Zx. Liao et al., Locoregional irradiation for inflammatory breast cancer: Effectiveness of dose escalation in decreasing recurrence, INT J RAD O, 47(5), 2000, pp. 1191-1200
Citations number
22
Categorie Soggetti
Radiology ,Nuclear Medicine & Imaging","Onconogenesis & Cancer Research
Journal title
INTERNATIONAL JOURNAL OF RADIATION ONCOLOGY BIOLOGY PHYSICS
Purpose: To evaluate the effect of radiation dose escalation on locoregiona
l control, overall survival, and long-term complication in patients with in
flammatory breast cancer.
Patients and Methods: From September 1977 to December 1993, 115 patients wi
th nonmetastatic inflammatory breast cancer were treated with curative inte
nt at The University of Texas M. D. Anderson Cancer Center. The usual seque
nce of multimodal treatment consisted of induction FAC or FACVP chemotherap
y, mastectomy (if the tumor was operable), further chemotherapy, and radiat
ion therapy to the chest wall and draining lymphatics. Sixty-one patients t
reated from September 1977 to September 1985 received a maximal radiation d
ose of 60 Gy to the chest wall and 45-50 Gy to the regional lymph nodes, 22
treated once a day at 2 Gy per fraction, and 35 were treated b.i.d. (32 af
ter mastectomy and all chemotherapy was completed, and 2 immediately after
mastectomy; one patient had distant metastases discovered during b.i.d. irr
adiation, and treatment was stopped). Four additional patients received pre
operative radiation with standard fractionation. Based on the analysis of t
he failure patterns of the patients, the dose was increased for the b.i.d.
patients in the new series, with 51 Gy delivered to the chest wall and regi
onal nodes, followed by a 15-Gy boost to the chest wall with electrons. Fro
m January 1986 to December 1993, 39 patients were treated b.i.d. to this hi
gher dose after mastectomy and all the chemotherapy was completed; and 8 ad
ditional patients received preoperative irradiation with b.i.d. fractionati
on to 51 Gy. During this period, another 7 patients were treated using stan
dard daily doses of 2 Gy per fraction to a total of 60 Gy, either because t
hey had a complete response or minimal residual disease at mastectomy or be
cause their work schedule did not permit the b.i.d. regimen. Comparison was
made between the groups for locoregional control, disease-free and overall
survival, and complication rates.
Results: The median follow-up time was 5.7 years (range, 1.8-17.6 years). F
or the entire patient group, the 5- and 10-year local control rates mere 73
.2% and 67.1%, respectively. The 5- and 10-year disease-free survival rates
were 32.0% and 28.8%, respectively, and the overall survival rates for the
entire group were 40.5% and 31.3%, respectively. To evaluate the effective
ness of dose escalation, a specific comparison of patients who received b.i
.d. radiation after mastectomy and completion of adjuvant chemotherapy was
performed. There were 32 patients treated b.i.d. to 60 Gy in the old series
versus 39 patients treated b.i.d. to 66 Gy in the new series. There was an
significant improvement in the rate of locoregional control for the b.i.d.
patients for the old vs. new series, from 57.8% to 84.3% and from 57.8% to
77.0% (p = 0.028) at 5 and 10 years, respectively. Chemotherapy regimens d
id not change significantly during this time period. Long-term complication
s of radiation, such as arm edema more than 3 cm (7 patients), rib fracture
(10 patients), severe chest wall fibrosis (4 patients), and symptomatic pn
eumonitis (5 patients), were comparable in the two groups, indicating that
the dose escalation did not result in increased morbidity. Significant diff
erences in the rates of locoregional control (p = 0.03) and overall surviva
l (p = 0.03), and a trend of better disease-free survival (p = 0.06) were a
lso observed that favored the recently treated patients receiving the highe
r doses of irradiation.
Conclusion: Twice-daily postmastectomy radiation to a total of 66 Gy for pa
tients with inflammatory breast cancer resulted in improved locoregional co
ntrol, disease free survival, and overall survival, and was well tolerated.
(C) 2000 Elsevier Science Inc.