Citations

Background. Previous reports have shown a positive association between serum calcium level and prostate cancer mortality. However, there is no data regarding whether higher serum calcium levels are associated with increased risk of biochemical recurrence (BCR) following salvage radiation therapy (SRT) for prostate cancer. Herein, we evaluate the association between pretreatment serum calcium levels and BCR in a cohort of men who underwent SRT. Methods. We evaluated 165 patients who underwent SRT at our institution. Median dose was 65.0 Gy (range: 54.0–72.4 Gy). We considered serum calcium as both a continuous variable and a 3-level categorical variable (low [≤9.0 mg/dL], moderate [>9.0 mg/dL and ≤9.35 mg/dL], and high [>9.35 mg/dL]) based on sample tertiles. Results. We observed no evidence of a linear association between serum calcium and BCR (relative risk (RR): 0.96, P=0.76). Compared to men with low calcium, there was no significantly increased risk of BCR for men with moderate (RR: 0.94, P=0.79) or high (RR: 1.08, P=0.76) serum calcium levels. Adjustment for clinical, pathological, and SRT characteristics in multivariable analyses did not alter these findings. Conclusion. Our results provide evidence that pretreatment serum calcium is unlikely to be a useful tool in predicting BCR risk following SRT.

Ductal carcinoma in situ (DCIS) of the breast represents a complex, heterogeneous pathologic condition in which malignant epithelial cells are confined within the ducts of the breast without evidence of invasion. The increased use of screening mammography has led to a significant shift in the diagnosis of DCIS, accounting for approximately 27% of all newly diagnosed cases of breast cancer in 2011, with an overall increase in incidence. As the incidence of DCIS increases, the treatment options continue to evolve. Consistent pathologic evaluation is crucial in optimizing treatment recommendations. Surgical treatment options include breast-conserving surgery (BCS) and mastectomy. Postoperative radiation therapy in combination with breast-conserving surgery is considered the standard of care with demonstrated decrease in local recurrence with the addition of radiation therapy. The role of endocrine therapy is currently being evaluated. The optimization of diagnostic imaging, treatment with regard to pathological risk assessment, and the role of partial breast irradiation continue to evolve.

Purpose. Women with ductal carcinomain situ(DCIS) are often candidates for breast-conserving therapy, and one option for radiation treatment is partial breast irradiation (PBI). This study evaluates the use of preoperative breast magnetic resonance imaging (MRI) for PBI selection in DCIS patients.Methods. Between 2002 and 2009, 136 women with newly diagnosed DCIS underwent a preoperative bilateral breast MRI at Mayo Clinic in Florida. One hundred seventeen women were deemed eligible for PBI by the NSABP B-39 (National Surgical Adjuvant Breast and Bowel Project, Protocol B-39) inclusion criteria using physical examination, mammogram, and/or ultrasound. MRIs were reviewed for their impact on patient eligibility, and findings were pathologically confirmed.Results. Of the 117 patients, 23 (20%) were found ineligible because of pathologically proven MRI findings. MRI detected additional ipsilateral breast cancer in 21 (18%) patients. Of these women, 15 (13%) had more extensive disease than originally noted before MRI, and 6 (5%) had multicentric disease in the ipsilateral breast. In addition, contralateral breast cancer was detected in 4 (4%).Conclusions. Preoperative breast MRI altered the PBI recommendations for 20% of women. Bilateral breast MRI should be an integral part of the preoperative evaluation of all patients with DCIS being considered for PBI.

The role of radiotherapy for local control of marginally resected, unresectable, and recurrent giant cell tumors of bone (GCToB) has not been well defined. The number of patients affected by this rare disease is low. We present a series of 58 patients with biopsy proven GCToB who were treated with radiation therapy. A retrospective review of the role of radiotherapy in the treatment of GCToB was conducted in participating institutions of the Rare Cancer Network. Eligibility criteria consisted of the use of radiotherapy for marginally resected, unresectable, and recurrent GCToB. Fifty-eight patients with biopsy proven GCToB were analyzed from 9 participating North American and European institutions. Forty-five patients had a primary tumor and 13 patients had a recurrent tumor. Median radiation dose was 50 Gy in a median of 25 fractions. Indication for radiation therapy was marginal resection in 33 patients, unresectable tumor in 13 patients, recurrence in 9 patients and palliation in 2 patients. Median tumor size was 7.0 cm. A significant proportion of the tumors involved critical structures. Median follow-up was 8.0 years. Five year local control was 85%. Of the 7 local failures, 3 were treated successfully with salvage surgery. All patients who received palliation achieved symptom relief. Five year overall survival was 94%. None of the patients experienced grade 3 or higher acute toxicity. This study reports a large published experience in the treatment of GCToB with radiotherapy. Radiotherapy can provide excellent local control for incompletely resected, unresectable or recurrent GCToB with acceptable morbidity.

Abstract Abstract #4020 Background: HER2 positive (HER2+) breast cancer accounts for 20% of all breast cancer and is an independent adverse prognostic factor. Breast magnetic resonance imaging (MRI) has been shown to identify additional mammographically occult ipsilateral (I/L) and contralateral (C/L) disease, however indications for preoperative MRI in patients with newly diagnosed breast cancer are not standardized. While invasive lobular cancer, younger patient age, and increased breast density have been suggested as routine indications, the role of preoperative MRI according to HER2 status has not been evaluated.
 Methods: All patients with invasive breast cancer who underwent preoperative MRI between January 2003 and December 2007 were reviewed. Retrospective chart review was performed to collect clinical, radiographic, and pathologic data. The incidence of additional I/L or C/L malignacy was calculated. Additionally, changes in surgical management because of MRI findings were recorded.
 Results: Of the 401 women with invasive breast cancer undergoing preoperative breast MRI, 51 (13%) had HER2+ tumors. The average age at the time of MRI was similar in both groups. HER2+ patients were more likely to have nodal disease, and tumors with higher rates of lymphovascular invasion or extensive intraductal components.
 
 When compared to HER2- patients, more HER2+ patients had additional ipsilateral MRI abnormalities. A second ipsilateral cancer was found in 31% of HER2+ patients compared to 25% of HER2- patients. When analyzed according to ER status, HER2+/ ER- patients were more likely to have an additional site of cancer compared to HER2+/ER+ patients (42% vs 23%). Conversely, among HER2- patients, rates of additional ipsilateral cancer were similar for HER2-/ER+ (26%) and HERr2-/ER- (23%) patients. Of the 216 patients (HER2+ and HER2-) with additional ipsilateral MRI findings (benign or malignant), 125/216 (58%) patients were deemed appropriate breast conservation (BCT) candidates after MRI. However, BCT was only chosen in 84/125 (67%) patients. Additional contralateral disease was documented in 8% of HER2+ versus 5% of HER2- patients.
 Conclusions: HER2 positivity remains and important prognostic factor for women with breast cancer. Indications for routine preoperative MRI are unclear. In patients with newly diagnosed Her2+ invasive breast cancer routine preoperative MRI may be valuable in the subset of patients who are also ER-. Further study is needed to determine the influence of MRI on patient decisions for surgical therapy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4020.

Abstract Abstract #4018 Background: Preoperative breast magnetic resonance imaging (MRI) has been shown to identify occult breast disease in women with newly diagnosed breast cancer. We sought to determine the accuracy of MRI in predicting the actual pathologic tumor size in women with newly diagnosed breast cancer.
 Methods: Preoperative breast MRI was reviewed in 460 women with newly diagnosed breast cancer. The size in terms of maximum tumor dimension, of 476 incident breast cancers on MRI were recorded and correlated with the actual pathologic size upon surgical resection. The correlation of size from MRI to pathology was determined. The size discrepancy was analyzed in relation to tumor size and histology.
 Results: MRI demonstrated 476 breast cancers (460 in the ipsilateral breast and 16 with concurrent contralateral breast cancer). Median age was 62 with a range of 25 to 91. The T stages of the population included T0 in 19% of the women, 60% had T1 lesions, 18% had T2 lesions and 3% were T3 or T4. The histology consisted of DCIS alone in 20%, infiltrating ductal in 74% and infiltrating lobular in 6%. Pre-operative MRI was unable to define an enhancing lesion usually due to hematoma following core needle biopsy in 9.8% (47/476). MRI described the size of the incident lesion in 90% (429/476). The mean difference in size between the preoperative MRI and the actual pathologic size for the entire group was 2.4 mm. MRI underestimated tumor size in only 3% of cases. The mean difference according to T stage and histology between MRI and actual pathologic size is listed in Table 1. The percentage of difference between MRI size and pathologic size for the entire group is presented in Table 2.
 
 
 
 Discussion: The mean difference in tumor size estimated by preoperative MRI in women with newly diagnosed breast cancer was within 5 mm of the actual pathologic size in 68% of patients. MRI was accurate in predicting T stage with no significant difference in relation to histology or T stage. This analysis further clarifies the role of preoperative MRI in surgical and treatment planning. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4018.

Abstract Abstract #4014 Background
 Preoperative magnetic resonance imaging (MRI) of the breasts in women with breast cancer (BC) has improved the detection of occult ipsilateral (I/L) and contralateral (C/L) malignancies. Breast MRI findings in patients with estrogen receptor (ER), progesterone receptor (PR), and HER2 negative (triple negative (TN)) disease have not been previously reported. Women with TN BC are at increased risk of distant metastases and a reduced survival vs. BC patients as a whole. One potential explanation may be the presence of occult disease. The role of bilateral breast MRI in these patients remains to be determined.
 Hypothesis
 Patients with TN BC are more likely to have occult malignancy identified by preoperative MRI vs. those with non-TN BC.
 Methods
 All newly diagnosed BC patients from 2003-2007 were reviewed. Information on age, race, histology, ER, PR, HER2, staging, treatment, MRI findings, subsequent investigations, and additional cancer diagnoses was recorded. The incidence of additional I/L or C/L malignany was calculated. The percentage of total patients initially felt to be candidates for partial breast irradiation who required a change in their cancer management was calculated.
 Results
 55 (11%) were diagnosed with TN BC, of whom 52 women completed preoperative MRI. 456 (89%) had non-TN BC; 421 completed preoperative MRI. The median age among TN and non-TN patients was 62 years (Table 1). A majority of women in both groups were Caucasian. African-American women were more likely to be diagnosed with TN vs. non-TN disease (11% vs. 6%).
 
 I/L BC was documented in 13/52 (25%) of TN patients vs. 25% of non-TN patients. No C/L cancers were detected in the TN group (6% in the non-TN group). Of the TN group, 15 patients required a change in their treatment (29%) based on findings from MRI vs. 32% of non-TN patients.
 Conclusions
 Patients with a new diagnosis of TN BC are not at increased risk of occult malignancy than those with non-TN BC. 25% of patients with TN BC had additional I/L disease not previously detected on clinical examination, mammogram, or ultrasound. Of those with non-TN BC, 25% were diagnosed with an additional I/L and 6% with C/L malignancy. The benefit of MRI was limited by false positives, with a number of patients in both groups undergoing a benign biopsy.
 These results suggest that patients with TN BC are not more likely than those with non-TN disease to have additional occult I/L or C/L cancer. The incidence of additional disease remains high and preoperative MRI may be beneficial. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4014.

To compare the radiation dose to normal cardiac tissue for 3Dimensional (3D) conformal external beam partial breast irradiation (PBI) and standard whole breast irradiation (WBI), and examine the effect of tumor bed location.For 14 patients with left breast tumors randomized on the National Surgical Adjuvant Breast and Bowel Project B‐39 protocol, computer‐generated radiotherapy treatment plans were devised for WBI and PBI. Tumor bed location was designated according to whether more than 50% of the excision cavity was medial or lateral to the nipple line. The volume of heart receiving doses of 2.5, 5, 10, and 20 Gy was calculated for all PBI and WBI plans. Dose to 5% of the heart volume (D5) and mean heart dose were also calculated. The biologically‐equivalent dose (BED) was calculated to account for the different fractionation used in PBI and WBI.Of the 14 patients, 8 had lateral tumor beds, and 6 had medial tumor beds. The volumes of heart receiving 2.5, 5, 10, and 20 Gy were significantly lower for lateral PBI compared with WBI. For medial PBI, significant cardiac sparing was only seen at a dose of 20 Gy. The difference of D5 values was significant for lateral PBI compared with WBI , but not for medial PBI compared with WBI . The mean dose was also significantly lower for lateral PBI compared with WBI , but not for medial PBI . The results from BED calculations did not change this outcome.Both 3D conformal PBI and standard WBI can deliver relatively low doses to the heart. For patients with lateralized tumor beds, PBI offers significant cardiac sparing compared with WBI. Patients with medial lesions have relatively similar heart dosimetry with PBI and WBI. 3D conformal PBI is an emerging treatment modality and continued participation on clinical trials is encouraged. Patients with left‐sided lesions and lateralized tumor beds warrant special consideration for PBI, given the significant cardiac dose sparing.PACS numbers: 87.53.Tf