Effectiveness of Breast-Conserving Surgery and 3-Dimensional Conformal Partial Breast Reirradiation for Recurrence of Breast Cancer in the Ipsilateral Breast

Abstract

IMPORTANCE Mastectomy is standard for recurrence of breast cancer after breast conservation therapy with whole breast irradiation. The emergence of partial breast irradiation led to consideration of its application for reirradiation after a second lumpectomy for treatment of recurrence of breast cancer in the ipsilateral breast.OBJECTIVES To assess the effectiveness and adverse effects of partial breast reirradiation after a second lumpectomy and whether the treatment is an acceptable alternative to mastectomy. DESIGN, SETTING, AND PARTICIPANTSThe NRG Oncology/Radiation Therapy Oncology Group 1014 trial is a phase 2, single-arm, prospective clinical trial of 3-dimensional, conformal, external beam partial breast reirradiation after a second lumpectomy for recurrence of breast cancer in the ipsilateral breast after previous whole breast irradiation. The study opened on June 4, 2010, and closed June 18, 2013. Median follow-up was 5.5 years. This analysis used all data received at NRG Oncology through November 18, 2018. Eligible patients experienced a recurrence of breast tumor that was less than 3 cm and unifocal in the ipsilateral breast more than 1 year after breast-conserving therapy with whole breast irradiation and who had undergone excision with negative margins.INTERVENTIONS Adjuvant partial breast reirradiation, 1.5 Gy twice daily for 30 treatments during 15 days (45 Gy), using a 3-dimensional conformal technique. MAIN OUTCOMES AND MEASURESThe main outcomes of the present study were the predefined secondary study objectives of recurrence of breast cancer in the ipsilateral breast, late adverse events (>1 year after treatment), mastectomy incidence, distant metastasis-free survival, overall survival, and circulating tumor cell incidence.RESULTS A total of 65 women were enrolled, with 58 evaluable for analysis (mean [SD] age, 65.12 [9.95] years; 48 [83%] white). Of the recurrences of breast cancer in the ipsilateral breast, 23 (40%) were noninvasive and 35 (60%) were invasive. In all 58 patients, 53 (91%) had tumors 2 cm or smaller. All tumors were clinically node negative. A total of 44 patients (76%) tested positive for estrogen receptor, 33 (57%) for progesterone receptor, and 10 (17%) for ERBB2 (formerly HER2 or HER2/neu) overexpression. Four patients had breast cancer recurrence, with a 5-year cumulative incidence of 5% (95% CI, 1%-13%). Seven patients underwent ipsilateral mastectomies for a 5-year cumulative incidence of 10% (95% CI, 4%-20%). Both distant metastasis-free survival and overall survival rates were 95% (95% CI, 85%-98%). Four patients (7%) had grade 3 and none had grade 4 or higher late treatment adverse events. CONCLUSIONS AND RELEVANCEFor patients experiencing recurrence of breast cancer in the ipsilateral breast after lumpectomy and whole breast irradiation, a second breast conservation was achievable in 90%, with a low risk of re-recurrence of cancer in the ipsilateral breast using adjuvant partial breast reirradiation. This finding suggests that this treatment approach is an effecti...

Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques

“…[ 32 ] 2019 50 12.7 Proton 45–76 – – 97 16 Arthur DW et al. [ 33 ] 2019 58 66 3D CRT 45 1.5 BID 5.2 95 7 # pts: number of patients; MFU: median follow-up; Dose/f: dose per fraction; 3 rd IBTE: third ipsilateral breast tumor event rate; OS: overall survival; ≥ G3 tox. : grade 3 and higher toxicity rate; 3DCRT: 3D conformal radiation therapy.…”

“…Re-irradiation of the regional nodes was done in 84% of the cases [ 32 ]. The results of the RTOG 10–14 phase 2 trial have been recently published with a MFU of 5.5 years [ 33 ]. With 4 pts out of 58 who developed a 3 rd IBTE, the authors reported a 3 rd IBTE 5-year cumulative incidence of 5% with an OS rate of 95%.…”

“…presented 16% of G3 toxicities, 10% of acute and 8% of late toxicities [ 32 ]. In the RTOG 10–14 phase 2 trial, the reported profile of tolerance was fairly acceptable with 7% of grade 3 late toxicity and no grade 4 [ 33 ]. In these studies, no heart or lung toxicity was described.…”

Breast-conserving surgery with intraoperative radiotherapy in recurrent breast cancer: the patient’s perspective

“…Outcomes after second BCS and partial breast re-irradiation is a very current topic in the literature [22,23]. Recently, a study by Arthur et al demonstrates the long-term safety of this procedure, emphasizing the results of the GEC-ESTRO trial [24,25]. Since there are comparatively few long-term QoL studies in IBTR, we focused particularly on this item in our study.…”

Locoregional Management of Early-Stage Breast Cancer

“…For patients who undergo a second lumpectomy (for local recurrence or new primaries), a reasonable option is partial breast reirradiation, based on the recent RTOG 1014 that found DFS and OS to be 95% at 5 years. 17 "For patients who are very motivated to keep their breasts, this can be an effective alternative to mastectomy," she commented.…”