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Background The role of radiation therapy (RT) following breast-conserving surgery (BCS) in ductal carcinoma in situ (DCIS) remains controversial. Trials have not identified a low-risk cohort, based on clinicopathologic features, who do not benefit from RT. A biosignature (DCISionRT®) that evaluates recurrence risk has been developed and validated. We evaluated the impact of DCISionRT on clinicians’ recommendations for adjuvant RT. Methods The PREDICT study is a prospective, multi-institutional, observational registry in which patients underwent DCISionRT testing. The primary endpoint was to identify the percentage of patients where testing led to a change in RT recommendations. Results Overall, 539 women were included in this study. Pre DCISionRT testing, RT was recommended to 69% of patients; however, post-testing, a change in the RT recommendation was made for 42% of patients compared with the pre-testing recommendation; the percentage of women who were recommended RT decreased by 20%. For women initially recommended not to receive an RT pre-test, 35% had their recommendation changed to add RT following testing, while post-test, 46% of patients had their recommendation changed to omit RT after an initial recommendation for RT. When considered in conjunction with other clinicopathologic factors, the elevated DCISionRT score risk group (DS > 3) had the strongest association with an RT recommendation (odds ratio 43.4) compared with age, grade, size, margin status, and other factors. Conclusions DCISionRT provided information that significantly changed the recommendations to add or omit RT. Compared with traditional clinicopathologic features used to determine recommendations for or against RT, the factor most strongly associated with RT recommendations was the DCISionRT result, with other factors of importance being patient preference, tumor size, and grade.

Adjuvant radiation therapy (RT) following breast-conserving surgery (BCS) represents a standard approach for most patients treated with breast-conserving therapy (BCT) for early-stage breast cancer. The first-generation of adjuvant RT schedules delivered daily treatment to the whole breast over 5–7 weeks. Although efficacious, this presented patients with a protracted course of treatment, reducing compliance and quality of life. While hypofractionated whole-breast irradiation (WBI) has become the standard, and part of the second-generation of RT regimens, it still requires 3–4 weeks. Concurrently, partial-breast irradiation (PBI) has also been explored as a technique to complete RT in a much shorter time period (1–3 weeks). There are now seven trials confirming the efficacy of this shorter treatment approach compared with standard WBI. In an effort to further reduce treatment duration, ultra-short WBI and PBI regimens have recently emerged as the third-generation of breast radiation schedules, allowing for the completion of treatment in 5 days or less. With respect to WBI, recent data from the FAST-Forward trial (which evaluated five fractions of WBI delivered in 1 week) demonstrated no difference in clinical outcomes at 5 years, with limited difference in toxicity, compared with hypofractionated 3-week WBI. Regarding PBI, published data on five-fraction regimens delivered in 2 weeks have also demonstrated comparable outcomes at 10 years, with reduced toxicities with long-term follow-up. This report will review additional ongoing studies evaluating even shorter courses of adjuvant RT treatment (one to five fractions), including single-fraction PBI or WBI.

Several randomized trials have been performed comparing partial breast irradiation (PBI) and whole breast irradiation (WBI) though controversy remains, including regarding differences by PBI technique. We performed a meta-analysis to compare results between WBI versus PBI and between PBI techniques. A systematic review was performed to identify modern randomized studies listed in MEDLINE from 2005 to 2020. PBI trials were divided into external beam radiation and brachytherapy techniques, with intraoperative radiation excluded. A Bayesian logistic regression model evaluated the risk of ipsilateral breast tumor recurrence (IBTR) and acute and chronic toxicities. The primary outcome was IBTR at 5 years with WBI compared with PBI. A total of 9758 patients from 7 studies were included (4840-WBI, 4918-PBI). At 5 years, no statistically significant difference in the rate of IBTR was noted between PBI (1.8%, 95% HPD 0.68–3.2%) and WBI (1.7%, 95% HPD 0.92–2.4%). By PBI technique, the 5-year rate of IBTR rate for external beam was 1.7% and 2.2% for brachytherapy. Rates of grade 2 + acute toxicity were 7.1% with PBI versus 47.5% with WBI. For late toxicities, grade 2/3 rates were 0%/0% with PBI compared with 1.0%/0% with WBI. IBTR rates were similar between PBI and WBI with no significant differences noted by PBI technique; PBI had reduced acute toxicities compared to WBI. Because studies did not provide toxicity data in a consistent fashion, definitive conclusions cannot be made with additional data from randomized trials needed to compare toxicity profiles between PBI techniques.

The optimal tumor-free margin definition and width following breast-conserving therapy (BCT) for early-stage invasive cancers has been evaluated in previous meta-analyses and guidelines. We performed an updated meta-analysis to assess how improvements in treatment over time have affected the impact of margins on local recurrence (LR) rates over time. A systematic literature review identified 38 eligible studies comprising 54,502 patients treated between 1968 and 2010. Inclusion criteria included patients treated with BCT and minimum follow-up of 50 months, pathologic definitions of margin status explicitly stated, and LR data in relation to margin status. Data were pooled using a Bayesian logistic regression model to evaluate the risk of LR in relation to both margin status and study enrollment periods. Median follow-up was 7.25 years. Absolute LR rates decreased over time for each margin width cohort, with maximum differences between negative margin groups of less than 1% for the most recent enrollment period. However, relative rates of LR between different margin groups remained stable over time. With an additional 22,000 patients compared with the previous meta-analysis, this updated meta-analysis supports the consensus guideline of “no tumor on ink” for the majority of patients. Additionally, while concerns exist regarding a benefit with wider margins from previous studies, the analysis demonstrates the impact of margin width on LR rates has declined substantially over time, with very small differences between the narrowest and widest margin groups in the most recent cohort. Hence, older studies appear to have limited value to inform current management guidelines.

Following partial mastectomy, whole-breast irradiation (WBI), delivered over 3 to 6 weeks, has been the standard adjuvant radiation approach for early-stage breast cancer. A growing body of literature over the past decade has suggested that irradiation of the partial breast, including the tumor bed plus a margin, may be a suitable alternative for appropriately selected patients. The use of partial breast irradiation (PBI) has been studied in multiple prospective randomized trials, now with up to 10 years of follow-up, establishing similar safety and efficacy compared with WBI. Advantages of PBI include (1) reduced treatment duration, (2) potential reductions in treatment-related toxicity, (3) improved cosmetic outcomes, and (4) reduced costs. The purpose of this article is to review appropriate patient selection criteria, clinical and toxicity outcomes data, clinical consensus practice guidelines, and the various PBI techniques. The National Surgical Adjuvant Breast and Bowel Project (NSABP) B39/Radiation Therapy Oncology Group (RTOG) 0413 study (NRG Oncology) is the most recently published (abstract form only) prospective randomized trial comparing PBI using 3D conformal external beam radiation therapy (3D-CRT, 38.5 Gy/10 fractions, twice daily) or brachytherapy (interstitial catheters or applicator based, 34 Gy/10 fractions, twice daily), vs. WBI (50 Gy ± tumor a bed boost). With a median follow-up of 10.2 years, the 10-year ipsilateral breast tumor recurrence-free interval was 95.2% vs. 95.9% for PBI and WBI, although it did not meet the statistical significance for equivalence. Similarly, the randomized trial of accelerated partial breast irradiation using 3-dimensional conformal radiotherapy (RAPID) trial is a prospective randomized trial comparing primarily 3D-CRT (38.5 Gy/10 fractions, twice daily) with WBI, (42.5 Gy/16 daily fractions or 50 Gy/25 daily fractions ± tumor bed boost). Rates of ipsilateral breast tumor recurrence (IBTR) at 8 years were not statistically significantly different (PBI vs WBI, 3% vs. 2.8%; HR = 1.27; 90% VI, 0.84–1.91). There is a growing body of literature supporting the use of PBI in appropriately selected patients and its use should continue to increase.

In the original publication of the article, under the heading, Study limitations in the Discussion section, the second paragraph, fifth sentence was published incorrectly as “Patients with an L-Dex increase of ≥ 5.5 undergo…sleeve for 4 weeks”.

The role of regional nodal irradiation (RNI) in patients with clinically positive axillary nodes (cN1) who demonstrate a pathologic complete response (CR) in the axilla following neoadjuvant chemotherapy remains unclear and is currently under study. The present study used the National Cancer Data Base (NCDB) to evaluate patterns of care and characteristics associated with receipt of RNI in this population of patients. The NCDB was queried for women diagnosed with breast cancer from 2006 to 2012. Patients with nonmetastatic-invasive ductal or lobular carcinoma with clinically positive nodes who underwent neoadjuvant chemotherapy with a pathologic CR in the axilla and known RNI status were included in our analysis. A total of 4381 patients met inclusion criteria. Within this cohort, 1997 (45.6%) patients received RNI and 2384 (54.4%) did not. On multivariable analysis, factors significantly associated with treatment with RNI included younger age (p = 0.02), shorter distance from hospital (p = 0.01), higher clinical T stage (p 69 years. Among patients who received adjuvant systemic therapy, RNI was used in 51.0% of cases, compared with 43.0% for those not receiving adjuvant systemic therapy. In this large cancer database study, we observed substantial variation in the use of RNI in clinically node-positive patients with pathologic CR following neoadjuvant chemotherapy based on patient-, tumor-, and treatment-related factors.

The aim of this review was to examine the incidence of nipple-areola complex (NAC) involvement, the rates of NAC recurrence, and the data regarding the role of radiation therapy (RT) following nipple-sparing mastectomy (NSM). A literature review was performed using the PubMed search engine, with articles selected based on standardized criteria. Additional articles included those known to the authors and those obtained by review of references from key studies. The reported incidence of NAC involvement ranges from 0 to 58 %. The most commonly associated factors with NAC involvement include tumor-to-NAC distance, tumor size, central location of the primary tumor, multicentricity/multifocality, and positive axillary lymph nodes. Following NSM, in the setting of proper patient selection, rates of NAC recurrence are generally low, with the majority of studies reporting rates ranging from 0 to 4 %. There is a paucity of data evaluating the role of RT after NSM and a lack of level I evidence, with the largest series documenting low rates of local recurrence with RT but failing to provide a control arm without radiotherapy. Optimal preoperative patient selection for NSM and intraoperative assessment of the NAC result in acceptably low rates of NAC involvement/recurrence. NSM alone is not adequate justification for post-mastectomy radiation. NSM should be taken into consideration to inform radiation decision making only when preoperative imaging, clinical features, or pathologic findings suggest higher risk for NAC involvement.

Ductal carcinoma in situ (DCIS) represents a quarter of newly diagnosed breast neoplasms, with the majority of cases detected on routine screening mammography in asymptomatic women. Currently, most women with newly diagnosed DCIS are eligible for breast conserving therapy (BCT); however, significant controversy exists regarding whether or not to add radiation treatment (RT) after surgical excision in low-risk patients. While four older prospective randomized clinical trials have shown that the addition of RT after lumpectomy reduces the risk of ipsilateral breast tumor recurrence (IBTR) by approximately 50 %, recent studies have continued to attempt to identify a subset of patients with favorable risk DCIS who are at a sufficiently low-risk of IBTR that omitting RT might be reasonable. While a number of smaller studies have shown promising results, recent prospective data have consistently affirmed the increased risk of IBTR with the omission of RT, with no subset of patients consistently identified that can be safely observed without RT. While radiation after lumpectomy remains the “standard of care,” even in these low-risk patients, future directions include improvements in genetic assays to better identify low-risk patients and new RT techniques and schedules that can potentially reduce the duration of therapy and toxicity while improving quality of life for patients. Based on the data available, we continue to recommend radiation therapy for low-risk patients with DCIS as no discernible subset has been identified that does not benefit from radiation therapy.

Breast-conserving therapy (BCT) represents the standard care in the management of early-stage breast cancer, because long-term outcomes with breast conservation are comparable with those of mastectomy. Adjuvant radiation therapy remains an essential component of BCT with standard techniques requiring 5–6½ weeks. Accelerated partial breast irradiation (APBI) is a technique developed over the past two decades that enables completion of treatment in one week or less. Review of the expanding literature reveals increasing support for APBI using several techniques, including interstitial brachytherapy, balloon-based brachytherapy, and external beam therapy. Novel treatment strategies, including intraoperative radiation therapy, hypofractionated APBI, and proton therapy, require further results before definitive conclusions can be made. Although there is currently a lack of level I evidence, with the pending publication of multiple phase III trials comparing whole-breast irradiation and APBI, modern treatment incorporating APBI should soon be developed.

The purpose of this study was to analyze the cost-efficacy of multiple accelerated partial-breast irradiation (APBI) techniques compared with whole breast irradiation (WBI) delivered utilizing 3-dimensional conformal radiotherapy (3D-CRT) and intensity-modulated radiation therapy (IMRT). A previously reported matched-pair analysis consisting of 199 patients receiving WBI and 199 patients receiving interstitial APBI formed the basis of this analysis. Cost analyses included a cost minimization analysis, incremental cost- effectiveness ratio (ICER) analysis, and cost per quality adjusted life year (QALY) analysis. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI IMRT is $14.9 million, $10.9 million, $8.8 million, $5.0 million, and $9.7 million for APBI 3D-CRT, APBI IMRT, APBI single-lumen (SL), APBI multi-lumen (ML), and APBI interstitial, respectively. Per 1,000 patients treated, the cost savings with the utilization of APBI compared to WBI 3D-CRT is $6.0 million, $2.0 million, and $0.7 million for APBI 3D-CRT, APBI IMRT, and APBI interstitial, respectively. The cost per QALY for APBI SL, APBI ML, and APBI interstitial compared with APBI 3D-CRT are $12,273, $66,032, and $546, respectively. When incorporating non-medical costs and cost of recurrences the cost per QALY was $54,698 and $49,009 for APBI ML compared with APBI 3D-CRT. When compared to WBI IMRT, all APBI techniques are cost-effective based on cost minimization, ICER, and QALY analyses. When compared to WBI 3D-CRT, external beam APBI techniques represent a more cost-effective approach based on cost minimization with brachytherapy representing a cost-effective approach based on cost per QALY.

Shorter courses of APBI, including single-fraction intraoperative therapy, are under active investigation. We designed a prospective trial to identify and address the potential radiobiological and logistical shortcomings of single-fraction APBI. We designed a single-arm, multi-institutional, prospective phase II trial that sequentially treats 3 cohorts of women (each n = 30) with 3 progressively hypofractionated schedules. Eligible women were age ≥50 years with unifocal invasive or in situ tumors ≤3.0 cm, excised with negative margins, and with negative lymph nodes and positive hormone receptors. We defined strict dosimetric criteria for appropriateness. A total of 30 patients were enrolled at the 7 Gy × 4 fractions dose-level and followed for 6 months. The median skin dose as a percent of prescription dose (PD) was 84 % (40–100), and the median rib dose was 71 % (16–119). Also, 95 % of the PTV_eval received a median of 95 % of PD (range 85–103). The V150 (range 14–48 cc) and V200 (range 0–29 cc) criteria were met in all cases. One breast infection occurred and was treated; 2 cases of symptomatic fat necrosis and 2 cases of symptomatic seromas occurred. Short-course APBI is dosimetrically feasible using the Contura MLB and appears to be tolerable in terms of acute toxicities. Our approach is based on well-defined radiobiological parameters and allows for an abbreviated course of treatment that is guided by full pathological review and the ability to objectively achieve and validate acceptable dosimetric criteria in each case. We have opened enrollment to the next schedule of 8.25 Gy for 3 fractions.

A lack of consistent data are available about optimizing cosmetic outcomes, reducing potential treatment-related toxicities, and defining important prognostic factors for women undergoing postmastectomy radiation therapy (PMRT) following breast reconstruction. A Medline search was conducted to summarize the latest data on the topic with a focus on both autologous and tissue expander/implant (E/I) reconstructions. Autologous tissue reconstructions (ATR) represent less than 20 % of all breast reconstructions and include several techniques. A multitude of small studies have suggested that ATR is associated with improved cosmetic outcomes and similar rates of complications compared with E/I reconstructions. With regards to ATRs, the addition of PMRT has been suggested but not definitively associated with a decrement in cosmetic outcome compared with patients not receiving radiation. Expander/implant-based reconstruction appears to be the most common form of breast reconstruction with large, prospective, and retrospective series demonstrating that 20-30 % of patients may require some type of revision/replacement with long-term follow-up based on large series from Memorial Sloan Kettering Cancer Center and the Cleveland Clinic. Whereas PMRT and the addition of regional irradiation has been traditionally associated with increased complications and worse outcomes with E/I reconstruction, recent data suggest that no difference in perioperative complications exists in patients receiving PMRT using modern techniques.

To analyze outcomes in patients with ductal carcinoma-in-situ (DCIS) treated with accelerated partial breast irradiation (APBI) within a pooled set of patients.A total of 300 women with DCIS underwent APBI between April 1993 and November 2010 as part of American Society of Breast Surgeons MammoSite Registry Trial (n = 192) or at William Beaumont Hospital (n = 108). Patients with pure DCIS3 cm (n = 125) were assigned to the cautionary risk group per American Society of Radiation Oncology consensus panel guidelines for off-protocol use of APBI and analyzed compared to a pooled invasive suitable (n = 653) risk group and pooled invasive suitable/cautionary (n = 1,298) risk group.The rate of ipsilateral breast tumor recurrence (IBTR) for all 300 DCIS patients was 2.6 % at 5 years with no regional recurrences, while cause-specific survival was 99.5 % and overall survival (OS) was 96.4 %. When comparing the cautionary DCIS group to the invasive suitable/cautionary group, no difference in IBTR was noted (2.6 vs. 3.1 %, P = 0.90) with significant improvements in distant metastases (0 vs. 2.5 %, P = 0.05), disease-free survival (98.5 vs. 94.4 %, P = 0.05), and OS (95.7 vs. 90.8 %, P = 0.03) noted for DCIS patients. When comparing cautionary DCIS patients to invasive suitable patients, no difference in IBTR were noted (2.6 vs. 2.4 %, P = 0.76), while improved OS for DCIS patients was noted (95.7 vs. 90.9 %, P = 0.02).This analysis of the largest cohort of patients with DCIS treated with APBI supports previously reported excellent outcomes; as a result of small numbers of events, further data are necessary to confirm these findings.

Randomized trials demonstrate that lumpectomy plus whole-breast irradiation (WBI) yields survival equivalent to mastectomy. Studies that use WBI, however, typically report higher tumor bed recurrence rates than elsewhere failures (EF) (historically considered new primary lesions). The rate of true recurrence (TR) versus EF was queried for a large patient cohort treated with accelerated partial breast irradiation (APBI).A total of 1,449 cases of early-stage breast cancer were treated on the American Society of Breast Surgeons MammoSite(®) Registry Trial with lumpectomy plus balloon-based APBI (34 Gy, 10 BID fractions). A total of 1,255 cases (87 %) had invasive breast cancer, and 194 patients (13 %) had ductal carcinoma in situ. Rates of TR versus EF were calculated and compared to historical WBI controls.Median follow-up was 60 (range 0-109) months. Fifty patients (3.5 %) developed an ipsilateral breast tumor recurrence (IBTR). The 5-year actuarial rate of IBTR was 3.6 % (invasive breast cancer 3.6 %, ductal carcinoma in situ 3.4 %). Fourteen IBTR (1.1 %) were TR, while 36 (2.6 %) were EF. Estrogen receptor-negative status was associated with IBTR for invasive malignancies as well as for EF only (p0.001). Trends for increased rates of EF were noted for increased tumor size (p = 0.067) and extensive intraductal component (p = 0.087). No pathologic factors were explicitly associated with TR.IBTR after balloon-based APBI is low and similar to rates reported for WBI. In this data set, APBI had fewer tumor bed recurrences (presumably initial cancer recurrences) than EF (presumably new primary lesions). This suggests that balloon-based APBI has a tumor bed control rate that is at least equal to (and potentially higher than) WBI.

Management of mammographically detected ductal carcinoma in situ (DCIS) at a single institution was reviewed to determine long-term clinical outcomes after treatment with breast-conserving therapy (BCT). Data from all patient-cases with DCIS who received BCT between 1980 and 1993 were reviewed. Patient demographics and pathologic factors were analyzed for their effect on outcomes, including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included breast-conserving surgery followed by external-beam radiotherapy to the whole breast, with 86 % of patients receiving a lumpectomy cavity boost. The median dose to the whole breast was 50 Gy and 60.4 Gy to the lumpectomy cavity. A total of 129 cases were evaluated; the median follow-up was 19.3 years. Twenty-one patients developed an ipsilateral breast tumor recurrence (IBTR), 76.2 % of which were invasive (n = 16). Fourteen recurrences (66 %) were within the same breast quadrant (true recurrence), while an additional 7 cases developed an IBTR elsewhere in the breast. True recurrences were more prevalent in women

Since the initial reports on use of MammoSite accelerated partial breast irradiation (APBI) for treatment of ductal carcinoma in situ (DCIS), additional follow-up data were collected. We hypothesized that APBI delivered via MammoSite would continue to be well tolerated, associated with a good cosmetic outcome, and carry a low risk for recurrence in patients with DCIS.From 2002-2004, 194 patients with DCIS were enrolled in a registry trial to assess the MammoSite. Follow-up data were available for all 194 patients. Median follow-up was 54.4 months; 63 patients had at least 5 years of follow-up. Data obtained included patient-, tumor-, and treatment-related factors, and recurrence incidence.Of the 194 patients, 87 (45%) had the MammoSite placed at lumpectomy; 107 patients (55%) had the device placed postlumpectomy. In the first year of follow-up, 16 patients developed a breast infection, though the method of device placement was not associated with infection risk. Also, 46 patients developed a seroma that was associated with applicator placement at the time of lumpectomy (P = 0.001). For patients with at least 5 years of follow-up, 92% had favorable cosmetic results. There were 6 patients (3.1%) who had an ipsilateral breast recurrence, with 1 (0.5%) experiencing recurrence in the breast and axilla, for a 5-year actuarial local recurrence rate of 3.39%.During an extended follow-up period, APBI delivered via MammoSite continued to be well tolerated for patients with DCIS. Use of this device may make lumpectomy possible for patients who would otherwise choose mastectomy because of barriers associated with standard radiation therapy.

Breast-conserving therapy is accepted as a standard of care option for patients with early-stage breast cancer. However, studies examining patterns of failure after treatment suggest that a lengthy course of adjuvant whole breast irradiation delivered as a component of breast-conserving therapy may not always be necessary; indeed, in appropriately selected patients, radiation therapy delivered only to the tumor bed may be acceptable. Several modalities of delivering accelerated partial breast irradiation (APBI) have been developed, the most prevalent being multi-catheter interstitial brachytherapy, the MammoSite breast brachytherapy catheter (Hologic Corporation, Bedford, MA) and three-dimensional conformal external-beam radiation therapy. The purpose of this article is to review the published experiences on the most common modalities of delivering APBI and to outline the current open national phase 3 trial. To date, phase 1/2 studies have demonstrated excellent local control and cosmetic outcomes in early-stage breast cancer patients treated with APBI. As increasing knowledge is accumulated regarding the efficacy and safety of APBI, a consensus will emerge regarding its potential replacement of whole breast irradiation in selected early-stage breast cancer patients.

The goal of the current study is to help refine guidelines for the need for re-excision and the appropriate amount of breast tissue to re-excise in patients with early breast cancer following excisional breast biopsy when treated with breast-conserving therapy (BCT).The study population consisted of 441 patients derived from a dataset of 607 consecutive cases of stage I and II breast cancer treated with BCT, in which patients underwent primary excisional diagnostic biopsy and subsequent re-excision prior to the initiation of radiation therapy (RT). A single pathologist reviewed all specimens. Re-excision was indicated because tumor was found close to or involving the resection margin. In 333 of the 441 cases, it was possible to measure the extension of carcinoma into the re-excision specimen. Margins were classified as negative (carcinoma4.2 mm from the margin), near (4.2 mm from the margin) or positive. Any carcinoma identified near the final margin was quantified by width of invasive carcinoma and number of ductal carcinoma in situ (DCIS) ducts near the margin and subdivided into three distinct groups: least, intermediate, and greatest amount. These factors were then analyzed to determine the likelihood and extent of residual carcinoma in re-excision specimens. Statistical analysis was performed using Systat version 10 (SPSS Inc., Chicago, IL).The quantity of carcinoma near the initial biopsy margin and the invasive carcinoma-to-specimen dimension ratio demonstrated a significant association with increasing amounts of residual carcinoma at re-excision. Combination of these two variables allowed for a statistically significant (P0.001) calculation of risk index for identifying significant residual invasive carcinoma or DCIS in the adjacent breast parenchyma at re-excision, and yielded stratification into low- (6%), intermediate- (27%), and high-risk (44%) groups. In re-excision specimens, the observed distance of carcinoma extension into adjacent breast tissue was associated with a statistically significant decrease in the ratio of the initial excisional biopsy specimen dimensions and invasive carcinoma dimensions. Combining the initial margin status with the specimen-to-invasive carcinoma maximum dimension ratio yielded an accurate predictor of the maximum distance of tumor extension.Evaluation of the initial excisional biopsy margin status in correlation with the invasive carcinoma-to-specimen maximum dimension ratio may be helpful for (1) identifying patients who require re-excision prior to RT and (2) predicting the quantity of additional breast tissue to excise to ensure adequate surgical margins with BCT.

The American Society of Breast Surgeons enrolled women onto a registry trial to prospectively study patients treated with the MammoSite Radiation Therapy System (RTS) breast brachytherapy device. This report examines local recurrence (LR), toxicity, and cosmesis as a function of age in women enrolled onto the trial. A total of 1449 primary early-stage breast cancers were treated in 1440 women. Of these, 130 occurred in women younger than 50 years of age. Fisher’s exact test was performed to correlate age (

Breast conserving therapy (BCT) has become an accepted option in the management of patients with early-stage breast cancer. However, studies have suggested that a lengthy course of adjuvant whole breast irradiation, as a component of BCT, may not always be necessary and that radiation therapy delivered only to the region of the tumor bed may be acceptable in appropriately selected patients. Several modalities are currently being explored as a means to deliver accelerated partial breast irradiation (APBI), including multicatheter interstitial brachytherapy, the MammoSite breast brachytherapy catheter (Cytyc Corporation, Marlborough, MA), and three-dimensional conformal external-beam radiation therapy. To date, phase 1/2 published data have demonstrated excellent local control rates and cosmesis. As additional data addressing the effectiveness of this treatment approach accumulate, a new standard of care may emerge. This review discusses data accumulated to date exploring the experience with all APBI modalities and presents future studies exploring this concept.

The MammoSite device was designed as a breast brachytherapy applicator and is currently used to deliver accelerated partial breast irradiation (APBI). We hypothesized that APBI delivered with the MammoSite device would be well tolerated and be associated with a good cosmetic outcome in patients with ductal carcinoma-in-situ (DCIS).From 2002 to 2004, 191 patients with DCIS were enrolled in a registry trial to assess the MammoSite applicator. Fifteen patients were excluded from analysis because of device- or patient-related factors; 7 patients were excluded after receiving a radiotherapy boost, thus leaving 169 patients available for study. Follow-up information was available for 158 patients. The average length of follow-up was 7.35 months. Forty-three patients had at least 1 year of follow-up.Skin spacing for the MammoSite applicator was as follows:5 mm, 3 patients (1.78%); 5 to 7 mm, 18 patients (10.65%); andor = 7 mm, 148 patients (87.57%). Patients with a device-to-skin distance ofor = 7 mm had the best cosmetic result. Patients with a device-to-skin distance ofor = 7 mm also had a lower incidence of radiation dermatitis. Data on 43 patients who were followed up for at least 1 year confirmed these findings. Additional adverse events were primarily related to skin changes, with breast infections occurring in five patients (3.16%). No patient in the study has experienced a recurrence.APBI delivered via MammoSite is well tolerated in patients with DCIS, and the lowest toxicity was obtained in patients with the greatest device-to-skin distance. Long-term follow-up data regarding patient satisfaction, cosmesis, and efficacy are needed and will be determined from a recently opened large randomized study.

The optimal treatment of patients with localized prostate cancer remains controversial. Significant clinical data are available, however, demonstrating that patients treated with radiation therapy (RT) have a significantly better outcome as the dose to the gland is increased. What remains debatable, however, is how to best deliver these higher doses of RT without significantly increasing normal tissue toxicities. Conformal high dose rate brachytherapy (C-HDR BT) represents an alternative means of precise dose delivery that offers similar tumoricidal effects as three-dimensional (3D) conformal external beam radiotherapy (EBRT) or permanent interstitial prostate seed implants with potential additional advantages. Since C-HDR BT consists of temporarily placing afterloading needles or catheters directly into the prostate gland under real-time ultrasound guidance, a steep dose gradient between the prostate and adjacent normal tissues can be generated that is minimally affected by organ motion and edema or treatment setup uncertainties. The ability to control the amount of time the single HDR radioactive source "dwells" at each position along the length of each brachytherapy catheter further enhances the conformity of the dose. In addition, recent radiobiological data on prostate cancer treatment suggest that C-HDR BT should produce tumor control and late normal tissue side effects that are at least as good as achieved with conventional fractionation, with the additional possibility that acute side effects might be reduced. Published data from several groups performing C-HDR BT as boosts in patients with locally advanced disease have supported these assumptions. Combined with the physical advantages discussed above, C-HDR BT should provide similar tumor control as 3D conformal EBRT with the added advantages of reduced treatment times, less acute toxicity, and no additional technological requirements to account and correct for treatment setup uncertainties and organ motion. Due to the success of C-HDR BT as boost treatment in locally advanced disease, this form of radiation treatment has recently been applied to low-risk prostate cancer patients as an alternative brachytherapy technique to permanent interstitial seed implantation. Advantages in this setting include an improved ability to define and deliver the prescribed dose, a significantly shortened treatment schedule compared to 3D conformal EBRT, and the fact that patients are not radioactive after implantation.

Over the past 2 decades, numerous advances and innovations have occurred in all technical aspects of radiation therapy (RT), including three-dimensional (3D) treatment planning, conformal radiation delivery, intensity-modulated radiation therapy (IMRT), patient immobilization, and precise treatment verification. Despite incredible progress on all fronts, standard RT for breast cancer has changed very little and has not fully exploited many of the advances commonly used to treat most other malignancies. Increasing data have also accumulated, indicating that dose non-uniformities within the breast with traditional RT techniques can be greater than in many other anatomic sites. These significant dose inhomogeneities can produce unnecessary acute and chronic toxicities as well as unacceptable long-term cosmetic results. In addition, the lack of accurate verification of target volume coverage (e.g. lumpectomy cavity or chest wall) may result in diminished tumor control.