Abstract
The standard treatment for early breast cancer comprises wide local excision, sentinel lymph node biopsy or axillary lymph node dissection, adjuvant medical treatment and radiotherapy to the whole breast. Many studies suggest that local control plays a crucial role in overall survival. The local recurrence rate is estimated to be 1% per year and varies between 4 and 7% after 5 years and up to 10 to 20% in the long-term follow up. On the basis of low local recurrence rates the concept of whole breast irradiation comes up for discussion, and partial breast irradiation (PBI) is increasingly under consideration. Intraoperative radiotherapy (IORT) is referred to as the delivery of a single high dose of irradiation directly to the tumor bed (confined target) during surgery. PBI (limited field radiation therapy, accelerated partial breast irradiation APBI) is the irradiation exclusively confined to a breast volume, the tumor surrounding tissue (tumor bed) either during surgery or after surgery without whole breast irradiation. Various methods and techniques for IORT or PBI are under investigation. The advantage of a very short radiation time or the integration of the complete radiation treatment into the surgical procedure convinces at a first glance. The promising short-term results of those studies must not fail to mention that local recurrence rates could probably increase and furthermore give rise to distant metastases and a reduction in overall survival. The combination of IORT in boost modality and whole breast irradiation has the ability to reduce local recurrence rates. The EBCTCG overview approves that differences in local treatment that substantially affect local recurrence rates would avoid about one breast cancer death over the next 15 years for every four local recurrences avoided, and should reduce 15-year overall mortality.
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References
Huston TL, Simmons RM. Locally recurrent breast cancer after conservation therapy. Am J Surg. 2005;189:229–35.
Clarke M, Collins R, Darby S, et al. 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;336:2087–106.
Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med. 1995;333(22):1456–61.
Fisher B, Anderson S, Bryant J, et al. 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(16):1233–41.
Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection and radiotherapy in patients with small cancers of the breast. N Engl J Med. 1981;305:6–11.
Veronesi U, Cascinelli N, Mariani L, et al. 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(16):1227–32.
Morrow M, Harris JR, Schnitt SJ. Local control following breast-conserving surgery for invasive cancer: results of clinical trials. J Natl Cancer Inst. 1995;87(22):1669–73.
Galper S, Blood E, Gelman R, et al. Prognosis after local recurrence after conservative surgery and radiation for early-stage breast cancer. Int J Radiat Oncol Biol Phys. 2005;61(2):348–57.
Clark RM, Whelan T, Levine M, et al. Randomized clinical trial of breast irradiation following lumpectomy and axillary dissection for node-negative breast cancer: an update. J Natl Cancer Inst. 1996;88(22):1659–64.
Freedman GM, Fowble BL. Local recurrence after mastectomy or breast-conserving surgery and radiation. Oncology. 2000;14(11):1561–81.
Haffty BG, Fischer D, Beinfield M, McKhann C. Prognosis following local recurrence in the conservatively treated breast cancer patient. Int J Radiat Oncol Biol Phys. 1991;21(2):293–8.
Dalberg K, Mattsson A, Sandelin K, Rutqvist LE. Outcome of treatment for ipsilateral breast tumor recurrence in early-stage breast cancer. Breast Cancer Res Treat. 1998;49(1):69–78.
Dalberg K, Mattsson A, Rutqvist LE, et al. Breast conserving surgery for invasive breast cancer: risk factors for ipsilateral breast tumor recurrences. Breast Cancer Res Treat. 1997;43(1):73–86.
Freedman G, Fowble B, Hanlon A, et al. Patients with early stage invasive cancer with close or positive margins treated with conservative surgery and radiation have an increased risk of breast recurrence that is delayed by adjuvant systemic therapy. Int J Radiat Oncol Biol Phys. 1999;44(5):1005–15.
Touboul E, Buffat L, Belkacemi Y, et al. Local recurrence and distant metastases after breast-conserving surgery and radiation therapy for early breast cancer. Int J Radiat Oncol Biol Phys. 1999;43:25–38.
Fortin A, Larochelle M, Laverdière J, et al. Local failure is responsible for the decrease in survival for patients with breast cancer treated with conservative surgery and postoperative radiotherapy. J Clin Oncol. 1999;17(1):101–9.
Fredriksson I, Liljegren G, Arnesson LG, et al. Local recurrence in the breast after conservative surgery—a study of prognosis and prognostic factors in 391 women. Eur J Cancer. 2002;38(14):1860–70.
Graham P, Fourquet A. Placing the boost in breast-conservation radiotherapy: a review of the role, indications and techniques for breast-boost radiotherapy. Clin Oncol. 2006;18:210–9.
Polgar C, Fodor J, Orosz Z, et al. Electron and high-dose-rate brachytherapy boost in the conservative treatment of stage I–II breast cancer first results of the randomized Budapest boost trial. Strahlenther Onkol. 2002;178:615–23.
Bartelink H, Horiot JC, Poortmans P, et al. 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(19):1378–87.
Romestaing P, Lehingue Y, Carrie C, et al. Role of a 10-Gy boost in the conservative treatment of early breast cancer: results of a randomized clinical trial in Lyon, France. J Clin Oncol. 1997;15(3):963–8.
Veronesi U, Orecchia R, Luini A, et al. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery: experience with 590 cases. Ann Surg. 2005;242:101–6.
Orecchia R, Ciocca M, Lazzari R, et al. Intraoperative radiation therapy with electrons (ELIOT) in early-stage breast cancer. Breast. 2003;12(6):483–90.
Veronesi U, Gatti G, Luini A, et al. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery. Arch Surg. 2003;138(11):1253–6.
Intra M, Gatti G, Luini A, et al. Surgical technique of intraoperative radiotherapy in conservative treatment of limited-stage breast cancer. Arch Surg. 2002;137(6):737–40.
Veronesi U, Orecchia R, Luini A, et al. A preliminary report of intraoperative radiotherapy (IORT) in limited-stage breast cancers that are conservatively treated. Eur J Cancer. 2001;37(17):2178–83.
Gatzemeier W, Orecchia R, Gatti G, et al. Intraoperative radiotherapy (IORT) in treatment of breast carcinoma—a new therapeutic alternative within the scope of breast-saving therapy? Current status and future prospects. Report of experiences from the European Institute of Oncology (EIO), Mailand. Strahlenther Onkol. 2001;177(7):330–7.
Reitsamer R, Sedlmayer F, Kopp M, et al. The Salzburg concept of intraoperative radiotherapy for breast cancer: results and considerations. Int J Cancer. 2006;118:2882–7.
Reitsamer R, Peintinger F, Sedlmayer F, et al. Intraoperative radiotherapy given as a boost after breast-conserving surgery in breast cancer patients. Eur J Cancer. 2002;38(12):1607–10.
Reitsamer R, Peintinger F, Kopp M, et al. Local recurrence rates in breast cancer patients treated with intraoperative electron-boost radiotherapy versus postoperative external-beam electron-boost irradiation. A sequential intervention study. Strahlenther Onkol. 2004;180(1):38–44.
Sedlmayer F, Reitsamer R, Menzel C, et al. IORT with electrons in limited-stage breast cancer—a novel boost strategy during breast conserving therapy. In: Kogelnik HD, Lukas P, Sedlmayer F, editors. Progress in radio-onocology VII. Bologna: Monduzzi; 2002. p. 323–332.
Vaidya JS, Baum M, Tobias JS, et al. The novel technique of delivering targeted intraoperative radiotherapy (Targit) for early breast cancer. Eur J Surg Oncol. 2002;28(4):447–54.
Vaidya JS, Baum M, Tobias JS, et al. Targeted intra-operative radiotherapy (Targit): an innovative method of treatment for early breast cancer. Ann Oncol. 2001;12(8):1075–80.
Perera F, Yu E, Engel J, et al. Patterns of breast recurrence in a pilot study of brachytherapy confined to the lumpectomy site for early breast cancer with six years’ minimum follow-up. Int J Radiat Oncol Biol Phys. 2003;57(5):1239–46.
Lawenda BD, Taghian AG, Kachnic LA, et al. Dose–volume analysis of radiotherapy for T1N0 invasive breast cancer treated by local excision and partial breast irradiation by low-dose-rate interstitial implant. Int J Radiat Oncol Biol Phys. 2003;56(3):671–80.
Vicini FA, Kestin L, Chen P, et al. Limited-field radiation therapy in the management of early-stage breast cancer. J Natl Cancer Inst. 2003;95(16):1205–10.
Arthur DW, Koo D, Zwicker RD, et al. Partial breast brachytherapy after lumpectomy: low-dose-rate and high-dose-rate experience. Int J Radiat Oncol Biol Phys. 2003;56:681–9.
King TA, Bolton JS, Kuske RR, et al. Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T(is,1,2) breast cancer. Am J Surg. 2000;180:299–304.
Baglan KL, Martinez AA, Frazier RC, et al. The use of high-dose-rate brachytherapy alone after lumpectomy in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2001;50(4):1003–11.
Wazer DE, Berle L, Graham R, et al. Preliminary results of a phase I/II study of HDR brachytherapy alone for T1/T2 breast cancer. Int J Radiat Oncol Biol Phys. 2002;53(4):889–97.
Vicini FA, Baglan KL, Kestin LL, et al. Accelerated treatment of breast cancer. J Clin Oncol. 2001;19(7):1993–2001.
Vicini FA, Kestin LL, Edmundson GK, et al. Dose–volume analysis for quality assurance of interstitial brachytherapy for breast cancer. Int J Radiat Oncol Biol Phys. 1999;45(3):803–10.
Vicini F, Kini VR, Chen P, et al. Irradiation of the tumor bed alone after lumpectomy in selected patients with early-stage breast cancer treated with breast conserving therapy. J Surg Oncol. 1999;70(1):33–40.
Vicini FA, Chen PY, Fraile M, et al. Low-dose-rate brachytherapy as the sole radiation modality in the management of patients with early-stage breast cancer treated with breast-conserving therapy: preliminary results of a pilot trial. Int J Radiat Oncol Biol Phys. 1997;38(2):301–10.
Zannis V, Beitsch P, Vicini F, et al. Descriptions and outcomes of insertion techniques of a breast brachytherapy balloon catheter in 1403 patients enrolled in the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. Am J Surg. 2005;190:530–8.
Vicini FA, Beitsch PD, Quiet CA, et al. First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity: results of the American Society of Breast Surgeons MammoSite breast brachytherapy trial. Cancer. 2005;104:1138–48.
Astrahan MA, Jozsef G, Streeter O. Optimization of Mammosite therapy. Int J Radiat Oncol Biol Phys. 2004;58(1):220–32.
Keisch M, Vicini F, Kuske RR, et al. Initial clinical experience with the Mammosite breast brachytherapy applicator in women with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2003;55(2):289–93.
Streeter OE, Vicini FA, Keisch M, et al. MammoSite(®) radiation therapy system. Breast. 2003;12(6):491–6.
Zannis VJ, Walker LC, Barclay-White B, Quiet CA. Postoperative ultrasound-guided percutaneous placement of a new breast brachytherapy balloon catheter. Am J Surg. 2003;186(4):383–5.
Edmundson GK, Vicini FA, Chen PY, et al. Dosimetric characteristics of the MammoSite RTS, a new breast brachytherapy applicator. Int J Radiat Oncol Biol Phys. 2002;52(4):1132–9.
Astrahan MA, Jozsef G, Streeter OE. Optimization of MammoSite therapy. Int J Radiat Oncol Biol Phys. 2004;58(1):220–32.
Vicini FA, Remouchamps V, Wallace M, et al. Ongoing clinical experience utilizing 3D conformal external beam radiotherapy to deliver partial-breast irradiation in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys. 2003;57(5):1247–53.
Baglan KL, Sharpe MB, Jaffray D, et al. Accelerated partial breast irradiation using 3D conformal radiation therapy (3D-CRT). Int J Radiat Oncol Biol Phys. 2003;55(2):302–11.
Benchalal M, Le Prise E, de Lafontan B, et al. Influence of the time between surgery and radiotherapy on local recurrence in patients with lymph node-positive, early-stage, invasive breast carcinoma undergoing breast-conserving surgery: results of the French Adjuvant Study Group. Cancer. 2005;104:240–50.
Lemanski C, Azria D, Thezenas S, et al. Intraoperative radiotherapy given as a boost for early breast cancer: long-term clinical and cosmetic results. Int J Radiat Oncol Biol Phys. 2006;64:1410–15.
Perera F, Yu E, Engel J, Holliday R, et al. Patterns of breast recurrence in a pilot study of brachytherapy confined to the lumpectomy site for early breast cancer with six years’ minimum follow-up. Int J Radiat Oncol Biol Phys. 2003;57:1239–46.
Kuerer HM, Julian TB, Strom EA, et al. Accelerated partial breast irradiation after conservative surgery for breast cancer. Ann Surg. 2004;239:338–51.
Pawlik TM, Perry A, Strom EA, et al. Potential applicability of balloon catheter-based accelerated partial breast irradiation after conservative surgery for breast carcinoma. Cancer. 2004;100:490–8.
Fyles AW, McCready DR, Manchul LA, et al. Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer. N Engl J Med. 2004;351:963–70.
Bartelink H, Horiot JC, Poortmans PM, et al. Impact of a higher 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; June 18 [Epub ahead of print].
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This article is based on an invited lecture delivered at the 15th Annual Meeting of the Japanese Breast Cancer Society, held in Yokohama June 29-30, 2007.
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Reitsamer, R., Sedlmayer, F., Kopp, M. et al. Concepts and techniques of intraoperative radiotherapy (IORT) for breast cancer. Breast Cancer 15, 40–46 (2008). https://doi.org/10.1007/s12282-007-0001-4
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DOI: https://doi.org/10.1007/s12282-007-0001-4