between American and Europeans in the radiation dose used to the whole breast or boost, with either negative or close margins.However, Europeans offered larger doses per fraction for the breast with negative margins (mean 2.25�0.1 vs 1.9�0.04,p�0.01) and close margins (2.1�0.07 vs 1.9�0.04, p�0.05). When asked if the recent EORTC boost study would affect therespondents’ boost regimen, there was no difference between the US and Europe (23% vs 22%).

Post-mastectomy RT: The results are shown in the table below. When LNs were present, U.S. respondents were more likelyto treat the chest wall and supraclavicular fossa, wheras Europeans were more likely to treat the IMC. Both Europeans andAmericans were more likely to offer chest wall RT to a T3NO lesion than a 1-3LN positive patient.

DCIS: There were profound differences in management techniques for DCIS between Europe and the U.S., especially withregards to favorable lesions, as Europeans offered observation more often (p�0.0001). Tamoxifen was recommended morefrequently in the U.S. (p�0.0001).

Conclusions: There are marked differences in the management of breast cancer in the U.S. and Europe. This internationalsurvey could be beneficial in initiating randomized studies to further define the optimal radiotherapeutic treatment of breastcancer.

Post Mastectomy RT 656 (USA) and 419 (Europe)

No RT (%)USA/Europe

Chest Wall (%)USA/Europe

Supraclav (%)USA/Europe

Axilla (%)USA/Europe

IMC (%)USA/Europe

Yes to any LNarea (%)

USA/Europe

T3NO 10/16 p�0.05 84/81 no diff 46/20 p�0.0001 14/9 p�0.05 6/10 no diff 49/27 p�0.0001pN1 1-3LNs 31/29 no diff 55/50 p�0.01 44/34 p�0.01 15/12 no diff 8/19 p�0.001 50/45 no diffpN1 1-3LNs

with ECE 9/13 no diff 79/67 p�0.0001 77/68 p�0.001 56/48 p�0.01 13/27 p�0.0001 83/75 p�0.001pN1 �4LNs 1/1 no diff 97/90 p�0.001 98/91 p�0.001 54/51 no diff 21/34 p�0.0001 98/94 p�0.001pN1 �4LNs

with ECE 0.2/0.5 no diff 97/91 p�0.001 99/95 p�0.01 75/69 p�0.01 22/37 p�0.0001 99/97 p�0.05

99 The Conservative Management of Paget’s Disease of the Breast with Radiotherapy: 10- and 15-Year Results

J.K. Marshall1, K.A. Griffith2, B.G. Haffty3, L.J. Solin4, F.A. Vicini5, B. McCormick6, D.E. Wazer7, A. Recht8,L.J. Pierce1

1Dept. of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI, 2Biostatistics Unit, University ofMichigan School of Medicine, Ann Arbor, MI, 3Dept. of Radiation Oncology, Yale University School of Medicine, NewHaven, CT, 4Dept. of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, PA, 5Dept. ofRadiation Oncology, William Beaumont Hospital, Royal Oak, MI, 6Dept. of Radiation Oncology, Memorial Sloan-KetteringCancer Center, New York, NY, 7Dept. of Radiation Oncology, Tufts–New England Medical Center, Boston, MA, 8Dept. ofRadiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA

Purpose/Objective: Previous reports have demonstrated the success at 5 years of breast-conserving surgery (BCS) andradiotherapy (RT) in patients treated for Paget’s disease of the breast. The purpose of the current report was to provide 10- and15-year estimates of tumor control in the breast, disease-free and overall survival following BCS and RT in a cohort of patientswith Paget’s disease presenting without a palpable mass or mammographic density.

Materials/Methods: Through a collaborative review from seven institutions of patients treated with BCS and RT, 38 cases ofPaget’s disease of the breast presenting without a palpable mass or mammographic density were identified. All patients hadpathologic confirmation of typical Paget’s cells at time of diagnosis. Thirty-six of 38 patients had a minimum follow-up ofgreater than 12 months and constitute the present study cohort. Ninety-four percent of patients underwent complete or partialexcision of the nipple-areolar complex and all patients received external beam irradiation to the whole breast, to a median doseof 50 Gray (Gy), range, 45-54 Gy. Ninety-seven percent of patients also received a boost to the remaining nipple or tumor bed,for a median total dose of 61.5 Gy, range, 50.4-70 Gy.

Results: With a median follow-up of 113 months (range, 18-257 months), 4 of 36 patients (11%) developed a recurrence inthe treated breast as the only site of first failure. Two of the four recurrences were DCIS only and 2 were invasive with DCIS.Two additional patients had a recurrence in the breast as a component of first failure. Actuarial local control rates for a breastfailure as the only site of first failure were 91% at 5 years (95% confidence interval (CI), 80-100%) and 87% (95% CI, 75-99%)at both 10 and 15 years. Actuarial local control rates for breast failure, as a component of first failure, were 91% (95% CI,80-100%), 83% (95% CI, 69-97%), and 76% (95% CI, 58-94%) at 5, 10, and 15 years, respectively. No clinical factors wereidentified as significant predictors for recurrence in the breast. Five of the six patients developing a breast recurrence underwentsalvage surgery, of which all were successfully salvaged. The sixth patient developed a simultaneous local and distantrecurrence and expired with disease without undergoing surgical salvage. Four of the five salvaged patients remain free ofdisease with a median follow-up of 12.3 years (range, 6.9-17.7 years), with the fifth patient expiring with disease following adistant recurrence. In total, of the 36 patients studied, 2 patients expired with disease and 2 patients expired free of disease,yielding 5-, 10-, and 15-year actuarial rates for survival without disease of 97% (95% CI, 90-100%) and 5-, 10-, and 15-yearactuarial rates for overall survival of 93% (95% CI, 84-100%) at 5 years and 90% (95% CI, 78-100%) at 10 and 15 years.

Conclusions: To our knowledge, these results represent the longest follow-up of a patient cohort treated with BCS and RT forPaget’s disease of the breast. These data confirm excellent rates of local control, disease-free and overall survival at 10 and 15years, and success of surgical salvage following a conservative approach. This study continues to support the recommendationof local excision and definitive breast irradiation as an alternative to mastectomy in the treatment of Paget’s disease presentingwithout a palpable mass or mammographic density.

60 I. J. Radiation Oncology ● Biology ● Physics Volume 54, Number 2, Supplement, 2002