Recent advances in breast cancer radiotherapy: Evolution or revolution, or how to decrease cardiac toxicity?

Use of helical tomotherapy in locally advanced and/or metastatic breast cancer for locoregional treatment

OBJECTIVE

Helical tomotherapy (HT) is a new promising tool whose use remains to be studied. This work assesses its impact for local irradiation in terms of side effects, as well as tumour control in locally advanced (LABC) and metastatic breast cancer (MBC).

METHODS

We retrospectively reviewed data of 66 patients with LABC and MBC. Patients received standard fractionated radiotherapy by HT, with or without concurrent systemic treatment.

RESULTS

The median age was 60 years (28-77). The median follow-up of the population was 35.9 months (10.6-95.8). For 91% of patients, HT was concomitant with systemic treatments. Three patients experienced grade 3 skin toxicity and all had concurrent 5FU-vinorelbine. One patient who was receiving concurrent treatment with trastuzumab-pertuzumab had a decreased left ventricular ejection fraction by 14%. No late cardiac or lung toxicity was observed. A clinical benefit was observed in 75% of cases. At 2 months after HT, we observed tumour regression in 7/8 patients, as following: 1 complete, 4 partial responses, and 2 stable disease. The median survival for MBC group was 64.4 months (42.6-65.8) and 21.1 (6.1-36.1) months for LABC.

CONCLUSION

This study suggests that the use of HT is well tolerated and feasible with a multimodal strategy that includes concurrent systemic treatments for patients with LABC and MBC. Advances in knowledge: The survival of LABC and MBC increases and new safe tools are needed to determine optimal strategies of treatment. To our knowledge, this is the first paper describing the use of HT for this population.

First international consensus guidelines for breast cancer in young women (BCY1)

The 1st International Consensus Conference for Breast Cancer in Young Women (BCY1) took place in November 2012, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for management of breast cancer in young women were developed and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Visualisation of the left anterior descending coronary artery on CT images used for breast radiotherapy planning

OBJECTIVE

To assess the visualisation of the left anterior descending (LAD) coronary artery on CT images used for breast radiation treatment planning.

METHODS

Delineation of the LAD artery was achieved for 25 breast patients by 1 radiologist and 1 radiation oncologist independently on two sets of images for each patient: one pre-operative CT scan using intravenous (IV) contrast media to determine the primary gross tumour volume (GTV) and one post-operative CT scan used for treatment planning. A Student's paired t-test was used to compare the number of CT slices in which the LAD was visible for each patient in the two series. Interpolations and extrapolations of the LAD volume were performed for the left-sided cases using a published heart atlas in order to report doses to the LAD structure.

RESULTS

There was a non-significant difference between the results with and without IV contrast media (p=0.34 for the radiologist; p=0.90 for the radiation oncologist). The visible LAD artery corresponded to a 30% portion (range 12-47%) of the interpolated structure. The maximum dose to the left artery varied widely, from 2.7 to 41.7 Gy, in the group of patients with left breast tumours. The largest values (>25 Gy) corresponded to those patients in whom the LAD artery distal extremity lay inside the breast fields.

CONCLUSIONS

With the current planning CT protocol, only one-third of the LAD artery could be objectively visualised. Contrast-enhanced imaging used for GTV delineation before the breast surgery did not improve the visualisation of the artery.

ADVANCES IN KNOWLEDGE

This study has revealed the lack of consistency that may be encountered when contouring heart vessels, thereby questioning the reliability of dose reporting.

Novel eradicative high-dose rate brachytherapy for internal mammary lymph node metastasis from breast cancer

AIM: To develop a method of delivering an eradicative high radiotherapeutic dose safely preserving the surrounding skin in the treatment of internal mammary lymph node metastasis (IMLNM) of breast cancer.

METHODS: We report a 38-year-old female patient with a solo IMLNM showing no response to 60 Gy in 2.5 Gy fractions of external beam radiotherapy. To eradicate this tumor, a boost brachytherapy plan was created after percutaneous insertion of an applicator needle into the IMLNM lesion avoiding the pleura and vessels under ultrasound monitoring. According to the dose distribution, the required thickness of a spacer between the skin and the tumor was determined, and hyaluronic gel was injected up to this thickness under ultrasound monitoring. We evaluated skin doses, target doses and clinical outcome.

RESULTS: All procedures were performed easily. Sixteen Gy (34.7 Gy equivalent in 2 Gy fractions calculated by the linear quadratic model at α/β = 10: EQD_{2, α/β = 10}, cumulative total was 101.9 Gy EQD10) to 100% of the target volume was irradiated with cumulative maximum skin dose of 70 Gy EQD_{2, α/β = 3} which was 98.7 Gy EQD_{2, α/β = 3} without spacer. No procedure related- or late complications and no local recurrence at the treated site were observed for three years until expiration.

CONCLUSION: We consider that this procedure will provide an eradicative high-dose irradiation to IMLNM of breast cancer, preserving skin from overdose complications.

Clinical practice guidelines for breast cancer rehabilitation: syntheses of guideline recommendations and qualitative appraisals

BACKGROUND

Despite strides in early detection and management of breast cancer, the primary treatments for this disease continue to result in physical impairments for some of the nearly 3 million people diagnosed annually. Over the past decade, evidence-based clinical practice guidelines (CPGs) have been developed with goals of preventing and ameliorating these impairments. However, translation of these guidelines into clinical practice needs to be accelerated.

METHODS

Relevant health science databases (2001-2011) were searched to identify CPGs on breast cancer rehabilitation for the following impairments: upper extremity restrictions, lymphedema, pain, fatigue, chemotherapy-induced peripheral neuropathy, treatment-related cardiotoxicity, bone health, and weight management.

RESULTS

Recommendations from 19 relevant CPGs were first summarized by impairment within tables; commonalities across guidelines, within each impairment, were then synthesized within the article. The CPGs were rated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II); wide variability was noted in rigor of development, clarity of presentation, and stakeholder involvement. The most rigorous and comprehensive of those rated was the adult cancer pain guideline from the Scottish Intercollegiate Guidelines Network.

CONCLUSIONS

Based on a large body of evidence published in recent years, including randomized trials and systematic reviews, there is an urgent need for updating the guidelines on upper extremity musculoskeletal impairments and lymphedema. Furthermore, additional research is needed to provide an evidence base for developing rehabilitation guidelines on management of other impairments identified in the prospective surveillance model, eg, arthralgia.

The impact of the loco-regional treatment in elderly breast cancer patients: hypo-fractionated exclusive radiotherapy, single institution long-term results

PURPOSE

To assess the efficacy of exclusive hypo-fractionated radiotherapy (HFRT) without previous breast-conserving surgery (BCS) in elderly women.

MATERIALS AND METHODS

From 1995 to 1999, we have treated with breast-conserving treatment 396 patients older than 70 years with early-stage breast cancer (T1,T2 tumours) at the Institut Curie, Paris, France. Seventy-nine consecutive elderly non-metastatic patients treated for early breast cancer have been treated with HFRT. Of them, 50 underwent BCS followed by HFRT of 32.5 Gy/5 fractions/5 weeks, and 29 patients (presented with different co-morbidities, inoperable or patients' refusal, and/or transportation problems) received the same HFRT schedule followed by a 13 Gy boost (two fractions of 6.5 Gy) as exclusive radiotherapy treatment. This population of 29 patients has been studied. In case of hormonal positive status, hormonal therapy was also proposed to the patients.

RESULTS

There was a median follow-up of 93 months (9-140 months). At 7-year follow-up, the cause-specific survival was 96.4% (confidence interval (CI) 95: 89.8.6-100%), the metastasis-free survival rate was 92.4% (CI 95: 82.8-100%) and the loco-regional control rate was 95.8% (CI 95: 88.2-100%).

CONCLUSIONS

This long-term follow-up retrospective study demonstrated acceptable local control and good outcome in elderly patients treated by exclusive HFRT for early breast cancer. However, large-scale prospective randomised trials are needed to confirm these results.