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Adjuvant Partial Breast Irradiation for Lower Risk, Early-Stage Breast Cancer
Partial breast irradiation (PBI) refers to the use of limited, focused radiation as a more convenient alternative to conventional whole breast radiation therapy (WBRT) after breast-conserving surgery for early-stage breast cancer. In a randomized trial, over 2000 women ≥50 years of age who had undergone breast-conserving surgery for lower risk, early-stage breast cancer were randomly assigned to 40 Gy WBRT (control); 36 Gy WBRT and 40 Gy PBI (reduced-dose group); or 40 Gy PBI (partial-breast group). Five-year local relapse rates were similar for all groups. For women who are ≥50 years of age with hormone receptor-positive, node-negative tumors ≤3 cm, PBI is a reasonable alternative to WBRT.
Whole-Body MRI in Li Fraumeni Syndrome
The high risk of new malignancies in individuals with Li Fraumeni syndrome (LFS) has led to the evaluation of whole-body MRI (WB-MRI) as a surveillance tool. A meta-analysis of the multicenter experience with this modality found that WB-MRI identified previously undiagnosed malignancies in 7 percent of individuals, most of whom were amenable to definitive treatment. However, 30 percent of individuals had a false-positive result that required further evaluation. Longitudinal studies are required to further define the role of WB-MRI in LFS.
Optimal Timing of Reoperation for Gallbladder Cancer Incidentally Found at Cholecystectomy
When gallbladder cancer is diagnosed incidentally after cholecystectomy, most patients require a second operation to remove residual disease. In a retrospective analysis of the optimal timing of reoperation by the US Extrahepatic Biliary Malignancy Consortium, reoperation four to eight weeks after the initial cholecystectomy was associated with improved overall survival compared with earlier or later reoperation. This finding requires prospective validation before we would routinely recommend scheduling reoperation four to eight weeks after initial surgery. In practice, timing reoperation may also be influenced by nonclinical factors, such as access to a qualified surgeon or center.
Adjuvant Chemoradiation for High-Risk Resected Endometrial Cancer
Optimal adjuvant management of high-risk resected endometrial cancer remains unclear. In the phase III GOG-258 trial, over 700 patients with high-risk resected endometrial cancer were randomly assigned to adjuvant chemoradiation versus chemotherapy alone. Although there was no difference in relapse-free survival between the groups, there were fewer lower vaginal, lower pelvic, and paraortic recurrences with the addition of radiation. Rates of severe toxicities were similar between the arms. Given these data, we offer adjuvant chemoradiation to those with resected endometrial cancer with risk factors for local relapse (eg, extensive lymph node involvement or deep invasion).
Hyperfractionation for Definitive Radiation Therapy of Head and Neck Cancer
Standard radiation therapy (RT) for definitive treatment of head and neck cancer is administered as a single daily dose, five days per week for seven weeks, but alternative schedules may improve outcomes in selected settings. In the MARCH meta-analysis, hyperfractionation without concurrent chemotherapy improved overall survival at 5 and 10 years, compared with once-a-day treatment. However, hyperfractionation has not been shown to improve survival in conjunction with concurrent chemotherapy. The relative benefits of hyperfractionation when given without concurrent chemotherapy need to be balanced against the increased cost and inconvenience associated with this approach.
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