Accelerated superfractionated radiotherapy for inflammatory breast carcinoma: Complete response predicts outcome and allows for breast conservation

Purpose: Chemotherapy and accelerated superfractionated radiotherapy were p rospectively applied for inflammatory breast carcinoma with the intent of b reast conservation. The efficacy, failure patterns, and patient tolerance u tilizing this approach were analyzed, Methods and Materials: Between 1983 and 1996, 52 patients with inflammatory breast carcinoma presented to the Medical College of Virginia Hospitals of VCU and the New England Medical Center, Thirty-eight of these patients wer e jointly evaluated in multidisciplinary breast clinics and managed accordi ng to a defined prospectively applied treatment policy. Patients received i nduction chemotherapy, accelerated superfractionated radiotherapy, selected use of mastectomy, and concluded with additional chemotherapy, The majorit y were treated with 1.5 Gy twice daily to field arrangements covering the e ntire breast and regional lymphatics. An additional 18-21 Gy was then deliv ered to the breast and clinically involved nodal regions. Total dose to cli nically involved areas was 63-66 Gy, Following chemoradiotherapy, patients were evaluated with physical examination, mammogram, and fine needle aspira tion x 3, Mastectomy was reserved for those patients with evidence of persi stent or progressive disease in the involved breast. All patients received additional chemotherapy. Results: Median age was 51 years, Median follow-up was 23.9 months (6-86) m onths. The breast preservation rate at the time of last follow-up was 74%. The treated breast or chest wall as the first site of failure occurred in o nly 13%, and the ultimate local control rate with the selected use of maste ctomy was 74%. Ten patients underwent mastectomy, 2 of which had pathologic ally negative specimens despite a clinically palpable residual mass. Respon se to chemotherapy was predictive of treatment outcome. Of the 15 patients achieving a complete response, 87% remain locoregionally controlled without the use of mastectomy. Five-year overall survival for complete responders was 68%. This is in contrast to the 14% 5-year overall survival observed wi th incomplete responders. The 5-year actuarial disease-free survival and ov erall survival for the entire patient cohort was 11% and 33%, respectively. All patients tolerated irradiation with limited acute effects, of which al l were managed conservatively. Conclusion: Our experience demonstrates that induction chemotherapy, accele rated superfractionated radiotherapy, and the selected use of mastectomy re sults in excellent locoregional control rates, is well tolerated, and optim izes breast preservation. Based on our present results, we recommend that a patient's response to induction chemotherapy guide the treatment approach used for locoregional disease, such that mastectomy be reserved for incompl ete responders and avoided in those achieving a complete response, (C) 1999 Elsevier Science Inc.