Ductal Carcinoma In Situ (DCIS) Radiation Oncology Perspective Part 3

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Radiation techniques for DCIS – Hypofractionation
    • ASTRO evidence-based guideline from 2018:
      • Stage (including DCIS vs invasive breast cancer):
        • Statement KQ1G:
          • Hypofractionation whole breast irradiation (WBI) may be used as an alternative to conventional fractionation (CF) CF-WBE in patients with DCIS
            • Recommendation strength: conditional
            • Quality of evidence: Moderate
            • Consensus: 86%
      • Age, grade, and margins for DCIS:
        • Statement KQ2D:
          • A tumor boost may be used for patients with DCIS who meet any of the following criteria:
            • Age =/< 50 years
            • High grade
            • Close (< 2 mm) or positive margins
          • Recommendation strength: conditional
          • Quality of evidence: Moderate
          • Consensus: 92%
  • This two statements from ASTRO rely of data from two randomized trials:
    • The DBCG Hypo Trial:
      • Entry criteria:
        • > 40 years of age
        • BCS for node-negative breast cancer
        • DCIS (13% of the cohort)
      • Primary endpoint:
        • Grade 2 to 3 breast induration assuming no inferiority regarding locoregional recurrence
      • Median follow-up of 7.26 years
The local control were the same between hypofractionation vs conventional fractionation.
Grade 2 to 3 induration rates were similar between hypofractionation vs conventional fractionation.
BIG 3-07 / TROG 07.01 Trial
  • BIG 3-07 / TROG 07.01:
    • Background:
      • Whole breast irradiation (WBI) after conservative surgery for ductal carcinoma in situ (DCIS) reduces local recurrence.
      • They investigated whether a tumor bed boost after WBI improved outcomes, and examined radiation dose fractionation sensitivity for non-low-risk DCIS.
    • Methods:
      • The study was an international, randomized, unmasked, phase 3 trial involving 136 participating centres of six clinical trials organisations in 11 countries (Australia, New Zealand, Singapore, Canada, the Netherlands, Belgium, France, Switzerland, Italy, Ireland, and the UK).
      • Eligible patients were women aged 18 years or older with unilateral, histologically proven, non-low-risk DCIS treated by breast-conserving surgery with at least 1 mm of clear radial resection margins.
      • They were assigned to one of four groups (1:1:1:1) of no tumour bed boost versus boost after conventional versus hypofractionated WBI, or randomly assigned to one of two groups (1:1) of no boost versus boost after each center prespecified conventional or hypofractionated WBI.
      • The conventional WBI used was 50 Gy in 25 fractions, and hypofractionated WBI was 42.5 Gy in 16 fractions. A boost dose of 16 Gy in eight fractions, if allocated, was delivered after WBI.
      • Patients and clinicians were not masked to treatment allocation. The primary endpoint was time to local recurrence.
    • Findings:
      • Between June 25, 2007, and June 30, 2014, 1608 patients were randomly assigned to have no boost (805 patients) or boost (803 patients).
      • Conventional WBI was given to 831 patients, and hypofractionated WBI was given to 777 patients.
      • Median follow-up was 6.6 years.
      • The 5-year free-from-local-recurrence rates were 92.7% (95% CI 90·6-94·4%) in the no-boost group and 97.1% (95·6-98·1%) in the boost group (hazard ratio 0·47; 0·31-0·72; p<0·001).
      • The boost group had higher rates of grade 2 or higher breast pain (10% [8-12%] vs 14% [12-17%], p=0·003) and induration (6% [5-8%] vs 14% [11-16%], p<0·001).
    • Interpretation:
      • In patients with resected non-low-risk DCIS, a tumor bed boost after WBI reduced local recurrence with an increase in grade 2 or greater toxicity.
      • The results provide the first randomised trial data to support the use of boost radiation after postoperative WBI in these patients to improve local control.
      • The international scale of the study supports the generalizability of the results.
  • Radiation Techniques for DCIS:
    • Accelerated partial breast irradiation:
ASTRO Evidence Based Consensus Statement
  • Summary:
    • Moderately hypo-fractionation WBI is a standard treatment
    • Consider boost for:
      • High grade DCIS
      • > 2 cm tumors
      • Positive or < 2 mm margins
      • Pre-menopausal patients
      • Patients less than 50 years of age
    • APBI in DCIS is safe and effective option in ASTRO “suitable”candidates
      • Not all techniques (just validated with external beam radiation)
    • Consider hormone therapy in aggressively minded patients or those wishing to decrease risk of contralateral breast cancer
    • Consider genomic assay assistance to aid in radiation decisions in select patients:
      • Postmenopausal patients with otherwise low-risk disease
#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #Doctor # Surgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico BreastCancer #BreastCancerAwareness
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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