LA RADIOTERAPIA EN LA RECURRENCIA IPSILATERAL DEL CÁNCER DE MAMA TRAS LA PRESERVACIÓN DE LA GLÁNDULA

Conclusión breve
La repetición de la tumorectomía y de la radioterapia posquirúrgica son factibles y podrían representar una alternativa a la mastectomía de rescate en las pacientes que evolucionan con recurrencia ipsilateral de cáncer de mama después de una cirugía de preservación mamaria.

Resumen

Objetivos: brindar una revisión del retratamiento radiante en el enfoque de las pacientes con recurrencia ipsilateral del cáncer de mama (RICM). Materiales y métodos: se efectuó una revisión de la bibliografía recinete y se la correlacionó con nuestra amplia experiencia de retratamiento en pacientes tratadas en forma original con tumorectomía y radioterapia postoperatoria en el marco de una RICM. Se informan los resultados actualizados de nuestras pacientes tratadas con implantes intersticial transitorios de baja dosis (LDR), braquiterapia con balón a altas dosis (HDR) o radioterapia conformacional tridimensional (3D-CRT) y su comparación con los resultados descritos por otros autores. Resultados: un total de 42 pacientes fueron tratadas según nuestro protocolo. Después de una media de seguimiento de 67.5 meses (intervalo de 5 a 115 meses), 21 de las 22 mujeres tratadas con LDR lograron control local después del último control o al momento del fallecimiento. La única paciente que presentó una segunda recurrencia local se trató de forma exitosa con mastectomía. Una de las 15 mujeres que recibieron HDR evolucionó con una recurrencia inflamatoria que se trató de forma exitosa con mastectomía de rescate. En las 5 pacientes tratadas con 3D-CRT se logró preservación mamaria. Dos de las pacientes que recibieron LDR presentaron disrupción cutánea localizada. Cinco de las 42 participantes murieron; 3 casos se atribuyeron a cáncer mamario metastático. Una de las pacientes falleció como consecuencia de enfermedad pulmonar obstructiva crónica. Otra enferma murió por complicaciones cardíacas de la radioterapia previa. En una de las mujeres se verificó aparición de cáncer de mama contralateal. Los resultados estéticos a largo plazo, definidos por la escala cosmética de Harvard y la modificación de Allegheny General (AGH) se consideraron aceptables. La escala AGH fue más precisa para notificar los cambios estéticos. Conclusiones: estos datos a largo plazo permite sugerir que la repetición de la tumorectomía y de la radioterapia posquirúrgica son factibles y podrían representar una alternativa a la mastectomía de rescate en las pacientes que evolucionan con RICM después de una cirugía de preservación mamaria. Se requiere un mejor sistema de cuantificación estética (escala AGH) para una identificación más adecuada del resultado cosmético posterior al retratamiento.

Palabras clave
cáncer de mama, recurrencia ipsilateral del cáncer de mama, radioterapia, preservación mamaria

Clasificación en siicsalud

Artículos originales> Expertos del Mundo>
página www.siicsalud.com/des/expertos.php/125118

Especialidades

Principal: Obstetricia y Ginecología, Oncología,

Relacionadas: Anatomía Patológica,

Enviar correspondencia a:
Mark Trombetta, Allegheny General Hospital Department of Radiation Oncology, PA 15212, Pittsburgh, EE.UU.

Radiotherapy in the treatment of ipsilateral breast tumor recurrence (IBTR) following breast conservation

Abstract
Purpose: To provide an overview of the state of retreatment irradiation in the management of patients who develop ipsilateral breast tumor recurrence (IBTR). Materials and methods: We reviewed the modern literature and correlated it with our extensive experience in retreatment of the breast in patients originally treated with lumpectomy and post-operative irradiation following IBTR. We report the updated results of our patients treated by low dose rate temporary interstitial implant (LDR), high dose rate (HDR) balloon brachytherapy, and three dimensional conformal radiotherapy (3-D CRT), and compare these to results reported by other authors. Results: A total of 42 patients have been treated on our protocol. With a mean follow up of 67.5 months (range 5-115 months), twenty-one of 22 LDR patients achieved local control at the time of last follow-up, or at the time of their death. The single patient who developed a second local recurrence was treated successfully with mastectomy. One of 15 HDR patients developed an inflammatory recurrence and was successfully treated by salvage mastectomy. All five 3-D CRT patients have retained their breasts. Two LDR patients developed localized skin breakdown. Five of 42 patients have expired with 3/5 succumbing to metastatic breast cancer. One patient died from chronic obstructive pulmonary disease, and one died from cardiac complications secondary to previous mantle radiotherapy. One patient developed a contralateral breast cancer. Long-term cosmetic results as defined by the Harvard cosmesis scale and the Allegheny General (AGH) modification were acceptable, and the AGH modification more accurately reported cosmetic changes. Conclusions: These long-term data suggest that repeat lumpectomy followed by repeat post-operative radiotherapy is feasible and may be an acceptable alternative to salvage mastectomy in patients who develop IBTR following conservation breast therapy. An improved cosmetic reporting system (the AGH modification) is required to more accurately identify post-retreatment cosmesis.

Key words
breast cancer, ipsilateral breast tumor recurrence, radiotherapy, breast conservation

LA RADIOTERAPIA EN LA RECURRENCIA IPSILATERAL DEL CÁNCER DE MAMA TRAS LA PRESERVACIÓN DE LA GLÁNDULA

(especial para SIIC © Derechos reservados)

Artículo completo

Bibliografía del artículo
1. 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 347:1227-32, 2002.
2. Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus radiation for the treatment of invasive breast cancer. N Engl J Med 347:1233-41, 2002.
3. Globocan 2008: http://globocan.iarc.fr/factsheets/cancers/all.asp.
4. Fowble BL, Solin LJ, Schultz DJ, et al. Ten year results of conservative surgery and irradiation for stage I and II breast cancer. Int J Radiat Oncol Biol Phys 21:269-277, 1991.
5. Abner AL, Recht A, Eberlein T, et al. Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol 11:44-48, 1993.
6. Ganz P, et al. Breast conservation versus mastectomy; is there a difference in Psychological adjustment or quality of life in the year after surgery? Cancer 69:1729-1738, 1992.
7. Rowland et al. Role of breast reconstruction in physical and emotional outcomes among breast cancer survivors. JNCI 92:1422-1429, 2000.
8. Maunsell E, et al. Psychological distress after initial treatment for breast cancer: a comparison of partial and total mastectomy. J Clin Epidemiol 42:765-771, 1989.
9. Benitez PR, Keisch ME, Vicini F, et al. Five-year results: the initial clinical trial of MammoSite balloon brachytherapy for partial breast irradiation in early stage breast cancer. Am J Surg 194:456-62, 2007.
10. Strnad V, Ott OJ, Hildebrandt G, et al. Partial breast irradiation using multicatheter interstitial brachytherapy for early breast cancer: Results of the German-Austrian multicenter Phase II trial. Brachytherapy 8:107, 2009.
11. 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 Tis, 1, 2 breast cancer. Am J Surg 180:299-304, 2000.
12. Polgar C, Fodor J, Major T, et al. Breast-conserving treatment with partial or whole breast irradiation for low-risk invasive breast carcinoma - 5-year results of a randomized trial. Int J Radiat Oncol Biol Phys 69:694-702, 2007.
13. Arthur DW, Winter K, Kuske RR, et al. A phase II trial of brachytherapy alone after lumpectomy for select breast cancer: tumor control and survival outcomes of RTOG 95-17. Int J Radiat Oncol Biol Phys 72:467-73, 2008.
14. Vicini FA, Antonucci V, Wallace M, et al. Long-term efficacy and patterns of failure after accelerated partial breast irradiation: a molecular assay-based clonality evaluation. Int J Radiat Oncol Biol Phys 68:341-6, 2007.
15. Polgar C, Major T, Fodor J, et al. Accelerated partial breast irradiation using high- dose-rate interstitial brachytherapy: 12-year update of a prospective clinical study. Radiother Oncol 94:274-279, 2010.
16. http://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/ctcaev3.pdf.
17. NSABP Protocol B-39/ RTOG Protocol 0413. A randomized phase III study of conventional whole breast irradiation (WBI) versus partial breast irradiation (PBI) for women with stage 0, I, or II breast cancer.
18. NSABP Protocol B-39/ RTOG Protocol 0413. A randomized phase III study of conventional whole breast irradiation (WBI) versus partial breast irradiation (PBI) for women with stage 0, I, or II breast cancer; form COS.
19. Trombetta M, Julian TB, Kim Y, et al. The Allegheny General Modification of the Harvard Breast Cosmesis Scale for the Retreated Breast. Oncology 23, 2009.
19. Trombetta M, Julian T, Bhandari T, et al. Breast conservation surgery and interstitial brachytherapy in the management of locally recurrent carcinoma of the breast: The Allegheny General Hospital experience. Brachytherapy 7(1):29-36, 2008.
20. Doyle T, Schultz D, et al. Long-term results of local recurrence after breast conservation treatment for invasive breast cancer. Int J Radiation Oncology Biol Phys 51(1):74-80, 2001.
21. Huang E, Bucholz T, et al. Classifying local disease recurrences after breast conservation therapy based on location and histology. Cancer 95(10):2059-2067, 2002.
22. Kurtz JM, et al. Results of salvage surgery for mammary recurrence following breast conserving therapy. Ann Surg 207:347-351, 1988.
23. Fowble B, Solin L, Schultz D, et al. Breast recurrence following conservation surgery and radiation: Patterns of failure, prognosis, and pathologic findings from mastectomy specimens with implications for treatment. Int J Radiat Oncol Biol Phys 19:833-842, 1990.
24. Haffty BG, Fischer D, Beinfield M, et al. Prognosis following local recurrence in the conservatively treated breast cancer patient. Int J Radiat Oncol Biol Phys 21:293-298, 1991.
25. Salvadori, B, Marubini E et al. Reoperation for locally recurrent breast cancer in patients previously treated with conservative surgery. Br Journ Surg 86:84-87, 1999.
26. Komoike Y, Motomura K, et al. Repeat lumpectomy for patients with ipsilateral breast tumor recurrence after breast conserving surgery. Oncology 64:1-6, 2003.
27. Abner AL, Recht A, Eberlein T, et al. Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol 11:44-48, 1993.
28. Cajucom C, Tsangaris T, Nemoto T, et al. Results of salvage mastectomy for local recurrence after breast-conserving surgery without radiation therapy. Cancer 57(5):1174-1779, 1993.
29. Recht A, Schnitt SJ, Connolly JL, et al. Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast cancer. Int J Radiat Oncol Biol Phys 16:3-9, 1989.
30. Deutsch M. Repeat high-dose external beam irradiation for in-breast tumor recurrence after previous lumpectomy and whole breast irradiation. Int J Radiation Oncology Biol Phys 53(3):687-691, 2002.
31. Chadha M, Feldman S, Boolbol S, et al. The feasibility of a second lumpectomy and beast brachytherapy for localized cancer in a breast previously treated with lumpectomy and radiation therapy for breast cancer. Brachytherapy 7:22-28, 2008.
32. Hannoun-Levi JM, Houvenaeghel G, Ellis S, et al. Partial breast irradiation as second conservative treatment for local breast cancer recurrence. Int J Radiat Oncol Biol Phys 60:1385-92, 2004.
33. Chadha M, Trombetta M, Boolbol S, et al. Management of a small recurrence in the previously irradiated breast; is there a second chance for breast conservation? Oncology 11:933-40, 2009.
34. Petrovich Z, Langholz B, Lam, K, et al. Interstitial microwave hyperthermia combined with Iridium-192 radiotherapy for recurrent tumors. Am J Clin Oncol 12(3):264-268, 1989.
35. Hannoun-Levi J, Castel J, Plesu, A et al. Second conservative treatment for ipsilateral breast cancer recurrence using high-dose rate interstitial brachytherapy: preliminary clinical results and evaluation of patient satisfaction. Brachytherapy 10(3):171-7, 2011.
36. Kauer-Dorner D, et al. Partial breast irradiation for locally recurrent breast cancer within a second breast conserving treatment: Alternative to mastectomy? Results from a prospective trial. Radiother Oncol (2011; E Pub ahead of print).
37. Trombetta M, Julian TB, Miften M, McWilliams W, Kim Y, Parda D. The use of the MammoSite® balloon applicator in re-irradiation of the breast. Brachytherapy 7:316-319, 2008.
38. Trombetta M, Julian TB, Werts ED, Colonias A, Betler J, Kotinsley K, Kim Y, Parda D. Comparison of conservative management techniques in the retreatment of ipsilateral breast tumor recurrence. Brachytherapy 10(1):74-80, 2011.
39. RTOG protocol 1014: A phase II study of repeat breast preserving surgery and 3D- conformal partial breast re-irradiation (PBRI) for local recurrence of breast carcinoma; http://www.rtog.org/ClinicalTrials/ProtocolTable/StudyDetails.aspx?study=1014.