early-stage breast cancer patients. J Clin Oncol
2005; 23: 7074-7080
26 Mitsumori M, Hiraoka
M, Inaji H, Noguchi S, Oishi H, Kodama H, Koyama H. Impact of radiation therapy
on breast-conserving therapy for breast cancer in Japanese women: a
retrospective analyses of multi-institutional experience. Kansai Breast Cancer
Radiation Therapy Study Group. Oncol Rep 2009; 21: 1461-1466
27 Bartelink H, Horiot JC,
Poortmans P, Struikmans H, Van den Bogaert W, Barillot I, Fourquet A, Borger J,
Jager J, Hoogenraad W, Collette L, Pierart M; European Organization for
Research and Treatment of Cancer Radiotherapy and Breast Cancer Groups.
European Organization for Research and Treatment of Cancer Radiotherapy and
Breast Cancer Groups: Recurrence rates after treatment of breast cancer with
standard radiotherapy with or without additional radiation. N Engl J Med
2001; 345: 1378-1387
28 Bartelink H, Horiot JC,
Poortmans PM, Struikmans H, Van den Bogaert W, Fourquet A, Jager JJ, Hoogenraad
WJ, Oei SB, Wárlám-Rodenhuis CC, Pierart M, Collette L. Impact of a higher
radiation dose on local control and survival in breast-conserving therapy of
early breast cancer: 10-year results of the randomized boost versus no boost
EORTC 22881-10882 trial. J Clin Oncol 2007; 25: 3259-3265
29 Chao KK, Vicini FA, Wallace
M, Mitchell C, Chen P, Ghilezan M, Gilbert S, Kunzman J, Benitez P, Martinez A.
Analysis of treatment efficacy, cosmesis, and toxicity using the MammoSite
breast brachytherapy catheter to deliver accelerated partial-breast
irradiation: The William Beaumont hospital experience. Int J Radiat Oncol
Biol Phys 2007; 69: 32-40
30 Wilkinson JB, Beitsch PD,
Shah C, Arthur D, Haffty BG, Wazer DE, Keisch M, Shaitelman SF, Lyden M, Chen
PY, Vicini FA. Evaluation of current consensus statement recommendations for
accelerated partial breast irradiation: a pooled analysis of William Beaumont
Hospital and American Society of Breast Surgeon MammoSite Registry Trial Data. Int
J Radiat Oncol Biol Phys 2013; 85: 1179-1185
Peer reviewer: Aman Sharma, Attending
Consultant, Department of Radiation Oncology, Fortis Memorial Research
Institute, Sector 44, Gurgaon, Haryana,122002, India.
Refbacks
- There are currently no refbacks.