Breast-Conserving Surgery and Radiation Therapy in Patients With Multiple Ipsilateral Breast Cancer

OBJECTIVES:

Primary

- To assess the local recurrence (LR) rate with breast-conservation in patients with
multiple ipsilateral primary breast cancer (MIBC).

Secondary

- To examine the conversion rate to mastectomy secondary to persistent positive margins;
poor cosmesis within the first year of attempting breast-conservation surgery (BCS) or
inability to satisfy the radiation dose constraints on the boost to the lumpectomy bed
of each site of disease.

- To assess whether patients who did not undergo re-excision for close margins (< 2 mm)
have a higher local recurrence (LR) rate than patients for whom negative margins were
achieved.

- To assess patient's perception of cosmesis and incidence of breast lymphedema.

- To assess incidence of breast lymphedema

- To examine the type and severity of adverse effects of breast conserving surgery and
radiation for women with multiple ipsilateral primary breast cancer (MIBC).

- To examine the radiation-related side effects of whole-breast radiation with a boost to
1 large or > 1 lumpectomy site.

OUTLINE: This is a multicenter study.

Patients undergo breast-conserving surgery (BCS) with all lesions resected to negative
margins using 1 lumpectomy or 2-3 separate lumpectomy incisions at the discretion of the
surgeon. Patients receive adjuvant chemotherapy and/or endocrine therapy at the discretion of
the treating medical oncologist based on tumor characteristics.

Registration Inclusion Criteria:

1. Age ≥ 40 years per National Comprehensive Cancer Network (NCCN) recommendations for
breast conservation.

2. Life Expectancy of at least 5 years, excluding diagnosis of breast cancer (Comorbid
conditions should be taken into consideration, but breast cancer diagnosis is not a
consideration)

3. Female Gender - Men are excluded from this study. Male breast cancer is a rare event.

Men are rarely candidates for breast conservation surgery due to small breast size.
Men are less likely to be candidates for breast conservation surgery if found to have
MIBC.

Men are rarely candidates for breast conservation surgery due to small breast size.
Men are less likely to be candidates for breast conservation surgery if found to have
MIBC.

4. Foci of Breast Cancer

4.1 Upon clinical exam and pre-operative imaging by mammogram +/- MRI, two or three
foci of biopsy proven breast cancer separated by > 2 cm of normal breast tissue.

4.2 Foci must include at least one focus of invasive breast carcinoma with another
focus of either invasive breast carcinoma or ductal carcinoma in situ (DCIS).

No more than 2 quadrants with biopsy proven breast cancer.

4.3 Note: The shortest distance between lesions must be reported on mammogram +/- MRI
and eligibility criteria must be met on both, if both are obtained.

4.4 Note: Patient is eligible for study if lesion is not visualized on all imaging
modalities (i.e., any of the lesion(s) is/are visualized on MRI but not on mammogram
OR visualized on mammogram but not on MRI).

4.5 Ultrasound cannot be used to determine patient eligibility; eligibility to be
determined by bilateral mammogram +/- MRI only.

4.6 Fine needle aspirate of the second or third lesion to document malignancy is
allowed if the first focus is shown to be invasive by core needle biopsy.

4.7 Patient may remain on study if, upon pathological assessment, two or three lesions
identified on pre-operative imaging represent one contiguous lesion.

5. Patients may be registered AFTER surgery and PRIOR TO radiation therapy if either of
the criteria is met:

5.1 An area of atypia > 2cm from the index lesion excised at the time of cancer
operation is upgraded to DCIS or invasive carcinoma thereby identifying MIBC. OR

5.2 Patient underwent resection of two or three foci of malignancy by breast
conservation surgery with a minimum of one invasive focus of breast cancer and a
minimum of 2 cm of normal breast tissue between the lesions on final pathology.

6. Mammogram Imaging - Bilateral mammogram ≤ 90 days prior to date of surgery.

6.1 Note: For patients undergoing more than 1 breast operation, this is the date of
the first breast surgery for breast cancer treatment.

7. Staging of Cancer - cN0 or cN1 disease

8. ECOG Performance Status (PS) - 0, 1, or 2.

9. Ability to Complete Questionnaires - Ability to complete questionnaire(s) by
themselves or with assistance

10. Ability to Provide Written Informed Consent

11. Willing to Return to Enrolling Institution - Willing to return to enrolling
institution for follow-up during the Active Monitoring Phase (the active treatment and
observation portions) of the study. Patients are encouraged to return to the enrolling
institution; however, patients may receive radiation therapy at a different
institution other than the enrolling institution.

Registration Exclusion Criteria:

1. Pregnancy, Nursing and Requirement for Contraception - Pregnant women, nursing women
and women of childbearing potential who are unwilling to employ adequate contraception
(as determined by the treating physician) are excluded from participation.

This study involves radiation therapy (WBI) that has known genotoxic, mutagenic and
teratogenic effects.

2. Size of Single Focus of Disease on Preoperative Imaging - Largest single focus of
disease > 5 centimeters by either mammogram or MRI or both. Note: Measurement of the
largest single focus should include any satellite lesions within 1 centimeter of the
index lesion.

3. Prior Staging Procedure - Surgical axillary staging procedure prior to first
definitive breast operation. Note: FNA or core needle biopsy of axillary node is
permitted.

4. Evidence of Metastatic Disease - Clinical or radiographic evidence of metastatic
disease

5. Prior History of Breast Cancer - Prior history of ipsilateral breast cancer [DCIS,
LCIS (lobular cancer in situ) or invasive]

6. Staging of Cancer - cNX, cN2, or cN3 disease

7. Breast Implants - Breast implants at time of diagnosis. Note: Patients who have had
implants previously removed prior to diagnosis are eligible.

8. Systemic Illnesses or Concurrent Disease - Co-morbid systemic illnesses or other
severe concurrent disease which, in the judgment of the investigator, would interfere
significantly with whole breast irradiation (such as connective tissue disorders,
lupus, scleroderma).

9. Uncontrolled Intercurrent Illness - Uncontrolled intercurrent illness including, but
not limited to, ongoing or active infection, symptomatic congestive heart failure,
unstable angina pectoris, cardiac arrhythmia, or psychiatric illness/social situations
that would limit compliance with study requirements.

10. Bilateral Breast Cancer - Prior or current LCIS, DCIS or invasive breast cancer in the
opposite breast (i.e., bilateral disease is not allowed).

11. Disallowed Prior Treatments - Treatment including radiation therapy, chemotherapy,
biotherapy, hormonal therapy for this cancer prior to surgery (i.e., any neoadjuvant
chemotherapy or endocrine therapy is not allowed). Patients who undergo surgical
resection with breast conservation and then are treated with adjuvant systemic therapy
are eligible to enroll prior to the start of radiotherapy.

12. Partial Breast Radiation - Planned partial breast radiation.

13. Known BRCA Mutations - Patients with known BRCA mutations. Patients who are not tested
or whose testing result is not returned at the time of registration are not excluded
from registering to this study.

14. Other Active Malignancies - Other active malignancy ≤ 5 years prior to registration.

14.1 Exceptions: Non-melanotic skin cancer or carcinoma-in-situ of the cervix.

14.2 Note: If there is a history of prior malignancy, they must not be receiving other
specific treatment for their cancer.