The use of adjuvant high-dose-rate breast brachytherapy in patients with collagen vascular disease: a collaborative experience.

PURPOSE: To analyze toxicity and cosmesis in patients with collagen vascular disease (CVD) treated with accelerated partial breast irradiation (APBI) via high-dose-rate (HDR) brachytherapy. METHODS AND MATERIALS: This is a pooled analysis of patients with early stage and in situ breast cancer with CVD treated with adjuvant multicatheter or balloon brachytherapy. Physicians at multiple institutions were asked to review their experience and report data regarding toxicity and cosmesis in patients with CVD. All patients fit American Society of Breast Surgeons recommendations for APBI and were treated with HDR brachytherapy with ≥ 3 months followup. RESULTS: Nine cases from five institutions are the subject of this analysis. The median patient age was 54 years and median followup was 31 months. All patients had documented history and active signs/symptoms of rheumatoid arthritis, systemic lupus erythematosis, psoriatic arthritis, or scleroderma. All patients had received medical therapy for CVD in the past, and 78% were under active treatment at the time of brachytherapy. All the patients were treated with multicatheter or balloon (MammoSite [Hologic, Inc., Marlboro, MA], MammoSite ML [Hologic, Inc., Marlboro, MA], or Contura [Senorx, Irvine, CA]) brachytherapy with a median volume of 45.5 cc and a median skin distance of 7.5mm. Acute toxicity included Grade 1 skin erythema (5) and catheter-site wound dehiscence (1). Late toxicity included seroma (5), induration (5), pain (2), telangectasia (2), and superficial infection (1). Cosmesis was excellent or good for all the patients. CONCLUSIONS: Women with CVD have a toxicity and cosmesis profile consistent with other APBI series. Although confirmatory data is needed, it may not be necessary to exclude these patients from clinical trials of APBI.

Casting-type calcifications with invasion and high-grade ductal carcinoma in situ: a more aggressive disease?

HYPOTHESIS: Women with breast cancer who have casting-type microcalcifications associated with multifocal invasion and extensive ductal carcinoma in situ (DCIS) form a subset of patients with a poor prognosis. Our study aims to identify the mammographic and pathologic features of this group. DESIGN: Women with casting-type microcalcifications, multifocal invasion, and extensive DCIS were identified from our tumor board registry. Mammographic features, tumor characteristics, treatment, and survival rates were evaluated. Invasive tumors were limited to 14 mm or smaller. SETTING: University medical teaching hospital and breast cancer specialty clinic. RESULTS: Of the 984 patients with breast cancer treated at our center, 15 patients were identified who had extensive casting-type calcifications and DCIS. Twelve of these patients also had multifocal invasive breast cancer. All had casting-type microcalcifications occupying more than 1 breast quadrant. All but 1 of the patients were treated using mastectomy with sentinel node biopsy or axillary node dissection. All but 1 patient had extensive grade 3 DCIS. Invasive tumors were negative for estrogen receptor and progesterone receptor expression in half of the patients, and 60% were positive for the HER-2-neu receptor. Positive axillary lymph nodes were found in 33% of patients, and 75% received adjuvant chemotherapy. After a median follow-up period of 20.5 months (range, 6-72 months), 1 patient had died and 1 had distant metastases. Of the 3 patients who had DCIS without invasion, 1 experienced a recurrence with infiltrating ductal carcinoma. CONCLUSIONS: In women with small multifocal breast cancers with extensive casting calcifications and DCIS, the incidence of positive lymph nodes was 33%, with a tendency for poor tumor markers. These women appear to be at substantial risk for systemic disease; lymph node sampling and adjuvant systemic therapy are recommended.