Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial.
BACKGROUND
Intraoperative radiotherapy with electrons allows the substitution of conventional postoperative whole breast irradiation with one session of radiotherapy with the same equivalent dose during surgery. However, its ability to control for recurrence of local disease required confirmation in a randomised controlled trial.


METHODS
This study was done at the European Institute of Oncology (Milan, Italy). Women aged 48-75 years with early breast cancer, a maximum tumour diameter of up to 2·5 cm, and suitable for breast-conserving surgery were randomly assigned in a 1:1 ratio (using a random permuted block design, stratified for clinical tumour size [<1·0 cm vs 1·0-1·4 cm vs ≥1·5 cm]) to receive either whole-breast external radiotherapy or intraoperative radiotherapy with electrons. Study coordinators, clinicians, and patients were aware of the assignment. Patients in the intraoperative radiotherapy group received one dose of 21 Gy to the tumour bed during surgery. Those in the external radiotherapy group received 50 Gy in 25 fractions of 2 Gy, followed by a boost of 10 Gy in five fractions. This was an equivalence trial; the prespecified equivalence margin was local recurrence of 7·5% in the intraoperative radiotherapy group. The primary endpoint was occurrence of ipsilateral breast tumour recurrences (IBTR); overall survival was a secondary outcome. The main analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01849133.


RESULTS
1305 patients were randomised (654 to external radiotherapy and 651 to intraoperative radiotherapy) between Nov 20, 2000, and Dec 27, 2007. After a medium follow-up of 5·8 years (IQR 4·1-7·7), 35 patients in the intraoperative radiotherapy group and four patients in the external radiotherapy group had had an IBTR (p<0·0001). The 5-year event rate for IBRT was 4·4% (95% CI 2·7-6·1) in the intraoperative radiotherapy group and 0·4% (0·0-1·0) in the external radiotherapy group (hazard ratio 9·3 [95% CI 3·3-26·3]). During the same period, 34 women allocated to intraoperative radiotherapy and 31 to external radiotherapy died (p=0·59). 5-year overall survival was 96·8% (95% CI 95·3-98·3) in the intraoperative radiotherapy group and 96·9% (95·5-98·3) in the external radiotherapy group. In patients with data available (n=464 for intraoperative radiotherapy; n=412 for external radiotherapy) we noted significantly fewer skin side-effects in women in the intraoperative radiotherapy group than in those in the external radiotherapy group (p=0·0002).


CONCLUSIONS
Although the rate of IBTR in the intraoperative radiotherapy group was within the prespecified equivalence margin, the rate was significantly greater than with external radiotherapy, and overall survival did not differ between groups. Improved selection of patients could reduce the rate of IBTR with intraoperative radiotherapy with electrons.


BACKGROUND
Italian Association for Cancer Research, Jacqueline Seroussi Memorial Foundation for Cancer Research, and Umberto Veronesi Foundation.
Scientific Directorate, European Institute of Oncology, Milan, Italy. Electronic address: umberto.veronesi@ieo.it.
Umberto
U
Veronesi
Roberto
R
Orecchia
Patrick
P
Maisonneuve
Giuseppe
G
Viale
Nicole
N
Rotmensz
Claudia
C
Sangalli
Alberto
A
Luini
Paolo
P
Veronesi
Viviana
V
Galimberti
Stefano
S
Zurrida
Maria Cristina
MC
Leonardi
Roberta
R
Lazzari
Federica
F
Cattani
Oreste
O
Gentilini
Mattia
M
Intra
Pietro
P
Caldarella
Bettina
B
Ballardini
D000368:Aged; D014408:Biomarkers, Tumor / Q000032:analysis; D001943:Breast Neoplasms / Q000737:chemistry / Q000473:pathology / Q000532:radiotherapy* / Q000601:surgery*; D018270:Carcinoma, Ductal, Breast / Q000532:radiotherapy; D018275:Carcinoma, Lobular / Q000532:radiotherapy; D019583:Dose Fractionation, Radiation; D004583:Electrons / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D015994:Incidence; D007432:Intraoperative Period; D007558:Italy; D053208:Kaplan-Meier Estimate; D008207:Lymphatic Metastasis; D015412:Mastectomy, Segmental / Q000379:methods*; D008875:Middle Aged; D060787:Neoplasm Grading; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology / Q000517:prevention & control*; D009367:Neoplasm Staging; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant / Q000379:methods*; D016896:Treatment Outcome
D014408:Biomarkers, Tumor