0360.3016/9l $3.00 + .oo C‘opynght c 1991 Pergamon Press plc
l Correspondence
TO BOOST
OR NOT TO BOOST:
AYE, THERE’S
THE
RUB!
Pezner. R. D.: Lipsett, J. A.: Desai. K.; Vera, N.: T&z. J.; Hill. L. R.; Luk, K. H. To boost or not to boost: decreasing radiation therapy in conservative breast cancer treatment when “inked” tumor resection margins are pathologically free of cancer. Int. J. Radiat. Oncol. Biol. Phys. 14: 873-877: 1988. Pezner, R. D.; Terz, J.; Ben-Ezra, J.: Hill, L. R. Now there are two effective conservation approaches for patients with Stage I and II breast cancer: how pathological assessment of inked resection margins can provide valuable information for the radiation oncologist. Am. J. Clin. Oncol. 13: 175-179; 1990. Recht, A.; Harris, J. R. To boost or not to boost. and how to do it. Int. J. Radiat. Oncol. Biol. Phys. 20: 177-178; 1991. Solin, L. J.; Fowble, B. L.; Schultz. D. J.: Goodman. R. L. The significance of pathologic margins of tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 19 (Suppl. I ): 130: 1990. (Abstr.)
To r/w Ed~ror. A recent editorial in this Journal discussed whether “to boost or not to boost” the tumor bed with additional radiation therapy (RT) following whole breast RT in patients undergoing conservation breast cancer treatment (4). Actually. the origin of this catchy phrase dates back to 1988, when our original contribution raised this issue (2). Our results suggested that patients who undergo tumor resection with pathologically clear “inked” specimen margins and receive 5000 cCiy whole breast RT without a local boost have local control rates equivalent to other conservation treatment approaches. A recent update continues to support the efficacy of this approach (3). Drs. Recht and Harris suggest that the data from the NSABP B-06 trial cannot be used to address the “boost” issue since “wedge” tissue compensators were not required for the opposed tangential RT fields (I). This raises the possibility that some patients on the protocol who did not have wedges might have received more than 5000 cGy to the tumor site. While this is indeed true, it is unlikely that many B-06 patients received 6000-6500 cGy, the total tumor bed dose recommended by Drs. Recht and Harris. In the City of Hope series, wedges tissue compensators were used in 99%’ of patients, whether or not a local boost was administered.
RKHARI) D. PEZNER, M.D. KENNETH H. LUK, M.D. JAMESA. LIPSETT,M.D.
Division of Radiation Oncology City of Hope National Medical Center Duarte. C.4 9 IO IO
Which patients, then, should receive a local RT boost? If specimen margins are either unevaluated or found involved by tumor, treatment options include total mastectomy. re-excision of the tumor bed to achieve clear margins, or delivery of a course of RT which includes a local boost. In NSABP B-06, approximately IO% of patients had margins involved by tumor (I). The protocol did not allow a choice; all patients with positive margins underwent mastectomy. In clinical practice, any of the above options may be appropriate. The choice will depend upon clinical, pathological. cosmetic, and patient preference factors.
RESPONSE
TO PEZNER
ET AL.
To I/IE&or: We agree with Drs. Pezner r/ u/. that dogmatic positions on the value of the boost to breast-conserving therapy are best avoided. However, we do not believe it has yet been established that pathologic assessment of resection margins is the best or only factor to consider in deciding whether or not to use a boost. The extent of breast resection and the histologic features ofthe tumor are likely to be important factors in assessing the clinical implications of margin involvement and hence the advisability of using a boost. One reason for our caution regarding the use of margins is that the definition of “involved margins” has not been agreed upon. This term can imply that cancer is seen either directly at an inked surface or within some arbitrary distance from an inked margin. Such a definition is obviously influenced by the number of sections assessed, as well as the orientation of those sections to the tumor and duct system. At present these parameters are not standardized, and therefore the experience of one institution may not predict the results that can be achieved at another. (Indeed. in our experience these parameters often vary from patient to patient even at one institution over time.) Further, the distinction between “focal” and more extensive involvement of the margins may be more important clinically than the exact distance of tumor from the ink. Thus, we believe that specimen margins must be considered in relationship to the pathologic features of the primary tumor and the extent of surgery, rather than as an isolated factor, in selection of patients and treatment techniques. We would also like to point out that there is no clear correlation between the status of the resection margins and clinical outcome, with retrospective series showing contradictory results. We agree that it is unlikely that the boost is of major importance in patients having a reexcision in which no tumor is found. However. we have found that a boost of moderate size and dose does not produce significant cosmetic deformities or complications. Therefore. we prefer to use a boost routinely (perhaps with the exception of the above-noted group) until further experience is available.
Is it desirable to avoid a local RT boost following whole breast RT? We strongly support the guidelines offered by Drs. Recht and Harris as a basis for performing local RT boosts, when local boosts are indicated. If, however, the local boost must encompass a large volume or deliver a high dose, significant fibrosis. retraction. and telangiectasia will frequently result. This may negate one of the major goals of conservation breast cancer treatment, which is to achieve a good cosmetic result. It must be emphasized that we recommend deletion of the local RT boost only if specimen margins are inked and shown to be free of cancer or if a tumor re-excision specimen shows no residual tumor. Should the pathologist routinelv ink specimen margins and perform the involved process of microscopic evaluation of numerous additional slides? Certainly it is becoming an increasingly common practice. This evaluation is performed at the hundreds of institutions that participate in NSABP trials. It is also commonly performed at other major institutions such as the Institut Gustave Roussy (personal communication. D. Sarrazin, 1987) and the University of Pennsylvania/Fox Chase Cancer Center (5). In summary. the issue is not whether “to boost or not to boost.” The question is: under what circumstances can the local RT boost be safely omitted without compromise to tumor control? We have found that pathological evaluation of “inked” specimen margins provides extremely valuable information to aid the radiation oncologist in making this clinical decision. 1. Fisher, B.; Redmond, C.; Poisson, R.; Margolese, R.; Wolmark, N.: Wickerham. L.: Fisher. E.: Deutsch. M.: CapIan. R.: Pilch, Y.; Glass. A.: Shibata, H.; Lemer, H.; Terz, J.; Sidoroiich, L. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. New Engl. J. Med. 320: 822-828: 1989.
ABRAM RECHr. M.D. JAY R. HARRIS, M.D.
Joint Center for Radiation 50 Binney St. Boston, MA 02 I I5
529
Therapy
Correspondence
530 CALCIFECI’OMY
To [he Edilor: I read the article by Solin PI al. (1) in the October issue of the journal on lntraductal Breast Cancer. I would like to point out that the name of the procedure for excision of microcalcifications is “Calcifectomy” (2, 3). This term applies especially when there is no lump and calcifications are the only evidence of disease. The word is easy to pronounce especially for lay people. It is an accurate description of a breast-conserving procedure which will be widely used. M. R. SHETTY, M.D. Medical Oncology
Northwest Community Hospital 800 West Central Road Arlington Heights. IL 60005-2392
I
Solin. L. J.; Fowble, B. L.; Schultz, D. J.; Yeh, 1. T.; et al. Definitive irradiation for intraductal carcinoma of the breast. Int. J. Radiat. One. Biol. Phys. 19843-850; 1990. 2. Shetty. M. R. Surgical pros and cons. Surg. Gynecol. Obstet. 170: 65: 1990. 3. Shetty, M. R. Calcifectomy for ductal carcinoma in siczr. Br. J. Surg. Vol. 76: I 102: 1989.
l Correspondence
TO BOOST
OR NOT TO BOOST:
AYE, THERE’S
THE
RUB!
Pezner. R. D.: Lipsett, J. A.: Desai. K.; Vera, N.: T&z. J.; Hill. L. R.; Luk, K. H. To boost or not to boost: decreasing radiation therapy in conservative breast cancer treatment when “inked” tumor resection margins are pathologically free of cancer. Int. J. Radiat. Oncol. Biol. Phys. 14: 873-877: 1988. Pezner, R. D.; Terz, J.; Ben-Ezra, J.: Hill, L. R. Now there are two effective conservation approaches for patients with Stage I and II breast cancer: how pathological assessment of inked resection margins can provide valuable information for the radiation oncologist. Am. J. Clin. Oncol. 13: 175-179; 1990. Recht, A.; Harris, J. R. To boost or not to boost. and how to do it. Int. J. Radiat. Oncol. Biol. Phys. 20: 177-178; 1991. Solin, L. J.; Fowble, B. L.; Schultz. D. J.: Goodman. R. L. The significance of pathologic margins of tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer. Int. J. Radiat. Oncol. Biol. Phys. 19 (Suppl. I ): 130: 1990. (Abstr.)
To r/w Ed~ror. A recent editorial in this Journal discussed whether “to boost or not to boost” the tumor bed with additional radiation therapy (RT) following whole breast RT in patients undergoing conservation breast cancer treatment (4). Actually. the origin of this catchy phrase dates back to 1988, when our original contribution raised this issue (2). Our results suggested that patients who undergo tumor resection with pathologically clear “inked” specimen margins and receive 5000 cCiy whole breast RT without a local boost have local control rates equivalent to other conservation treatment approaches. A recent update continues to support the efficacy of this approach (3). Drs. Recht and Harris suggest that the data from the NSABP B-06 trial cannot be used to address the “boost” issue since “wedge” tissue compensators were not required for the opposed tangential RT fields (I). This raises the possibility that some patients on the protocol who did not have wedges might have received more than 5000 cGy to the tumor site. While this is indeed true, it is unlikely that many B-06 patients received 6000-6500 cGy, the total tumor bed dose recommended by Drs. Recht and Harris. In the City of Hope series, wedges tissue compensators were used in 99%’ of patients, whether or not a local boost was administered.
RKHARI) D. PEZNER, M.D. KENNETH H. LUK, M.D. JAMESA. LIPSETT,M.D.
Division of Radiation Oncology City of Hope National Medical Center Duarte. C.4 9 IO IO
Which patients, then, should receive a local RT boost? If specimen margins are either unevaluated or found involved by tumor, treatment options include total mastectomy. re-excision of the tumor bed to achieve clear margins, or delivery of a course of RT which includes a local boost. In NSABP B-06, approximately IO% of patients had margins involved by tumor (I). The protocol did not allow a choice; all patients with positive margins underwent mastectomy. In clinical practice, any of the above options may be appropriate. The choice will depend upon clinical, pathological. cosmetic, and patient preference factors.
RESPONSE
TO PEZNER
ET AL.
To I/IE&or: We agree with Drs. Pezner r/ u/. that dogmatic positions on the value of the boost to breast-conserving therapy are best avoided. However, we do not believe it has yet been established that pathologic assessment of resection margins is the best or only factor to consider in deciding whether or not to use a boost. The extent of breast resection and the histologic features ofthe tumor are likely to be important factors in assessing the clinical implications of margin involvement and hence the advisability of using a boost. One reason for our caution regarding the use of margins is that the definition of “involved margins” has not been agreed upon. This term can imply that cancer is seen either directly at an inked surface or within some arbitrary distance from an inked margin. Such a definition is obviously influenced by the number of sections assessed, as well as the orientation of those sections to the tumor and duct system. At present these parameters are not standardized, and therefore the experience of one institution may not predict the results that can be achieved at another. (Indeed. in our experience these parameters often vary from patient to patient even at one institution over time.) Further, the distinction between “focal” and more extensive involvement of the margins may be more important clinically than the exact distance of tumor from the ink. Thus, we believe that specimen margins must be considered in relationship to the pathologic features of the primary tumor and the extent of surgery, rather than as an isolated factor, in selection of patients and treatment techniques. We would also like to point out that there is no clear correlation between the status of the resection margins and clinical outcome, with retrospective series showing contradictory results. We agree that it is unlikely that the boost is of major importance in patients having a reexcision in which no tumor is found. However. we have found that a boost of moderate size and dose does not produce significant cosmetic deformities or complications. Therefore. we prefer to use a boost routinely (perhaps with the exception of the above-noted group) until further experience is available.
Is it desirable to avoid a local RT boost following whole breast RT? We strongly support the guidelines offered by Drs. Recht and Harris as a basis for performing local RT boosts, when local boosts are indicated. If, however, the local boost must encompass a large volume or deliver a high dose, significant fibrosis. retraction. and telangiectasia will frequently result. This may negate one of the major goals of conservation breast cancer treatment, which is to achieve a good cosmetic result. It must be emphasized that we recommend deletion of the local RT boost only if specimen margins are inked and shown to be free of cancer or if a tumor re-excision specimen shows no residual tumor. Should the pathologist routinelv ink specimen margins and perform the involved process of microscopic evaluation of numerous additional slides? Certainly it is becoming an increasingly common practice. This evaluation is performed at the hundreds of institutions that participate in NSABP trials. It is also commonly performed at other major institutions such as the Institut Gustave Roussy (personal communication. D. Sarrazin, 1987) and the University of Pennsylvania/Fox Chase Cancer Center (5). In summary. the issue is not whether “to boost or not to boost.” The question is: under what circumstances can the local RT boost be safely omitted without compromise to tumor control? We have found that pathological evaluation of “inked” specimen margins provides extremely valuable information to aid the radiation oncologist in making this clinical decision. 1. Fisher, B.; Redmond, C.; Poisson, R.; Margolese, R.; Wolmark, N.: Wickerham. L.: Fisher. E.: Deutsch. M.: CapIan. R.: Pilch, Y.; Glass. A.: Shibata, H.; Lemer, H.; Terz, J.; Sidoroiich, L. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. New Engl. J. Med. 320: 822-828: 1989.
ABRAM RECHr. M.D. JAY R. HARRIS, M.D.
Joint Center for Radiation 50 Binney St. Boston, MA 02 I I5
529
Therapy
Correspondence
530 CALCIFECI’OMY
To [he Edilor: I read the article by Solin PI al. (1) in the October issue of the journal on lntraductal Breast Cancer. I would like to point out that the name of the procedure for excision of microcalcifications is “Calcifectomy” (2, 3). This term applies especially when there is no lump and calcifications are the only evidence of disease. The word is easy to pronounce especially for lay people. It is an accurate description of a breast-conserving procedure which will be widely used. M. R. SHETTY, M.D. Medical Oncology
Northwest Community Hospital 800 West Central Road Arlington Heights. IL 60005-2392
I
Solin. L. J.; Fowble, B. L.; Schultz, D. J.; Yeh, 1. T.; et al. Definitive irradiation for intraductal carcinoma of the breast. Int. J. Radiat. One. Biol. Phys. 19843-850; 1990. 2. Shetty. M. R. Surgical pros and cons. Surg. Gynecol. Obstet. 170: 65: 1990. 3. Shetty, M. R. Calcifectomy for ductal carcinoma in siczr. Br. J. Surg. Vol. 76: I 102: 1989.
