Skip to main content

Advertisement

Log in

Single-Center Long-Term Follow-Up After Intraoperative Radiotherapy as a Boost During Breast-Conserving Surgery Using Low-Kilovoltage X-Rays

Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Intraoperative radiotherapy (IORT) during breast-conserving surgery as a boost followed by whole-breast radiotherapy is increasingly used.

Methods

Between February 2002 and December 2008, a total of 197 patients were treated with IORT as a boost (20 Gy, 50 kV x-rays; Intrabeam System, Carl Zeiss Surgical, Oberkochen, Germany) during breast-conserving surgery, followed by whole-breast radiotherapy (46–50 Gy). Systemic therapy was provided according to the St. Gallen consensus. Patients were recalled every 6–12 months for follow-up. Findings were scored according to the LENT-SOMA scale.

Results

Median age was 61.8 (range 30–84) years, and median follow-up was 37 (range 5–91) months. There were T1, T2, and Tx tumors in 129, 67, and 1 patients, respectively, and N0, N1, N2, and N3 disease in 144, 36, 15, and 2 patients, respectively. Until December 2009, 5 local invasive relapses, 1 local ductal carcinoma-in-situ, 1 axillary relapse, 6 secondary cancers, and 11 distant metastases were seen, resulting in a 5-year disease-free survival of 81.0% and an overall survival of 91.3%. Local relapse-free survival (invasive cancers) at 3 and 5 years was 97.0%. After a follow-up of 5 years (n = 58), only 8 patients (13.8%) had chronic skin toxicities, and 2 patients (3.4%) had a marked increase in density (fibrosis III), while 62.0% had no/barely palpable fibrosis 0–I. Other toxicities observed included severe pain (n = 4, 6.9%), retraction (n = 17, 29.3%), edema of the breast (n = 1, 1.7%), and lymphedema in general (n = 2, 3.4%).

Conclusions

After IORT as a tumor bed boost with low-kilovoltage x-rays followed by whole-breast radiotherapy, low local recurrence and chronic toxicity rates were seen after 5-year follow-up.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

References

  1. Fisher B, Jeong JH, Anderson S, et al. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med. 2002;347:567–75.

    Article  PubMed  Google Scholar 

  2. 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;347:1227–32.

    Article  PubMed  Google Scholar 

  3. Clarke M, Collins R, Darby S, et al. 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;366:2087–106.

    CAS  PubMed  Google Scholar 

  4. Bartelink H, Horiot JC, Poortmans PM, et al. 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;25:3259–65.

    Article  PubMed  Google Scholar 

  5. Antonini N, Jones H, Horiot JC, et al. Effect of age and radiation dose on local control after breast conserving treatment: EORTC trial 22881-10882. Radiother Oncol. 2007;82:265–71.

    Article  PubMed  Google Scholar 

  6. Benda RK, Yasuda G, Sethi A, et al. Breast boost: are we missing the target? Cancer. 2003;97:905–9.

    Article  PubMed  Google Scholar 

  7. Pezner RD. Cosmetic breast fibrosis: it’s the local boost! Int J Radiat Oncol Biol Phys. 1994;30:1251–2.

    CAS  PubMed  Google Scholar 

  8. Kraus-Tiefenbacher U, Steil V, Bauer L, et al. A novel mobile device for intraoperative radiotherapy (IORT). Onkologie. 2003;26:596–8.

    Article  CAS  PubMed  Google Scholar 

  9. Arthur DW, Vicini FA. Accelerated partial breast irradiation as a part of breast conservation therapy. J Clin Oncol. 2005;23:1726–35.

    Article  PubMed  Google Scholar 

  10. Polgar C, Strnad V, Kovacs G. Partial-breast irradiation or whole-breast radiotherapy for early breast cancer: a meta-analysis of randomized trials. Strahlenther Onkol. 2010;186:113–4.

    Article  PubMed  Google Scholar 

  11. Reitsamer R, Sedlmayer F, Kopp M, et al. Concepts and techniques of intraoperative radiotherapy (IORT) for breast cancer. Breast Cancer. 2008;15:40–6.

    Article  PubMed  Google Scholar 

  12. Sedlmayer F, Fastner G, Merz F, et al. IORT with electrons as boost strategy during breast conserving therapy in limited stage breast cancer: results of an ISIORT pooled analysis. Strahlenther Onkol. 2007;183 Spec No 2:32–34.

    Article  PubMed  Google Scholar 

  13. Vaidya JS, Baum M, Tobias JS, et al. Targeted intraoperative radiotherapy (TARGIT) yields very low recurrence rates when given as a boost. Int J Radiat Oncol Biol Phys. 2006;66:1335–8.

    PubMed  Google Scholar 

  14. Herskind C, Steil V, Kraus-Tiefenbacher U, Wenz F. Radiobiological aspects of intraoperative radiotherapy (IORT) with isotropic low-energy X rays for early-stage breast cancer. Radiat Res. 2005;163:208–15.

    Article  CAS  PubMed  Google Scholar 

  15. Merrick HW 3rd, Battle JA, Padgett BJ, Dobelbower RR Jr. IORT for early breast cancer: a report on long-term results. Front Radiat Ther Oncol. 1997;31:126–30.

    Article  PubMed  Google Scholar 

  16. Kraus-Tiefenbacher U, Bauer L, Kehrer T, et al. Intraoperative radiotherapy (IORT) as a boost in patients with early-stage breast cancer—acute toxicity. Onkologie. 2006;29:77–82.

    Article  PubMed  Google Scholar 

  17. Wenz F, Welzel G, Keller A, et al. Early initiation of external beam radiotherapy (EBRT) may increase the risk of long-term toxicity in patients undergoing intraoperative radiotherapy (IORT) as a boost for breast cancer. Breast. 2008;17:617–22.

    Article  PubMed  Google Scholar 

  18. Vaidya JS, Tobias JS, Baum M, et al. Intraoperative radiotherapy for breast cancer. Lancet Oncol. 2004;5:165–73.

    Article  PubMed  Google Scholar 

  19. Vaidya JS, Tobias JS, Baum M, et al. TARGeted Intraoperative radiotherapy (TARGIT): an innovative approach to partial-breast irradiation. Semin Radiat Oncol. 2005;15:84–91.

    Article  PubMed  Google Scholar 

  20. Kraus-Tiefenbacher U, Bauer L, Scheda A, et al. Intraoperative radiotherapy (IORT) is an option for patients with localized breast recurrences after previous external-beam radiotherapy. BMC Cancer. 2007;7:178.

    Article  PubMed  Google Scholar 

  21. Kraus-Tiefenbacher U, Scheda A, Steil V, et al. Intraoperative radiotherapy (IORT) for breast cancer using the Intrabeam System. Tumori. 2005;91:339–45.

    PubMed  Google Scholar 

  22. Kraus-Tiefenbacher U, Bauer L, Scheda A, et al. Long-term toxicity of an intraoperative radiotherapy boost using low energy X-rays during breast-conserving surgery. Int J Radiat Oncol Biol Phys. 2006;66:377–81.

    PubMed  Google Scholar 

  23. Goldhirsch A, Wood WC, Gelber RD, et al. Progress and promise: highlights of the international expert consensus on the primary therapy of early breast cancer 2007. Ann Oncol. 2007;18:1133–44.

    Article  CAS  PubMed  Google Scholar 

  24. Denekamp J, Bartelink H, Rubin P. Correction for the use of the SOMA LENT tables. American and European LENT Working Committees. Radiother Oncol. 1996;39:191.

    Article  CAS  PubMed  Google Scholar 

  25. LENT SOMA tables. Radiother Oncol. 1995;35:17–60.

    Google Scholar 

  26. Feyer P, Sautter-Bihl ML, Budach W, et al. DEGRO practical guidelines for palliative radiotherapy of breast cancer patients: brain metastases and leptomeningeal carcinomatosis. Strahlenther Onkol. 2010;186:63–9.

    Article  PubMed  Google Scholar 

  27. Sanghani M, Truong PT, Raad RA, et al. Validation of a Web-based predictive nomogram for ipsilateral breast tumor recurrence after breast conserving therapy. J Clin Oncol. 2010;28:718–22.

    Article  PubMed  Google Scholar 

  28. 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;177:330–7.

    Article  CAS  PubMed  Google Scholar 

  29. Kraus-Tiefenbacher U, Welzel G, Brade J, et al. Postoperative seroma formation after intraoperative radiotherapy using low-kilovoltage X-rays given during breast-conserving surgery. Int J Radiat Oncol Biol Phys. 2010;77:1140–5.

    PubMed  Google Scholar 

  30. Wenz F, Welzel G, Blank E, et al. Intraoperative radiotherapy as a boost during breast-conserving surgery using low-kilovoltage x-rays: the first 5 years of experience with a novel approach. Int J Radiat Oncol Biol Phys. 2010;77:1309–14.

    PubMed  Google Scholar 

  31. Blank E, Welzel G, Tome O, et al. Erhöhtes Risiko von Spätfolgen bei zu kurzem Intervall zwischen intraoperativem Tumorbettboost und Mammahomogenbestrahlung. Geburtsh Frauenheilk. 2008;68:729–33.

    Article  Google Scholar 

  32. Herskind C, Griebel J, Kraus-Tiefenbacher U, Wenz F. Sphere of equivalence—a novel target volume concept for intraoperative radiotherapy using low-energy X rays. Int J Radiat Oncol Biol Phys. 2008;72:1575–81.

    PubMed  Google Scholar 

  33. Herskind C, Schalla S, Hahn EW, et al. Influence of different dose rates on cell recovery and RBE at different spatial positions during protracted conformal radiotherapy. Radiat Prot Dosimetry. 2006;122:498–505.

    Article  CAS  PubMed  Google Scholar 

  34. Belletti B, Vaidya JS, D’Andrea S, et al. Targeted intraoperative radiotherapy impairs the stimulation of breast cancer cell proliferation and invasion caused by surgical wounding. Clin Cancer Res. 2008;14:1325–32.

    Article  CAS  PubMed  Google Scholar 

  35. Fehlauer F, Tribius S, Alberti W, Rades D. Late effects and cosmetic results of conventional versus hypofractionated irradiation in breast-conserving therapy. Strahlenther Onkol. 2005;181:625–31.

    Article  PubMed  Google Scholar 

  36. Nairz O, Deutschmann H, Kopp M, et al. A dosimetric comparison of IORT techniques in limited-stage breast cancer. Strahlenther Onkol. 2006;182:342–8.

    Article  PubMed  Google Scholar 

  37. 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;180:38–44.

    Article  PubMed  Google Scholar 

  38. 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;64:1410–5.

    PubMed  Google Scholar 

  39. Vicini F, Arthur D, Polgar C, Kuske R. Defining the efficacy of accelerated partial breast irradiation: the importance of proper patient selection, optimal quality assurance, and common sense. Int J Radiat Oncol Biol Phys. 2003;57:1210–3.

    PubMed  Google Scholar 

  40. Harms W, Krempien R, Hensley FW, et al. 5-Year results of pulsed dose rate brachytherapy applied as a boost after breast-conserving therapy in patients at high risk for local recurrence from breast cancer. Strahlenther Onkol. 2002;178:607–14.

    Article  PubMed  Google Scholar 

  41. Lilla C, Ambrosone CB, Kropp S, et al. Predictive factors for late normal tissue complications following radiotherapy for breast cancer. Breast Cancer Res Treat. 2007;106:143–50.

    Article  PubMed  Google Scholar 

  42. Niehoff P, Polgar C, Ostertag H, et al. Clinical experience with the MammoSite radiation therapy system for brachytherapy of breast cancer: results from an international phase II trial. Radiother Oncol. 2006;79:316–20.

    Article  PubMed  Google Scholar 

  43. Poortmans P, Bartelink H, Horiot JC, et al. The influence of the boost technique on local control in breast conserving treatment in the EORTC “boost versus no boost” randomised trial. Radiother Oncol. 2004;72:25–33.

    Article  PubMed  Google Scholar 

  44. Bartelink H, Horiot JC, Poortmans P, et al. Recurrence rates after treatment of breast cancer with standard radiotherapy with or without additional radiation. N Engl J Med. 2001;345:1378–87.

    Article  CAS  PubMed  Google Scholar 

  45. Lemanski C, Azria D, Gourgon-Bourgade S, et al. Intraoperative radiotherapy in early-stage breast cancer: results of the Montpellier phase II trial. Int J Radiat Oncol Biol Phys. 2010;76:698–703.

    PubMed  Google Scholar 

  46. Luini A, Orecchia R, Gatti G, et al. The pilot trial on intraoperative radiotherapy with electrons (ELIOT): update on the results. Breast Cancer Res Treat. 2005;93:55–9.

    Article  PubMed  Google Scholar 

  47. Mussari S, Sabino Della Sala W, Busana L, et al. Full-dose intraoperative radiotherapy with electrons in breast cancer. First report on late toxicity and cosmetic results from a single-institution experience. Strahlenther Onkol. 2006;182:589–95.

    Article  PubMed  Google Scholar 

  48. 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.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgment

The project is supported by grant FKZ 01ZP0508 from the “Bundesministerium für Bildung und Forschung.” We thank Mrs. Anette Kipke, Erika Filp and Mrs. Dr. med. Brigitte Hermann, MD for organizational support. Radiobiological research in the laboratory of F.W. is supported by Carl Zeiss Surgery, Oberkochen, Germany.

Conflict of Interest

None.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Elena Blank MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Blank, E., Kraus-Tiefenbacher, U., Welzel, G. et al. Single-Center Long-Term Follow-Up After Intraoperative Radiotherapy as a Boost During Breast-Conserving Surgery Using Low-Kilovoltage X-Rays. Ann Surg Oncol 17 (Suppl 3), 352–358 (2010). https://doi.org/10.1245/s10434-010-1265-z

Download citation

  • Received:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-010-1265-z

Keywords

Navigation