Evaluation of irradiation of the peripheral lymphatics in conjunction with radical mastectomy for cancer of the breast

The Changing Face of Mastectomy (from Mutilation to Aid to Breast Reconstruction)

Breast cancer is the most common cancer in women. Primary treatment is surgery, with mastectomy as the main treatment for most of the twentieth century. However, over that time, the extent of the procedure varied, and less extensive mastectomies are employed today compared to those used in the past, as excessively mutilating procedures did not improve survival. Today, many women receive breast-conserving surgery, usually with radiotherapy to the residual breast, instead of mastectomy, as it has been shown to be as effective as mastectomy in early disease. The relatively new skin-sparing mastectomy, often with immediate breast reconstruction, improves aesthetic outcomes and is oncologically safe. Nipple-sparing mastectomy is newer and used increasingly, with better acceptance by patients, and again appears to be oncologically safe. Breast reconstruction is an important adjunct to mastectomy, as it has a positive psychological impact on the patient, contributing to improved quality of life.

Management of the axilla after the finding of a positive sentinel lymph node: a proposal for an evidence-based risk-adapted algorithm

Axillary lymph node dissection after the finding of a positive sentinel lymph node is a common clinical practice. A review is performed for the efficacy and morbidity of axillary lymph node dissection, the rationale for nonsurgical management of the axilla, and the efficacy, technical limitations, and toxicity of axillary radiation therapy; a management algorithm is then proposed based upon currently available prediction tools.

Determination of optimal radiation energy for different breast sizes using CT-simulator [correction of simulatior] in tangential breast irradiation

BACKGROUND

The purpose of this study is to determine and recommend the optimal radiation source according to breast size for tangential irradiation in breast conserving therapy.

METHODS

Twenty-eight patients treated at our department from January 1994 to January 1996 were studied. The dose distribution within the irradiated breast was calculated using a (60)Co-gamma ray and 6 MV-X ray. Then we compared 3-D dose distributions of the (60)Co-gamma ray and 6 MV-X ray in different-sized breasts. Three parameters (breast volume, chest wall separation, and breast height) were adopted as representative of breast size. We also examined correlations among the three parameters.

RESULTS

When the breast size was large (breast volume >400 cm(3), chest wall separation > 19.5 cm, or breast height > 6.5 cm), the average volume of normal tissue which received more than 110% of the isocenter dose ("hot spot") was significantly greater with the (60)Co-gamma ray than with the 6 MV-X ray (p < 0.05). A similar result was obtained with regard to hot spots in the clinical target volume. The cold area that received less than 95% of the isocenter dose was greater using a 6 MV-X ray when the breast size was small (breast volume <200 cm(3), chest wall separation <17.5 cm, or breast height <5.0 cm). However, the difference was not significant. There was a significant correlation between breast volume and chest wall separation (r =0.849, p <0.001). Breast volume and breast height were also significantly correlated (r =0.813, p <0.001).

CONCLUSIONS

Since breast volume and shape are different in each patient, the optimal energy should be selected for each case to obtain uniform dose distribution in breast-conserving therapy. Chest wall separation or breast height, which are measurable without a 3-D planning system, can substitute for breast volume as parameters for breast size. We recommend that the (60)Co-gamma ray not be used for treating large breasts, those with chest wall separation > or =19.5 cm or breast height > or =6.5 cm.

The significance of a supraclavicular node metastasis in patients with breast cancer. A literature review

BACKGROUND

Data on the incidence, the risk factors, the possibilities of the different adjuvant therapies in the prevention and the prognosis of a supraclavicular metastatic node in a patient with breast cancer are rather scarce, when compared with the literature on axillary nodes.

MATERIALS

Relevant literature.

RESULTS

In spite of the low attention in the literature, we could have an insight on its incidence, the impact of positive axillary nodes, the rather low efficiency of chemotherapy in preventing them and the more pronounced effect of locoregional radiotherapy.

CONCLUSION

The prognosis is rather dismal as supraclavicular nodes are mostly the prelude to new metastases. Supraclavicular nodes can well be treated but the treatment does not influence survival.

Invited review: tangential breast irradiation--rationale and methods for improving dosimetry

In recent years there have been great advances and innovations in all technical aspects of radiotherapy, including three dimensional (3D) computer planning, patient immobilization, radiation delivery and treatment verification. Despite this progress, the technique of tangential breast irradiation has changed little over this period and has not exploited these advances. There is increasing evidence that dose inhomogeneity within the breast is greater than at other anatomical sites, especially in women with large breasts. This paper is a review of the factors contributing to poor dosimetry in the breast, the clinical consequences of an inhomogeneous dose distribution, and how breast dosimetry could be improved by considering each of the stages from planning to accurate treatment delivery. It also highlights the particular problem of women with large breasts who may be more likely to have a poorer cosmetic outcome after a fractionated course of radiotherapy than women with small/medium-sized breasts, and supports the clinical impression that such women are also more likely to have greater dose inhomogeneity when 3D treatment plans are examined. Preliminary data from our current computed tomography (CT) planning study are presented to support these observations.

Classical prognostic factors for survival and loco-regional control in breast cancer patients treated with radical mastectomy alone

A retrospective analysis of clinical and pathological prognostic factors was performed in 1,068 breast cancer patients treated with radical mastectomy alone in 1952-1980. Three endpoints were considered: 10-year survival, 10-year disease-free survival and 10-year loco-regional relapse-free survival. Both univariate and multivariate analyses confirmed the prognostic significance of tumour size, histological type and grade (Bloom classification) and involvement of axillary nodes for all three endpoints. Additionally, young age appeared to be a significant risk factor for loco-regional disease-free survival. Prognostic subgroups were defined by the use of 3 main indicators. In node negative patients with T1 tumours the prognosis seemed to be good regardless of histological grade (80-90% 10-year disease-free survival), in T2 tumours the survival was significantly dependent on histological type and grade. In node positive patients increasing number of involved nodes and higher histological grade had an independent adverse effect on all three endpoints. The study demonstrates that classical, commonly available prognostic factors clearly distinguish subgroups with different prognosis, which may be helpful when deciding on the use of adjuvant local and/or systemic therapies.

Breast-conserving treatment of early breast cancer. Results in a common clinical trial

Results of large prospective trials, often based on selected series and optimal treatment techniques, indicate that breast conserving therapy is appropriate for most patients with early breast cancer. Questions remain regarding the therapeutic outcome in common practice. We report on a series of 206 consecutive, unselected patients treated with current radiotherapy procedures. The Kaplan-Meier evaluation showed 5- and 8-year survival rates (93%, 91%), distant disease-free survival rates (87%, 85%) and local relapse-free survival rates (90%, 88%) that were comparable to those of the conservative arms in reported randomised trials and to the data from retrospective studies reported by authoritative institutions. However, subanalysis according to prognostic factors such as menopausal status, age and axillary nodal status was of limited value, due to the small number of cases.

Prognosis and treatment in minimal breast cancer

Of 176 patients with minimal breast cancer, 138 had intraductal carcinoma in situ, 21 minimally invasive carcinoma, and 17 lobular carcinoma in situ. Various modalities of treatment were used including radical, modified radical, and simple mastectomy with and without radiation therapy. Long-term postoperative follow-up was available in all but five patients and ranged from one year to twenty-one years. Actuarial analysis projected a twenty year survival of 93.2 per cent for the entire group. Analysis of survival figures based on each of the several treatment modalities showed no definite advantage of one form of treatment over another. The data suggest that minimal breast cancer is a prognostically favorable diagnosis, provided invasive carcinoma is not present or does not develop in the opposite breast. It is also indicated that breast cancer is potentially a bilateral disease and that follow-up and treatment of the opposite breast must be of major concern in the care of these patients.

Review of local soft tissue recurrence of breast cancer irradiated with and without actinomycin-D

Between 1962 and 1973, regionally recurrent breast cancer was treated in 156 patients by irradiation alone or irradiation with concurrent actinomycin-D. Thirty-two patients were entered into a randomized trial, and 124 patients were retrospectively reviewed. Local control with irradiation alone was achieved in 48 of 80 patients (60%) and in 60 of 76 patients (79%) treated with irradiation and actinomycin-D (p less than .05). Results were remarkably similar in the randomized and retrospective series.

The role of postoperative irradiation in carcinoma of the breast

Chest wall and regional nodal recurrences, and survival following postmastectomy radiation therapy, were analyzed in 352 patients. Patients with T1 and T2 central and medial breast lesions, negative axillary nodal findings, and no evidence of skin or chest wall extension received irradiation to the peripheral lymphatics alone. There were no chest wall recurrences among these patients. The remainder of the patients, including those with axillary nodal involvement, regardless of the site of the primary breast lesion received irradiation by a three-field technique directed to both chest wall and regional nodes. The chest wall recurrence rate was 1.9% when axillary nodes were negative for metastatic disease, 1.3% when the axillary nodes showed less than 50% positivity, and 14.2% when axillary nodes showed greater than 50% involvement. The overall chest wall recurrence rate was 5.1%. A possible mechanism of chest wall recurrence is discussed. Cumulative 5-year survival for stage I is 76%, for stage II, 79%, and for stage III, 57%. If chemotherapy proves to be effective in controlling distant microscopic disease local control may become an equally critical issue in long-term survival of patients with breast carcinoma.