BACKGROUND:Oncoplastic breast-conserving surgery (OP-BCS) is becoming increasingly popular to avoid mastectomy or optimize cosmetic outcomes of breast-conserving surgery (BCS). Few studies have compared clinical outcomes and patient-reported outcomes (PROs) of OP-BCS to conventional BCS (C-BCS). This study aims to compare clinical outcomes and short- and long-term PROs after OP-BCS and C-BCS in a large prospective breast cancer cohort. METHODS:Women in the prospective, multicenter UMBRELLA (Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaLuAtion) breast cancer cohort who underwent OP-BCS or C-BCS were included. Clinical outcomes and PROs (measured by EORTC QLQ-C30/BR23) up to 24 months postoperatively were evaluated. Mixed-model analysis was performed to assess differences in PROs over time between groups. RESULTS:A total of 1628 (84.9%) patients received C-BCS and 290 (15.1%) received OP-BCS. After C-BCS and OP-BCS, free resection margins were obtained in 84.2% (n = 1370) and 86.2% (n = 250), respectively, reoperation for re-excision of margins within 3 months occurred in 5.3% (n = 86) and 4.8% (n = 14), and the median time interval from surgery until adjuvant systemic therapy was 66 and 63 days, and 36 and 41 days until radiotherapy. Shortly postoperative, OP-BCS was associated with statistically significant lower mean scores for physical functioning (83.6 vs 87.2) and body image (82.8 vs 89.4) and more pain (19.8 vs 26.5) and breast symptoms (22.7 vs 30.3) than C-BCS. Body image scores remained statistically significantly less favorable after OP-BSC than C-BCS up to 24 months postoperatively (87.8 vs 92.2). CONCLUSIONS:Oncoplastic surgery safely enables BCS but may lead to less favorable long-term body image compared to C-BCS. These findings are important for patient education and shared decision-making.

PURPOSE:Preoperative partial breast irradiation (PBI) can increase accuracy of target volume definition and decrease irradiated volumes compared with postoperative PBI. In the ABLATIVE trial (NCT02316561), 15 of 36 patients achieved pathologic complete response 6 to 8 months after preoperative PBI and breast-conserving surgery (BCS). We now present the 5-year results. METHODS AND MATERIALS:The ABLATIVE trial is a Dutch prospective cohort study conducted in 4 hospitals. Women aged ≥50 years with unifocal, nonlobular breast cancer, estrogen receptor-positive, HER2-negative, and a tumor negative sentinel node were treated between 2015 and 2018 with preoperative single-dose PBI followed by BCS after 6 or 8 months. The primary endpoint was pathologic complete response. Secondary endpoints were annually evaluated oncological outcomes, toxicity, cosmetic outcome (assessed by patients and physicians), and quality of life. RESULTS:Thirty-six patients were treated with BCS 6 (n = 15) and 8 (n = 21) months following PBI. Median tumor size was 13 mm (IQR 9-16 mm). After a median follow-up of 5.5 years (IQR, 5.1-6.0), 2 (6%) patients had ipsilateral breast events and 2 (6%) distant metastases. The 5-year overall survival was 94% (95% CI, 87-100). The 5-year cumulative incidence of clinician-reported grade 1/2 breast fibrosis and breast discomfort/pain were 94%/6% and 75%/6%, respectively. The proportion of patients (very) satisfied with the cosmetic results was 89% at baseline and 78% at 5 years. Cosmetic results evaluated using the BCCT.core software were excellent or good in all patients. The 4-year median global quality of life score was 83 (IQR, 67-92), similar to baseline (83; IQR, 75-83; P = .42). CONCLUSIONS:Preoperative single-dose PBI and BCS may be an oncologically safe treatment with mild late toxicity and no decline in cosmetic results and quality of life during 5 years of follow-up. This means that preoperative instead of standard postoperative irradiation has the potential to challenge the current clinical practice.

Background: Immediate oncoplastic breast conserving surgery (OP-BCS) is becoming increasingly popular to optimize cosmetic outcomes after BCS. Observational studies suggest promising oncological and aesthetic outcomes after OP-BCS. However, only few prospective studies evaluated patient-reported outcomes (PROs) after OP-BCS versus standard BCS (S-BSC) longitudinally. Therefore, the aim of this study was to compare short- and long-term quality of life (QoL), physical and psychosocial well-being, cosmetic and clinical outcomes in breast cancer survivors treated with OP-BCS versus S-BCS.

PurposeDuring the first SARS-CoV-2-infection wave, a deterioration in emotional well-being and increased need for mental health care were observed among patients treated or being treated for breast cancer. In this follow-up study, we assessed patient-reported quality of life (QoL), physical functioning, and psychosocial well-being during the second SARS-CoV-2-infection wave in a large, representative cohort.MethodsThis longitudinal cohort study was conducted within the prospective, multicenter UMBRELLA breast cancer cohort. To assess patient-reported QoL, physical functioning and psychosocial well-being, COVID-19-specific surveys were completed by patients during the first and second SARS-CoV-2-infection waves (April and November 2020, respectively). An identical survey was completed by a comparable reference population during the second SARS-CoV-2-infection waves. All surveys included the validated EORTC-QLQ-C30/BR23, HADS and "De Jong-Gierveld Loneliness" questionnaires. Pre-COVID-19 EORTC-QLQ-C30/BR23 and HADS outcomes were available from UMBRELLA. Response rates were 69.3% (n = 1106/1595) during the first SARS-CoV-2-infection wave and 50.9% (n = 822/1614) during the second wave. A total of 696 patients responded during both SARS-CoV-2-infection waves and were included in the analysis comparing patient-reported outcomes (PROs) during the second SARS-CoV-2-infection wave to PROs during the first wave. Moreover, PROs reported by all patients during the second SARS-CoV-2-infection wave (n = 822) were compared to PROs of a similar non-cancer reference population (n = 241) and to their pre-COVID-19 PROs.ResultsPatient-reported QoL, physical functioning, and psychosocial well-being of patients treated or being treated for breast cancer remained stable or improved from the first to the second SARS-CoV-2-infection wave. The proportion of emotional loneliness reduced from 37.6 to 29.9% of patients. Compared to a similar non-cancer reference population, physical, emotional, and cognitive functioning, future perspectives and symptoms of dyspnea and insomnia were worse in patients treated or being treated for breast cancer during the second SARS-CoV-2-infection wave. PROs in the second wave were similar to pre-COVID-19 PROs.ConclusionAlthough patients scored overall worse than individuals without breast cancer, QoL, physical functioning, and psychosocial well-being did not deteriorate between the first and second wave. During the second wave, PROs were similar to pre-COVID-19 values. Overall, current findings are cautiously reassuring for future mental health of patients treated or being treated for breast cancer.

Purpose To evaluate perceived access to health care and preferences for health care provision among patients (being) treated for breast cancer during the COVID-19 pandemic. Methods Longitudinal study within the prospective, multicenter UMBRELLA cohort of patients (being) treated for breast cancer. All cohort participants enrolled in UMBRELLA between October 2013 and November 2020 were sent a COVID-19-specific survey during the first and second wave of the COVID-19 pandemic, i.e., April 2020 and November 2020, respectively. Results In total, 1106 (69.3%) and 822 (50.9%) cohort participants completed the survey in the first and second wave, respectively. The proportion of patients experiencing that their treatment or follow-up care was affected due to COVID-19 decreased from 28.4% (n = 198) in April 2020 to 14.8% (n = 103) in November 2020. Throughout the pandemic, one or more hospital consultations were postponed in 10.0% (n = 82) of all patients and changed into a teleconsultation in 23.1% (n = 190). The proportion of patients who experienced a higher threshold to contact their general practitioner due to COVID-19 decreased from 29.9% (n = 204) in the first wave to 20.8% (n = 145) in the second wave. In-person consultations remained most preferred in 35.2% (n = 289) of all patients. Nearly half of all patients (48.3%, n = 396) indicated that telehealth would be a useful alternative for in-person consultations in future. Conclusion Perceived access to health care has improved substantially throughout the pandemic. Digital care is well received by patients (being) treated for breast cancer.

Purpose To identify factors associated with (perceived) access to health care among (ex-)breast cancer patients during the COVID-19 pandemic. Methods Cross-sectional study within a large prospective, multicenter cohort of (ex-)breast cancer patients, i.e., UMBRELLA. All participants enrolled in the UMBRELLA cohort between October 2013 and April 2020 were sent a COVID-19-specific survey, including the Hospital Anxiety and Depression Scale (HADS) questionnaire. Results In total, 1051 (66.0%) participants completed the survey. During COVID-19, 284 (27.0%) participants reported clinically relevant increased levels of anxiety and/or depression, i.e., total HADS score ≥ 12. Participants with anxiety and/or depression reported statistically significant higher barriers to contact their general practitioner (47.5% vs. 25.0%, resp.) and breast cancer physicians (26.8% vs. 11.2%, resp.) compared to participants without these symptoms. In addition, a higher proportion of participants with anxiety and/or depression reported that their current treatment or (after)care was affected by COVID-19 compared to those without these symptoms (32.7% vs. 20.5%, resp.). Factors independently associated with symptoms of anxiety and/or depression during COVID-19 were pre-existent anxiety (OR 6.1, 95% CI 4.1–9.2) or depression (OR 6.0, 95% CI 3.5–10.2). Conclusion During the COVID-19 pandemic, (ex-)breast cancer patients with symptoms of anxiety and/or depression experience higher barriers to contact health care providers. Also, they more often report that their health care was affected by COVID-19. Risk factors for anxiety and/or depression during COVID-19 are pre-existent symptoms of anxiety or depression. Extra attention—including mental health support—is needed for this group.

ABSTRACTPurposeThe COVID-19 pandemic and the resulting social distancing and lockdown measures are having a substantial impact on daily life and medical management of people with breast cancer. We evaluated to what extent these changes have affected quality of life and physical, and psychosocial wellbeing of people (being) treated for breast cancer.MethodsThis study was conducted within the prospective Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaluation (UMBRELLA). Shortly after the implementation of COVID-19 measures, extra questionnaires were sent to 1595 cohort participants, including standard UMBRELLA quality of life (EORTC) questionnaires. Patient-reported outcomes (PROs) were compared to the most recent PROs collected within UMBRELLA before COVID-19. The impact of COVID-19 on PROs was evaluated using mixed models analysis.ResultsIn total, 1051 patients (66%) completed the questionnaires. One third (n = 327, 31%) reported a higher threshold to contact their general practitioner due to COVID-19. A significant deterioration in emotional functioning was observed (82·6 to 77·9, p < 0.001) and 505 (48%, 95% CI 45-51) patients reported moderate to severe loneliness. Small significant improvements were observed in QoL, physical-, social- and role functioning scores. In the subgroup of 51 patients under active treatment, there was a strong deterioration in social functioning (69·8 to 5·0, p = 0·03).ConclusionDue to COVID-19, patients (being) treated for breast cancer are less likely to contact physicians, and experience a deterioration in emotional functioning. Patients undergoing active treatment report a strong drop in social functioning. One in two patients reports (severe) loneliness. Online applications facilitating peer contact and e-mental health interventions could support mental health and social interaction times of total lockdown or social distancing.

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic (officially declared on the March 11, 2020), and the resulting measures, are impacting daily life and medical management of breast cancer patients and survivors. We evaluated to what extent these changes have affected quality of life, physical, and psychosocial well-being of patients previously or currently being treated for breast cancer. Methods This study was conducted within a prospective, multicenter cohort of breast cancer patients and survivors (Utrecht cohort for Multiple BREast cancer intervention studies and Long-term evaLuAtion). Shortly after the implementation of COVID-19 measures, an extra survey was sent to 1595 participants, including the validated European Organization for Research and Treatment of Cancer (EORTC) core (C30) and breast cancer- specific (BR23) Quality of Life Questionnaire (EORTC QLQ-C30/BR23) and Hospital Anxiety and Depression Scale (HADS) questionnaire. Patient-reported outcomes (PROs) were compared with the most recent PROs collected within UMBRELLA pre–COVID-19. The impact of COVID-19 on PROs was assessed using mixed model analysis, adjusting for potential confounders. Results 1051 patients and survivors (65.9%) completed the survey; 31.1% (n = 327) reported a higher threshold to contact their general practitioner amid the COVID-19 pandemic. A statistically significant deterioration in emotional functioning was observed (mean = 82.6 [SD = 18.7] to 77.9 [SD = 17.3]; P < .001), and 505 (48.0%, 95% confidence interval [CI] = 45.0% to 51.1%) patients and survivors reported moderate to severe loneliness. Small improvements were observed in quality of life and physical, social, and role functioning. In the subgroup of 51 patients under active treatment, social functioning strongly deteriorated (77.3 [95% CI = 69.4 to 85.2] to 61.3 [95% CI = 52.6 to 70.1]; P = .002). Conclusion During the COVID-19 pandemic, breast cancer patients and survivors were less likely to contact physicians and experienced a deterioration in their emotional functioning. Patients undergoing active treatment reported a substantial drop in social functioning. One in 2 reported loneliness that was moderate or severe. Online interventions supporting mental health and social interaction are needed during times of social distancing and lockdowns.

Purpose: To assess the pathologic and radiologic response in patients with low-risk breast cancer treated with magnetic resonance (MR) guided neoadjuvant partial breast irradiation (NA-PBI) and to evaluate toxicity and patient-reported outcomes (PROs). Methods and Materials: For this single-arm prospective trial, women with unifocal, non-lobular tumors with a maximum diameter of 20 mm (age, 50-70 years) or 30 mm (age, >= 70 years) and tumor-negative sentinel node(s) were eligible. Patients were treated with a single ablative dose of NA-PBI followed by breast-conserving surgery after an interval of 6 to 8 months. Target volumes were defined on radiation therapy planning computed tomography scan and additional magnetic resonance imaging. Prescribed doses to gross tumor volume and clinical target volume (gross tumor volume plus 20 mm margin) were 20 Gy and 15 Gy, respectively. Primary outcome was pathologic complete response (pCR). Secondary outcomes were radiologic response (on magnetic resonance imaging), toxicity (Common Terminology Criteria for Adverse Events), PROs (European Organisation for Research and Treatment of Cancer QLQ-BR23, Hospital Anxiety and Depression Scale), and cosmesis (assessed by patient, radiation oncologist, and BCCT.core software). Results: Thirty-six patients were treated with NA-PBI, and pCR was reported in 15 patients (42%; 95% confidence interval, 26%-59%). Radiologic complete response was observed in 15 patients, 10 of whom had pCR (positive predictive value, 67%; 95% confidence interval, 39%-87%). After a median follow-up of 21 months (range, 12-41), all patients experienced grade 1 fibrosis in the treated breast volume. Transient grade 2 and 3 toxicity was observed in 31% and 3% of patients, respectively. Local recurrences were absent. No deterioration in PROs or cosmetic results was observed. Conclusions: NA-PBI has the potential to induce pCR in a substantial proportion of patients, with acceptable toxicity. This treatment seems a feasible alternative to standard postoperative irradiation and could even result in postponement or omission of surgery if pCR can be accurately predicted in selected low-risk patients. (C) 2019 Elsevier Inc. All rights reserved.

Purpose or ObjectiveTo evaluate pathologic and radiologic response to single dose pre-operative ablative radiotherapy (RT) in women with low-risk breast cancer.

IntroductionIn ES-SCLC patients with residual intrathoracic disease after first-line chemotherapy, the addition of thoracic radiotherapy reduces the risk of intrathoracic recurrence, and improves 2-year survival. To identify patient subgroups for future trials investigating higher dose (extra)thoracic radiotherapy, we investigated the prognostic importance of number and sites of metastases in patients included in the CREST trial.Materials/ methodsAdditional data on sites and numbers of metastases were collected from individual records of 260 patients from the top 9 recruiting centers in the randomized CREST trial (53% of 495 study patients), which compared thoracic radiotherapy (TRT) to no TRT in ES-SCLC patients after any response to chemotherapy. All patients received prophylactic cranial irradiation.ResultsThe clinical characteristics and outcomes of the 260 patients analyzed here did not differ significantly from that of the other 235 patients included in the CREST trial, except that fewer patients had a WHO=0 performance status (24% vs 45%), and a higher proportion had WHO=2 (15% vs 5%; p<0.0001). No distant metastases were recorded in 5%, 39% had metastases confined to one organ, 34% to two, and 22% to three or more organ sites. Metastases were present in the liver (47%), bone (40%), lung (28%), extrathoracic (non-supraclavicular) lymph nodes (19%), supraclavicular nodes (18%), adrenals (17%) and other sites (12%). The OS (p=0.02) and PFS (p=0.04) were significantly better in patients with 2 or fewer metastases, with OS significantly worse if liver (p=0.03) and/or bone metastases (p=0.04) were present.DiscussionThis analysis of patients recruited from the top 9 accruing centers in the CREST trial suggests that future studies evaluating more intensive thoracic and extra-thoracic radiotherapy in ES-SCLC should focus on patients with fewer than 3 distant metastases.

Purpose To quantify the impact of the degree of robustness against setup errors and range errors on organ-at-risk (OAR) dose and normal tissue complication probabilities (NTCPs) in intensity-modulated proton therapy for oropharyngeal cancer patients. Material and methods For 20 oropharyngeal cases (10 unilateral and 10 bilateral), robust treatment plans were generated using ‘minimax’ worst-case optimization. We varied the robustness against setup errors (‘setup robustness’) from 1 to 7 mm and the robustness against range errors (‘range robustness’) from 1% to 7% (+1 mm). We evaluated OAR doses and NTCP-values for xerostomia, dysphagia and larynx edema. Results Varying the degree of setup robustness was found to have a considerably larger impact than varying the range robustness. Increasing setup robustness from 1 mm to 3, 5, and 7 mm resulted in average NTCP-values to increase by 1.9, 4.4 and 7.5 percentage point, whereas they increased by only 0.4, 0.8 and 1.2 percentage point when increasing range robustness from 1% to 3%, 5% and 7%. The degree of setup robustness was observed to have a clinically significant impact in bilateral cases in particular. Conclusions For oropharyngeal cancer patients, minimizing setup errors should be given a higher priority than minimizing range errors.

In responding patients with ES-SCLC who have residual intrathoracic disease after induction chemotherapy, the addition of thoracic radiotherapy reduces the risk of intrathoracic recurrence and improves overall survival. In order to identify patients most likely to benefit from inclusion in studies evaluating high-dose thoracic or extra-thoracic radiotherapy, we studied the prognostic importance of metastatic load (numbers, sites) in patients included in the CREST trial. Additional patient data was collected from the top 9 recruiting centers in the randomized CREST trial comparing thoracic radiotherapy (TRT) with no TRT in ES-SCLC patients after any response to chemotherapy. All patients received prophylactic cranial irradiation. Individual records of 260 patients (53% of 495 study patients) were analyzed for details on sites and numbers of metastases. Median age was 63 years, 52% male, 24% WHO Performance Status (PS) = 0, 61% WHO PS = 1 and 15% WHO PS = 2. At randomization, 4% of patients had a CR after chemotherapy, 69% a PR and 27% a “good response.” Post-chemotherapy residual intrathoracic disease was present in 89% of patients. The characteristics and clinical outcome of the 260 patients analyzed were not significantly different from the 235 non-selected patients included in the CREST trial, with the exception of fewer WHO 0 scores (24% vs 45%) and a higher portion of WHO = 2 patients (15% vs 5%; overall: P < 0.0001). Patients in the analysis had a similar PFS (3.5 months), but a trend for inferior OS compared to the non-selected patients (median 7.4 vs 8.1 months; P = 0.06). No distant metastases were recorded in 5%, 39% had metastases confined to one organ, 34% to two, and 22% to three or more organ sites. Metastases were present in liver (47%), bone (40%), lung (28%), distant lymph nodes (19%), supraclavicular nodes (18%), adrenal glands (17%), and other sites (12%). The OS (P = 0.02) and PFS (P = 0.04) were significantly better in patients with up to 2 metastases, and OS was significantly worse if liver (P = 0.03) and/or bone metastases (P = 0.04) were present. In 121 patients with liver metastases, TRT did not significantly influence OS or PFS. However, in 119 patients without liver metastases, TRT was associated with significantly longer PFS (P = 0.001) and a trend for improved OS (P = 0.08). This analysis of patients recruited from the top 9 accruing CREST centers suggests that future studies evaluating more intensive thoracic and extrathoracic radiotherapy in ES-SCLC should focus on patients with less than 3 metastases and without liver or bone metastases.Abstract 346; Table 1Variablen =Overall survivalProgression-free survival0-2 metastases72HR = 1.43(95%CI = 1.07-1.92)P = 0.02HR = 1.35(95%CI = 1.02-1.78)P = 0.04> 2 metastases188No liver metastases139HR = 1.34(95%CI = 1.03-1.73)P = 0.03HR = 1.27(95%CI = 0.99-1.53)P = 0.06Liver metastases121No bone metastases157HR = 1.33(95%CI = 1.02-1.73)P = 0.04HR = 1.39(95%CI = 1.08-1.79)P = 0.01Bone metastases103 Open table in a new tab

For breast boost radiotherapy or accelerated partial breast irradiation, the tumor bed (TB) is delineated by the radiation oncologist on a planning computed tomography (CT) scan. The aim of the present study was to investigate whether the interobserver variability (IOV) of the TB delineation is reduced by providing the radiation oncologist with additional magnetic resonance imaging (MRI) or CT scans. A total of 14 T1-T2 breast cancer patients underwent a standard planning CT in the supine treatment position following lumpectomy, as well as additional pre- and postoperative imaging in the same position. Post-lumpectomy TBs were independently delineated by four breast radiation oncologists on standard postoperative CT and on CT registered to an additional imaging modality. The additional imaging modalities used were postoperative MRI, preoperative contrast-enhanced (CE)-CT and preoperative CE-MRI. A cavity visualization score (CVS) was assigned to each standard postoperative CT by each observer. In addition, the conformity index (CI), volume and distance between centers of mass (dCOM) of the TB delineations were calculated. On CT, the median CI was 0.57, with a median volume of 22 cm3 and dCOM of 5.1 mm. The addition of postoperative MRI increased the median TB volume significantly to 28 cm3 (P<0.001), while the CI (P=0.176) and dCOM (P=0.110) were not affected. The addition of preoperative CT or MRI increased the TB volume to 26 and 25 cm3, respectively (both P<0.001), while the CI increased to 0.58 and 0.59 (both P<0.001) and the dCOM decreased to 4.7 mm (P=0.004) and 4.6 mm (P=0.001), respectively. In patients with CVS≤3, the median CI was 0.40 on CT, which was significantly increased by all additional imaging modalities, up to 0.52, and was accompanied by a median volume increase up to 6 cm3. In conclusion, the addition of postoperative MRI, preoperative CE-CT or preoperative CE-MRI did not result in a considerable reduction in the IOV in postoperative CT-guided TB delineation, while target volumes marginally increased. The value of additional imaging may be dependent on CVS.

Metastases in cervical lymph nodes from distant primary (nonhead and neck) tumors are rare but may be seen across a wide spectrum of cancer types, including lung cancer.1Aldridge T. Kusanale A. Colbert S. et al.Supraclavicular metastases from distant primaries: what is the role of the head and neck surgeon?.Br J Oral Maxillofac Surg. 2013; 51: 288-293Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Because the disease is often widespread at this stage, adequate palliative management is essential. Surgical management has always been a point of discussion in palliative care.2Miner T.J. Palliative surgery for advanced cancer: lessons learned in patient selection and outcome assessment.Am J Clin Oncol. 2005; 28: 411-414Crossref PubMed Scopus (40) Google Scholar To increase the awareness of this approach in the palliative care of patients with non-small cell lung cancer (NSCLC) and cervical lymph node metastases, we present a case in which a symptomatic supraclavicular lymph node was surgically removed for palliative purposes. In February 2014, a 55-year-old woman was referred to the pulmonologist because of complaints suspicious for lung cancer. Positron emission tomography/computed tomography (CT) scans showed a malignant process of the lung with positive ipsilateral hilar and subcarinal lymph nodes and an enlarged left adrenal gland. After staging, which included bronchoscopy, mediastinoscopy, endoscopic ultrasound, and a magnetic resonance imaging scan of the cerebrum, the tumor was classified as a highly probable cT2N1M0 lung carcinoma. Surgical intervention with curative intent was advised by the multidisciplinary cancer board. Via video-assisted thoracoscopic surgery, a lobectomy of the right inferior lobe was performed, accompanied by an ipsilateral lymph node dissection and perioperative mediastinal and subcarinal staging. Pathology revealed a pT2N1M0 NSCLC (histologically classified as an adenocarcinoma). Adjuvant chemotherapy was advised, but, three weeks after surgery, an enlarged, suspicious, supraclavicular lymph node was found. Incisional biopsy revealed a metastasis of the NSCLC, with central necrosis, indicating rapid progression. A CT scan was done for restaging, which, in addition to the supraclavicular tumor (Fig. 1), showed a contralateral pulmonary metastasis and progressive growth of the adrenal gland. Genetic analysis of the tumor revealed Kirsten-rat sarcoma (K-RAS) oncogene positivity and negative anaplastic lymphoma kinase (ALK) mutation. After careful consideration of the risks and benefits, the patient declined conventional palliative chemotherapy. The patient had a large, visible, ulcerating, and painful tumor just above the clavicle (Fig. 1). The multidisciplinary team recommended surgical removal of the supraclavicular tumor, with palliative intent. The tumor was removed by a selective neck dissection. Direct examination of nodal Levels 4 and 5 extended by palpation and visual exploration of Levels 2 and 3 did not reveal other suspicious lymph nodes. The tumor's location was favorable and resection spared the brachial plexus, the accessory nerve, the phrenic nerve, and the thoracic duct. Pathology confirmed radical removal of the 8.1 cm tumor. Other dissected lymph nodes did not show malignancy. The procedure was successful and uncomplicated. Postoperative pain was minimal, and, after recovery, the patient was pain free. Medical recovery took two days. There was no local recurrence until the time of death two months later. Only 30% of all patients presenting with NSCLC are considered for curative treatment, often surgical.3NSCLC Meta-Analyses Collaborate GroupChemotherapy in addition to supportive care improves survival in advanced non-small-cell lung cancer: a systematic review and meta-analysis of individual patiënt data from 16 randomized controlled trials.J Clin Oncol. 2008; 26: 4617-4625Crossref PubMed Scopus (545) Google Scholar The role of surgery for patients with widespread disease is minor and for Stage IV disease, negligible.4Varela G. Thomas P.A. Surgical management of advanced non-small cell lung cancer.J Thorac Dis. 2014; 6: S217-S223PubMed Google Scholar Chemotherapy and supportive care are now considered the standard of care.3NSCLC Meta-Analyses Collaborate GroupChemotherapy in addition to supportive care improves survival in advanced non-small-cell lung cancer: a systematic review and meta-analysis of individual patiënt data from 16 randomized controlled trials.J Clin Oncol. 2008; 26: 4617-4625Crossref PubMed Scopus (545) Google Scholar Studies considering surgical palliation in advanced NSCLC are rare, and those studying palliative neck surgery in NSCLC even rarer. Metastasectomy in general has been shown to provide a survival benefit, and even long-term survival, for specific patients. This significant improvement has been seen in patients with synchronous solitary (skip) metastasis and a primary tumor suitable for radical therapy. With extended lymph node involvement and multiple site metastatic disease, there has been little to no additional survival benefit after surgery.4Varela G. Thomas P.A. Surgical management of advanced non-small cell lung cancer.J Thorac Dis. 2014; 6: S217-S223PubMed Google Scholar, 5Ashworth A.B. Senan S. Palma D.A. et al.An individual patient data metaanalysis of outcomes and prognostic factors after treatment of oligometastatic non-small-cell lung cancer.Clin Lung Cancer. 2014; 15: 346-355Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar Metastasectomy for supraclavicular metastasis has not been mentioned in prior studies. Only one study, done in Japan, specifically considered neck surgery in NSCLC for curative purposes. However, patients still had poor prognoses after dissection, with high local recurrence rates; neck dissection was not advised in the management of NSCLC.6Miyamoto H. Hata E. Sakao Y. et al.Evaluation of neck lymph node dissection and extended lymphadenectomy through a collar incision and median sternotomy for lung cancer [article in Japanese].Nihon Kyobu Geka Gakkai Zasshi. 1995; 43: 1804-1809PubMed Google Scholar For palliative purposes, no literature was found on this very specific topic.1Aldridge T. Kusanale A. Colbert S. et al.Supraclavicular metastases from distant primaries: what is the role of the head and neck surgeon?.Br J Oral Maxillofac Surg. 2013; 51: 288-293Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Our patient had received initial surgical treatment but required a new treatment strategy after discovery of the additional metastases. Although chemotherapy was indicated, the patient declined any systemic treatment as she felt it would decrease her quality of life; her wishes were respected. Eventually, however, palliation for the supraclavicular lymph node tumor was necessary as it was a significant physical and psychological burden for the patient. The tumor was close to the skin surface and, therefore, noticeable with every neck movement; she was confronted with the disease at every moment of every day. Also, the ulcerating lesion was painful, and the patient needed morphine therapy for pain control. Because further growth of the lymph node metastasis could lead to destruction of surrounding structures, such as the brachial plexus, the phrenic nerve, or the thoracic duct, metastasis-directed therapy was called for. Given the short life expectancy of palliative care patients, metastasis-directed therapy should be short, nondistressing, and effective. Evidence specifically for cervical lymph node metastases in NSCLC is unavailable, but it may be extrapolated. For surgical palliation in general, significant symptom resolution can be attained in 80%–90.7% of patients. Maximum palliation of symptoms is achieved within a maximum of 30 days.7Miner T.J. Brennan M.F. Jaques DP A prospective, symptom related, outcomes analysis of 1022 palliative procedures for advanced cancer.Ann Surg. 2004; 240 (discussion 726–727): 719-726PubMed Google Scholar The associated short period of discomfort including postoperative pain, hospitalization, and nursing requirements do not appear to have a negative effect on quality-of-life measurements.2Miner T.J. Palliative surgery for advanced cancer: lessons learned in patient selection and outcome assessment.Am J Clin Oncol. 2005; 28: 411-414Crossref PubMed Scopus (40) Google Scholar The downside is frequent recurrence of symptoms in need of reintervention and, therefore, a limited durability of the palliative effect.7Miner T.J. Brennan M.F. Jaques DP A prospective, symptom related, outcomes analysis of 1022 palliative procedures for advanced cancer.Ann Surg. 2004; 240 (discussion 726–727): 719-726PubMed Google Scholar For radiotherapy, studies considering patients with superior vena cava syndrome (from malignant lymph nodes) show an 80% success rate.8Hoegler D. Radiotherapy for palliation of symptoms in incurable cancer.Curr Probl Cancer. 1997; 21: 129-183Abstract Full Text PDF PubMed Google Scholar Maximal palliation is generally reached after 35–50 days, although relief might be noticed sooner, and may last up to 22 weeks.9Kramer G.W. Wanders S.L. Noordijk E.M. et al.Results of the Dutch national study of the palliative effect of irradiation using two different treatment schemes for non-small-cell lung cancer.J Clin Oncol. 2005; 23: 2962-2970Crossref PubMed Scopus (95) Google Scholar In our case, the lymph node metastasis was 8.1 cm in diameter, and radiation therapy was thought to be insufficient for fully resolving the symptoms. Furthermore, because of dermal involvement, radiation dermatitis would have been unavoidable and added to the patient's discomfort. Therefore, surgery was chosen as the palliative treatment, with awareness of the possible damage to surrounding structures. Patient selection criteria for palliative surgery of metastases are not specifically outlined as surgery must be considered solely on a case-by-case basis. When considering palliative outcomes in general, poor World Health Organization performance status (3 of 4), poor nutrition status, excessive weight loss, and absence of primary tumor management were associated with poor palliative outcomes.7Miner T.J. Brennan M.F. Jaques DP A prospective, symptom related, outcomes analysis of 1022 palliative procedures for advanced cancer.Ann Surg. 2004; 240 (discussion 726–727): 719-726PubMed Google Scholar Age also appears to be a major factor as the median age of patients in studies regarding surgical management is approximately 10 years younger than the patient population in general.5Ashworth A.B. Senan S. Palma D.A. et al.An individual patient data metaanalysis of outcomes and prognostic factors after treatment of oligometastatic non-small-cell lung cancer.Clin Lung Cancer. 2014; 15: 346-355Abstract Full Text Full Text PDF PubMed Scopus (312) Google Scholar Because local recurrence is proven to be frequent in surgically managed metastases2Miner T.J. Palliative surgery for advanced cancer: lessons learned in patient selection and outcome assessment.Am J Clin Oncol. 2005; 28: 411-414Crossref PubMed Scopus (40) Google Scholar and also is suggested after neck surgery,6Miyamoto H. Hata E. Sakao Y. et al.Evaluation of neck lymph node dissection and extended lymphadenectomy through a collar incision and median sternotomy for lung cancer [article in Japanese].Nihon Kyobu Geka Gakkai Zasshi. 1995; 43: 1804-1809PubMed Google Scholar postoperative radiation could have been added to the palliative treatment. It might be beneficial to prolong the progression-free period as extra nodal extension is very likely in an 8 cm tumor. Literature supports this assumption.10Colletier P.J. Garden A.S. Morrison W.H. et al.Postoperative radiation for squamous cell carcinoma metastatic to cervical lymph nodes from an unknown primary site: outcomes and patterns of failure.Head Neck. 1998; 20: 674-681Crossref PubMed Scopus (118) Google Scholar But considering the wishes of the patient, we excluded radiation therapy from our palliative strategy. Often surgery is not considered in Stage IV lung cancer, although survival benefit after solitary metastasectomy has been demonstrated. In this case, surgical palliation of a supraclavicular lymph node metastasis from NSCLC was successful, effective, quick, and uncomplicated. This is remarkable because the metastasis was large and in an anatomically complicated location. Surgical palliation should be considered in patients with a high symptom burden and favorable factors, such as age or performance status, but who are unlikely to respond to either chemotherapy and/or radiotherapy.

Accurate tumor bed delineation after breast-conserving surgery is important. However, consistency among observers on standard postoperative radiotherapy planning CT is low and volumes can be large due to seroma formation. A preoperative delineation of the tumor might be more consistent. Therefore, the purpose of this study was to determine the consistency of preoperative target volume delineation on CT and MRI for breast-conserving radiotherapy.