Intraoperative Radiation Therapy for Breast Cancer has the Highest Risk of Local Recurrence of all the Partial Breast Irradiation

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Standard whole breast irradiation (WBI):
    • Historically represented the gold standard technique and was utilized in all randomized trials comparing mastectomy and breast conservation surgery
    • It is traditionally delivered over 5 to 6½ weeks and may incorporate a boost to the tumor bed
  • More recently, hypofractionated WBI has been evaluated in several randomized trials:
    • Whelan et al. compared 50 Gy in 25 fractions to 42.5 Gy in 16 fractions:
      • Eligibility criteria included patients with T1, T2, N0 disease and negative margins
      • At 10 years, no difference in the rate of local control was noted with comparable cosmetic and toxicity profile’s
  • Similarly, the UK Standardisation of Breast Radiotherapy (START) A and B trials:
    • Compared hypofractionated WBI with standard fractionation WBI:
      • With no difference in local recurrence and a suggestion for improved cosmetic outcomes in the hypofractionated regimens
  • With the most recent update to the National Comprehensive Cancer Network guidelines and American Society for Radiation Oncology (ASTRO) guidelines:
    • Both WBI and hypofractionation are considered standard regimens, with hypofractionation preferred in appropriate patients
  • Accelerated partial breast irradiation:
    • Includes interstitial, applicator, and external beam techniques
    • Randomized data from the Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO), which used interstitial brachytherapy:
      • Have demonstrated no difference in the rates of local control at 5 and 10 years, respectively, compared with standard fractionation WBI, with no difference in toxicity or cosmetic outcomes
    • Intraoperative radiation therapy:
      • Although a form of partial breast irradiation, is not the same as APBI:
        • Data from APBI should not be utilized to validate the use of IORT off-protocol
      • The targeted intraoperative radiotherapy (TARGIT) study was a non-inferiority study that included 3,451 patients who were randomized to IORT (50 Kvp x-rays) or standard fractionation WBI
        • Remedial WBI was given to 15% to 20% of the IORT cohort
        • Despite follow-up of only 29 months, 5-year outcomes have been reported and demonstrate higher rates of local recurrence with IORT (3.3% vs. 1.3%)
    • The intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT):
      • Study utilized intraoperative electrons, enrolling 1,305 patients with tumors < 2.5 cm
      • No remedial WBI was given
      • At 5 years, IORT was associated with an increase in local recurrence rates (4.4% vs. 0.4%).5
    • ASTRO IORT guidelines state that the electron beam IORT should be restricted to women with invasive disease considered suitable to partial breast irradiation (PBI) (age > 50 years, margins > 2 mm, T1)
    • Low energy X-ray IORT should be used within the context of a prospective registry or clinical trial:
      • When used, it should be restricted to suitable PBI patients
  • References
    • Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362(6):513-520.
    • Haviland JS, Owen JR, Dewar JA, et al; START Trialists’ Group. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early stage breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14(11):1086-1094.
    • Strnad V, Ott OJ, Hildebrandt G, et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 2016;387(10015):229-238.
      • Vaidya JS, Wenz F, Bulsara M, et al; TARGIT Trialists’ Group. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014;383(9917):603-613
      • Veronesi U, Orecchia R, Maisonneuve P, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013;14(13):1269-1277.
      • Correa C, Harris EE, Leonardi MC, et al. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73-79.
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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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