**Radiotherapy After Surgery for Small Breast Cancers of Stellate Appearance**

Laszlo Tabar1, Nadja Lindhe1, Amy M.F. Yen2, Tony H.H. Chen2,3, Sherry Y.H. Chiu3, Jean C.Y. Fann2, Sam L.S. Chen4, Grace H.M. Wu2, Rex C.C. Huang2, Judith Offman5, Fiona A. Dungey6, Wendy Y.Y. Wu2, Robert A. Smith7 and Stephen W. Duffy5\*

#### **1. Introduction**

216 Imaging of the Breast – Technical Aspects and Clinical Implication

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utility of breast MRI as a problem-solving tool. *Breast Journal,* Vol. 17, No. 3, (May-June 2011), pp. 273-280. ISSN: 1075-122X (Print), 1524-4741 (Electronic), 1075-122X Radiotherapy is widely used in breast cancer treatment, particularly in patients undergoing breast conserving surgery, principally in order to reduce risk of local recurrence (Liljegren et al. 1999; Fisher et al. 2002). Although radiation therapy has been observed in a major metaanalysis to confer a net survival benefit (Clarke et al. 2005), it is not without side-effects. It has been observed to confer increased risks of cardiovascular events and lung tumours (Clarke et al. 2005; Darby et al. 2005). The fact that radiation therapy confers both benefits and harms raises issues pertinent to all treatments, i.e., the importance of selecting patient populations for which the balance of benefits to harms is optimised, and of excluding those patients who will not benefit from the treatment, or at least not sufficiently to outweigh the risk of adverse effects. Given the current lack of confidence that the prognostic indicators for such selection exist, conservative therapy includes post-surgical radiotherapy as a standard of care.

It has been reported that patients with invasive breast tumours less than 15 mm in size have mammographic tumour features that are good indicators of prognosis, and in particular, good long term survival has been observed in stellate lesions of this size without accompanying calcifications or with only non-specific calcifications (Smith et al. 2004; Tabar et al. 2000). The large majority of these patients did not receive adjuvant therapy other than radiotherapy, and since long-term survival was very high, the potential for modern adjuvant therapies to further improve upon the survival of these cases is very small. However, the extent to which these patients benefited from radiotherapy, in terms of reduction of risk of local recurrence, is not known. In this paper, we review the treatment and tumour features of 425 stellate invasive breast cancers of

<sup>\*</sup>*1 Mammography Department, Central Hospital, Sweden* 

*<sup>2</sup> College of Public Health, National Taiwan University, Taiwan* 

*<sup>3</sup> Tampere School of Public Health, Finland* 

*<sup>4</sup> Changhua Christian Hospital, Taiwan* 

*<sup>5</sup> Centre for Cancer Prevention, Queen Mary, University of London, UK* 

*<sup>6</sup> Cancer Research UK & UCL Cancer Trials Centre, UK* 

*<sup>7</sup> American Cancer Society, USA* 

Radiotherapy After Surgery for Small Breast Cancers of Stellate Appearance 219

factors that were not statistically significant when adjusted for other variables, we used the final Cox regression model to estimate the absolute reductions in 15-year risk of recurrence

Survival in this group was generally excellent. Figure 1 shows survival by size group (1-9 mm and 10-14 mm) and radiotherapy. In all four groups, long-term survival was 90% or

> 0 5 10 15 20 25 30 Time

Fig. 1. Breast cancer specific survival of 425 1-14 mm stellate invasive breast cancers by size

Table 1 shows the study subjects and recurrence rates by tumour, host, diagnostic and treatment features. There were 70 local recurrences in 425 patients. Overall, the average rate of recurrence was 1.6% per annum. Notably high recurrence rates were observed in grade 3 tumours and lobular carcinoma cases. Because 51% of the cases were diagnosed before 1990, the proportions of subjects treated with breast conserving surgery and with hormone therapy were considerably smaller than would be the case in tumours diagnosed at the

No radiation, 1-9 mm Radiation, 1-9 mm No radiation, 10-14 Radiation, 10-14

**5. Recurrence rates in patients with small stellate breast cancers** 

greater. There was no significant effect of radiotherapy on survival.

(only 22% of subjects had follow-up in excess of 15 years).

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

group and radiotherapy.

present time.

Survival

maximum diameter less than 15 mm, with a view to developing an index of risk of local recurrence and possibly of identifying patient populations suitable and unsuitable for radiotherapy. The research was approved by the Ethics Committee of Falun Central Hospital.
