The use of electron beams in treating local recurrence of breast cancer in previously irradiated fields

SEOM clinical guidelines in advanced and recurrent breast cancer (2018)

Although the metastasic breast cancer is still an incurable disease, recent advances have increased significantly the time to progression and the overall survival. However, too much information has been produced in the last 2 years, so a well-based guideline is a valuable document in treatment decision making. The SEOM guidelines are intended to make evidence-based recommendations on how to manage patients with advanced and recurrent breast cancer to achieve the best patient outcomes based on a rational use of the currently available therapies. To assign a level of certainty and a grade of recommendation the United States Preventive Services Task Force guidelines methodology was selected as reference.

Re-irradiation and Hyperthermia in Breast Cancer

Half of locoregional recurrences after breast cancer treatment are isolated events. Restaging should be carried out to select patients for curative salvage treatment. The approach depends on the characteristics of the primary and recurrent cancer, previous locoregional and systemic treatments, site of recurrence, comorbidities and the patient's wishes. A multidisciplinary discussion should be associated with the shared decision-making process. In view of the potential long-term disease-free survival, meticulous target volume delineation and selection of the most appropriate techniques should be used to decrease the risk of toxicity. This overview aims to provide clinicians with tools to manage the different scenarios of breast cancer patients with locoregional recurrences in the context of re-irradiation.

Plesiobrachytherapy for chest wall recurrences of breast cancer after mastectomy and radiotherapy for breast cancer

PURPOSE

The purpose of the study was to evaluate the results of high-dose-rate plesiobrachytherapy for local relapse after mastectomy and radiotherapy in terms of both local control and survival.

METHODS

We reviewed retrospectively 43 patients who experienced a chest wall relapse of breast cancer after local excision (22 patients) or not (21 patients). Patients were treated with an individually designed mold with four to six fractions of 3-6 Gy high-dose-rate brachytherapy, two fractions per week. Mean total dose was 24 Gy.

RESULTS

After surgical resection, the 3- and 5-year local control rates were 80% and 73%, respectively. For nonresectable patients, the overall response rate was 86%, and the 3-year infield local control and chest wall local control were 51% and 26%, respectively. The 5-year survival rate was 50.5% for the whole population, 62% after surgery, and 45.4% for irresectable patients. Acute Grade 2 or 3 toxicity occurred in 43% of the patients, resolving in a few days. Two patients had a local necrosis lasting 3 to 7 months. Late toxicity was observed in 5 patients.

CONCLUSIONS

High-dose-rate plesiobrachytherapy is a simple outpatient technique to treat chest wall local relapse of breast cancer. As a reirradiation technique, its tolerance is acceptable. This technique may obtain long-term local control after incomplete surgery; in case of nonresectable disease, a high response rate was observed, which might improve the quality of life of these patients.

DEGRO practical guidelines for radiotherapy of breast cancer VI: therapy of locoregional breast cancer recurrences

Objective

To update the practical guidelines for radiotherapy of patients with locoregional breast cancer recurrences based on the current German interdisciplinary S3 guidelines 2012.

Methods

A comprehensive survey of the literature using the search phrases “locoregional breast cancer recurrence”, “chest wall recurrence”, “local recurrence”, “regional recurrence”, and “breast cancer” was performed, using the limits “clinical trials”, “randomized trials”, “meta-analysis”, “systematic review”, and “guidelines”.

Conclusions

Patients with isolated in-breast or regional breast cancer recurrences should be treated with curative intent. Mastectomy is the standard of care for patients with ipsilateral breast tumor recurrence. In a subset of patients, a second breast conservation followed by partial breast irradiation (PBI) is an appropriate alternative to mastectomy. If a second breast conservation is performed, additional irradiation should be mandatory. The largest reirradiation experience base exists for multicatheter brachytherapy; however, prospective clinical trials are needed to clearly define selection criteria, long-term local control, and toxicity.

Following primary mastectomy, patients with resectable locoregional breast cancer recurrences should receive multimodality therapy including systemic therapy, surgery, and radiation +/− hyperthermia. This approach results in high local control rates and long-term survival is achieved in a subset of patients. In radiation-naive patients with unresectable locoregional recurrences, radiation therapy is mandatory. In previously irradiated patients with a high risk of a second local recurrence after surgical resection or in patients with unresectable recurrences, reirradiation should be strongly considered. Indication and dose concepts depend on the time interval to first radiotherapy, presence of late radiation effects, and concurrent or sequential systemic treatment. Combination with hyperthermia can further improve tumor control.

In patients with isolated axillary or supraclavicular recurrence, durable disease control is best achieved with multimodality therapy including surgery and radiotherapy. Radiation therapy significantly improves local control and should be applied whenever feasible.

Current Treatment of Isolated Locoregional Breast Cancer Recurrences

Patients with isolated locoregional breast cancer recurrences should be treated with curative intent. Mastectomy is regarded as the standard of care for patients with ipsilateral breast tumor recurrence. In a selected group of patients, partial breast irradiation after second breast-conserving surgery is a viable alternative to mastectomy. If a second breast conservation is performed, additional irradiation should be mandatory, especially in patients who had not been irradiated previously. In case of re-irradiation, the largest experience exists for multi-catheter brachytherapy. Prospective clinical trials are needed to clearly define selection criteria, long-term local control, and toxicity. In patients with resectable locoregional breast cancer recurrences after mastectomy, multi-modal therapy comprising complete resection, radiation therapy in previously unirradiated patients, and systemic therapy results in 5-year disease-free and overall survival rates of 69% and 88%, respectively. In radiation-naive patients with unresectable, isolated locoregional recurrences, radiation therapy is mandatory. In selected patients with previous irradiations and unresectable locoregional recurrences, a second irradiation as part of an individual treatment concept can be applied. The increased risk of severe toxicity should always be weighed up against the potential clinical benefit. A combination therapy with hyperthermia can further improve the treatment results.

Absorbing materials with applications in radiotherapy and radioprotection

The radiotherapy centres are using linear accelerators equipped with multi-leaf collimators (MLCs) for treatments of various types of cancer. For superficial cancers located at a maximum depth of 3 cm high-energy electrons are often used, but MLC cannot be used together with electron applicators. Due to the fact that the tumour shape is not square (as electron applicators), searching for different materials that can be used as absorbents or shields for the protection of adjacent organs is of paramount importance. This study presents an experimental study regarding the transmitted dose through some laboratory-made materials when subjected to electron beams of various energies (ranging from 6 to 15 MeV). The investigated samples were composite materials consisting of silicon rubber and micrometre aluminium particles with different thicknesses and various mass fraction of aluminium. The measurements were performed at a source surface distance of 100 cm in the acrylic phantom. The experimental results show that the transmitted dose through tested samples is ranging between ∼1.8 and 90%, depending on the electron beam energy, sample thickness and sample composition. These preliminary results suggest that the analysed materials can be used as absorbers or shields in different applications in radiotherapy and radioprotection.

Bolus electron conformal therapy for the treatment of recurrent inflammatory breast cancer: a case report

The treatment of locoregionally recurrent breast cancer in patients who have previously undergone radiation therapy is challenging. Special techniques are often required that both eradicate the disease and minimize the risks of retreatment. We report the case of a patient with an early-stage left breast cancer who developed inflammatory-type recurrence requiring re-irradiation of the chest wall using bolus electron conformal therapy with image-guided treatment delivery. The patient was a 51-year-old woman who had undergone lumpectomy, axillary lymph node dissection, and adjuvant whole-breast radiation therapy for a stage I left breast cancer in June 1998. In March 2009, she presented at our institution with biopsy-proven recurrent inflammatory carcinoma and was aggressively treated with multi-agent chemotherapy followed by mastectomy that left a positive surgical margin. Given the patient's prior irradiation and irregular chest wall anatomy, bolus electron conformal therapy was used to treat her chest wall and draining lymphatics while sparing the underlying soft tissue. The patient still had no evidence of disease 21 months after treatment. Our results indicate that bolus electron conformal therapy is an accessible, effective radiation treatment approach for recurrent breast cancer in patients with irregular chest wall anatomy as a result of surgery. This approach may complement standard techniques used to reduce locoregional recurrence in the postmastectomy setting.

Reirradiation as a component of the multidisciplinary management of locally recurrent breast cancer

BACKGROUND AND PURPOSE

Our intent was to review a modern multidisciplinary institutional experience involving reirradiation of the breast, chest wall, and lymphatics for locoregional recurrences of breast cancer and report toxicity and clinical outcomes.

MATERIALS AND METHODS

Between 1995 and 2009, 12 locoregional recurrences were reirradiated in 8 patients. The mean dose of initial radiotherapy was 57.1 Gy (range, 50.4-60.6 Gy), and the mean dose of reirradiation was 46.7 Gy (range, 30-62.1 Gy). The second course of radiotherapy was delivered using daily radiotherapy to 5 recurrences, twice-daily radiotherapy to 5 recurrences (1 with mold brachytherapy boost), and a combination of once- and twice-daily radiotherapy to 2 recurrences.

RESULTS

The median follow-up from time of completion of reirradiation was 30 months (range, 1.5-67 months). Local control was achieved in 7 of 8 patients and 11 of 12 recurrences. Regional control was achieved in 5 of 8 patients and 6 of 12 recurrences. Distant control was achieved in 5 of 8 patients. At time of analysis, 5 of 8 patients were alive. Median survival since reirradiation completion was 36 months (range, 4.5-47 months). Acute toxicity included grade 2 dermatitis in 4 patients, ipsilateral shoulder pain in 1 patient, and ipsilateral pleurisy in 1 patient. Late skin and soft tissue toxicity manifested as fibrosis in 4 patients, hyperpigmentation in 3 patients, and telangiectasia in 3 patients. Three patients reported lymphedema, 1 patient reporting chest wall pain and 1 patient with an ipsilateral rib fracture.

CONCLUSIONS

Multidisciplinary management of locoregional recurrence of breast cancer using reirradiation is well tolerated as salvage treatment and provides durable locoregional control.

Isolated skin recurrence following salvage mastectomy for intramammary recurrence (after initial breast conservation therapy): is it a fatal event?

AIMS

The authors analyzed the outcome of patients with Isolated Skin Recurrence After Salvage Mastectomy (ISRASM) performed after conservative treatment for breast carcinoma, taking into account initial tumor characteristics, intramammary recurrence (first recurrence) characteristics, local skin recurrence (second recurrence) characteristics, and the type of treatment at each stage of the breast cancer continuum.

METHODS

Forty-two patients who had ISRASM between 1976 and 2007 were included in this retrospective study. Twenty-six factors were studied in univariate and multivariate analyses.

RESULTS

Mean Overall Survival (OS) was 70.3 (±4.1) months. The 5-year OS rate was 66.6%. 31% of patients did not present any recurrence, 52% had locoregional recurrence and 14% metastatic recurrence following ISRASM. Univariate analysis showed that 4 prognostic factors were significantly related to OS and/or Disease-Free Survival (DFS): (1) initial chemotherapy after primary breast cancer (P = 0.09 and 0.01 respectively), (2) presence of emboli at the site of intramammary recurrence (first recurrence) (P = 0.02 and 0.03), (3) interval between first and second surgery of less than 3 years (P = 0.09 and 0.0003), and (4) inflammatory skin involvement at ISRASM (P = 0.005 and 0.17). Multivariate analysis showed that presence of emboli at the site of intramammary recurrence was significantly related to OS and that an interval between first and second recurrence of less than 3 years was significantly related to DFS.

CONCLUSION

Our results show that ISRASM affects a group of breast cancer patients with predominantly local rather than metastatic disease. Prognostic factors depend on characteristics at initial breast cancer, first recurrence and second recurrence. Evidence-based guidelines are still required for ISRASM management.

Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region

PURPOSE

Reirradiation of breast cancer locoregional recurrence (LRR) in the setting of prior post-mastectomy radiation poses a significant clinical challenge due to the high risk for severe toxicity. In an attempt to reduce these toxicities, we have developed pulsed reduced dose-rate radiotherapy (PRDR), a reirradiation technique in which a series of 0.2 Gy pulses separated by 3-min time intervals is delivered, creating an apparent dose rate of 0.0667 Gy/min. Here we describe our early experience with PRDR.

PATIENTS AND METHODS

We reirradiated 17 patients with LRR breast cancer to the chest wall, axilla, or supraclavicular region using PRDR. The median prior radiation dose was 60 Gy. We delivered a median PRDR dose of 54 Gy (range 40-66 Gy) in 1.8-2.0 Gy per fraction. Eight patients received concomitant low dose capecitabine for radiosensitization. The median treatment volume was 2,084 cm(3) (range 843-7,881 cm(3)).

RESULTS

At a median follow-up of 18 months (range 4-75 months) only 2 patients have had tumor failure in the treatment region. Estimated 2-year local control rate is 92%. Treatment was well tolerated with 4 patients experiencing grade 3 acute skin toxicity. Despite a median cumulative dose of 110 Gy (range 80-236 Gy), there has been only one grade 3 and one grade 4 late toxicity.

CONCLUSIONS

With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.

Multi-institutional review of repeat irradiation of chest wall and breast for recurrent breast cancer

PURPOSE

To review the toxicity and clinical outcomes for patients who underwent repeat chest wall or breast irradiation (RT) after local recurrence.

METHODS AND MATERIALS

Between 1993 and 2005, 81 patients underwent repeat RT of the breast or chest wall for locally recurrent breast cancer at eight institutions. The median dose of the first course of RT was 60 Gy and was 48 Gy for the second course. The median total radiation dose was 106 Gy (range, 74.4-137.5 Gy). At the second RT course, 20% received twice-daily RT, 54% were treated with concurrent hyperthermia, and 54% received concurrent chemotherapy.

RESULTS

The median follow-up from the second RT course was 12 months (range, 1-144 months). Four patients developed late Grade 3 or 4 toxicity. However, 25 patients had follow-up >20 months, and no late Grade 3 or 4 toxicities were noted. No treatment-related deaths occurred. The development of Grade 3 or 4 late toxicity was not associated with any repeat RT variables. The overall complete response rate was 57%. No repeat RT parameters were associated with an improved complete response rate, although a trend was noted for an improved complete response with the addition of hyperthermia that was close to reaching statistical significance (67% vs. 39%, p = 0.08). The 1-year local disease-free survival rate for patients with gross disease was 53% compared with 100% for those without gross disease (p < 0.0001).

CONCLUSIONS

The results of our study have shown that repeat RT of the chest wall for patients with locally recurrent breast cancer is feasible, because it is associated with acceptable acute and late morbidity and encouraging local response rates.

Long-term results of reirradiation for patients with recurrent rectal carcinoma

BACKGROUND

The current study was conducted to assess the long-term results of reirradiation in patients with recurrent rectal carcinoma.

METHODS

One hundred and three patients with recurrent adenocarcinoma of the rectum underwent reirradiation with concurrent 5-fluorouracil-based chemotherapy. The initial radiation dose to the pelvis ranged from 3000 to 7400 centigrays (cGy) with a median dose of 5040 cGy. The median time from initial treatment to recurrence was 19 months. Irradiation techniques consisted of two lateral fields with/without a posterior pelvic field to include recurrent tumor with a margin of 2-4 cm only. The reirradiation doses ranged from 1500 to 4920 cGy with a median dose of 3480 cGy. Total cumulative doses ranged from 7060 to 1080 cGy with a median total dose of 8580 cGy. After the reirradiation, 34 patients also underwent surgical resection for residual disease. Fourteen patients underwent pelvic exenteration, 11 patients underwent abdominoperineal resection, 4 patients underwent transanal transabdominal proctosigmoidectomy, 2 patients underwent full thickness local excision, and 3 patients underwent a Hartmann resection.

RESULTS

Follow-up ranged from 3 84 months with a median follow-up of 2 years. The median survival for the whole group was 26 months and the 5-year actuarial survival rate was 19%. The median interval and 5-year survival rate of patients undergoing surgical resection after reirradiation was 44 months and 22% compared with 14 months and 15% for patients treated with reirradiation only (P = 0.001). Treatment was generally well tolerated. Fifteen patients required a treatment break and early termination of treatment for Grade 3 and higher diarrhea, moist desquamation, or mucositis. Late complications were seen in 22 patients, including persistent severe diarrhea in 18 patients with 10 patients requiring long-term parental support, small bowel obstruction was seen in 15 patients, fistula formation in 4 patients, and coloanal stricture in 2 patients. There was no difference in incidence of acute or long-term complications by the total radiation dose delivered.

CONCLUSIONS

In patients with recurrent rectal carcinoma, high doses of reirradiation can be delivered with acceptable risks without prohibitive long-term side effects. Surgical salvage and long-term survival of patients are possible.

The role of radiotherapy in patients undergoing mastectomy for carcinoma of the breast

Several factors, including T stage, nodal involvement, grade, the presence of lymphovascular invasion, and possibly involved or close surgical margins, have been found to affect local recurrence after mastectomy. The majority of recurrences will occur in the first 5 years and 50% of patients will have metastatic disease at the time of recurrence. Early studies on the use of adjuvant radiotherapy are difficult to interpret owing to poor radiotherapy techniques, inadequate dose or a variety of confounding variables within a particular trial. More recent reports have confirmed that adjuvant radiotherapy will reduce the risk of local recurrence and in tumours of <5 cm with involved nodes, produce a reduction in breast cancer deaths. Improvements in breast cancer mortality may however be counterbalanced by increases in cardiac events and deaths caused by second malignancies. This stresses the importance of using megavoltage irradiation and avoiding excess cardiac doses particularly when treating left-sided tumours. Adjuvant radiotherapy combined with tamoxifen has been shown to produce an improvement in both local control and survival in postmenopausal node-positive patients who have undergone mastectomy. Adjuvant radiation combined with systemic chemotherapy has a significant effect on local recurrence and probably on survival in node-positive patients after mastectomy. There is little controversy over its role in patients with tumours >5 cm, with more than four nodes involved or with one to three nodes with extracapsular extension, or in those in whom axillary surgery has been deemed inadequate (i.e. <10 nodes). Debate still exists concerning T1/T2, G1/G2 tumours with only one to three nodes involved when the axillary surgery has been satisfactory (>10 nodes). The ongoing Intergroup trial may answer this question but until then other factors such as tumour grade and the presence of lymphovascular invasion can be included in the equation to determine which of the patients in the latter group should receive postoperative radiotherapy. Controversy still exists about what fields should be irradiated and in particular whether the supraclavicular fossa and internal mammary node chain should be included in adjuvant therapy. The EORTC is presently conducting a randomized trial, which should give us the answer. Treatment at relapse on the chest wall may require a combination of surgery, radiotherapy and chemotherapy, depending on previous therapy. If radiotherapy has not previously been used, then wide-field irradiation should be administered, including both chest wall and supraclavicular fossa with or without the axilla, depending on the extent of previous axillary surgery and the risk of lymphoedema. Re-irradiation after radical adjuvant radiotherapy can be considered only for selected patients when an adequate discussion with them has taken place with regard to the relative benefits versus toxicity.

Results of chest wall reirradiation using pulsed-dose-rate (PDR) brachytherapy molds for breast cancer local recurrences

PURPOSE

We report in a retrospective study on the effect and toxicity of chest wall reirradiation using pulsed-dose-rate (PDR) afterloading molds.

METHODS AND MATERIALS

Between 1993 and 1999, a total of 58 patients were treated. All patients presented with locally recurrent breast cancer (31 patients had concomitant distant metastases) after mastectomy and a previously completed course of radiation therapy (median, 54 Gy; range, 36-70). Indication for reirradiation was a progressive macroscopic skin recurrence in 30 cases and an incomplete surgical resection in 28 patients. Standard treatment consisted of a split course with two fractions of 20 Gy (interval, 31 days). The reference dose was prescribed to the skin surface at 5 mm distance from the source. PDR brachytherapy (37 GBq, (192)Ir) was carried out after geometric distance optimization with 0.5-1 Gy/pulse/h. The irradiated median area was 423 cm(2) (range, 100-919). The median follow-up was 18 months (range, 7-84).

RESULTS

The actuarial 1-, 2- and 3-year local recurrence-free survival rates in patients treated for macroscopic disease (microscopic disease in parenthesis) were 89% (96%), 81% (85%), and 75% (71%). Local control was obtained in 24/30 (22/28) patients. Twenty-nine of the 34 patients (85%) who deceased during follow-up were locally controlled. 9/58 patients experienced Grade III acute toxicity, 35/58 patients Grade III (29/58 telangiectasia, 6/58 contracture), and 4/58 Grade IV late toxicity (RTOG/EORTC).

CONCLUSION

Reirradiation of the chest wall using PDR brachytherapy molds is effective and provides a high local control rate with acceptable toxicity.

Clinical experience with retreatment for palliation

Every radiation oncologist is faced occasionally with the need to consider reirradiation for palliation. Because reirradiation has the potential to exceed normal tissue tolerances, there is a need to have information on the efficacy and toxicity of retreatment. This article reviews the reirradiation literature and provides guidance to clinicians with regard to the risks, benefits, and side effects of retreatment.

Curative surgical resection following reirradiation for recurrent rectal cancer

PURPOSE

In spite of adjunctive radiation and chemotherapy, 10 to 25% of patients with resected rectal cancer develop local recurrence in the pelvis. This study evaluates the potential for curative surgical resection of residual disease following reirradiation for recurrent rectal cancer.

METHODS AND MATERIALS

Thirty-nine patients with recurrent adenocarcinoma of the rectum following prior adjunctive therapy underwent reirradiation of the pelvis with concurrent intravenous infusion of 5-fluorouracil. Median time to recurrence following initial treatment was 18 months. Prior radiation doses to the pelvis ranged from 40 to 66 Gy with a median of 50.4 Gy. Reirradiation doses ranged from 20 Gy to 49.2 Gy with a median total dose of 36 Gy. Eight to 12 weeks following reirradiation patients underwent surgical resection of disease. Thirty-one patients had gross total resection of tumor.

RESULTS

Patients have been followed for 24 months to 75 months after reirradiation for recurrent rectal cancer with a median follow-up of 3 years. Reirradiation was well tolerated, with seven patients requiring a significant treatment break. Early termination of reirradiation occurred in five patients because of diarrhea, moist desquamation, or mucositis. No surgical mortality was observed. Postoperatively, two patients developed delayed wound healing. Late complications included six patients who developed small bowel obstruction with three patients developing a bowel fistula. The median survival of patients is 45 months, with a 5-year actuarial survival of 24%. Actuarial local control at 5 years was 45%. The rate of distant metastases was 17%.

CONCLUSION

Selected patients with rectal cancer who develop recurrent disease following previous adjuvant therapy can undergo successful curative surgical resection following reirradiation/chemotherapy with significant long-term survival.

Palliative reirradiation for recurrent rectal cancer

PURPOSE

The purpose of this study was to analyze the efficacy and acute and late toxicity of reirradiation for recurrent rectal cancer.

METHODS AND MATERIALS

Fifty-two patients with recurrent rectal adenocarcinoma following previous pelvic RT underwent reirradiation. Median initial RT dose to the pelvis was 50.4 Gy. Median reirradiation dose was 30.6 Gy. Twenty-two patients received 1.2 Gy b.i.d., and 30 patients received 1.8-2.0 Gy daily. Total cumulative doses ranged from 66.6 to 104.9 Gy (median: 84.4 Gy). Forty-seven patients (90%) received concurrent 5-FU chemotherapy. Forty-four patients were followed until death, and the median follow-up time was 16 months.

RESULTS

The RTOG Grade 3 acute toxicity rate was 31%. The RTOG Grade 3 and 4 late toxicity rates were 23 and 10%, respectively. On multivariate analysis, the only factor associated with reduced late toxicity was hyperfractionated delivery of reirradiation. Bleeding, pain, and mass effect were palliated completely in 100, 65, and 24% of instances, respectively, and the majority of responding patients were palliated until death. The overall median survival time from retreatment was 12 months. The 2- and 3-year overall actuarial survival rates were 25 and 14%, respectively.

CONCLUSION

This unique institutional approach to recurrent rectal cancers resulted in excellent palliation of symptoms. Late complications appeared reduced by hyperfractionated treatment delivery.

First experiences with superfractionated skin irradiations using large afterloading molds

PURPOSE

Radiotherapy of cutaneous metastases of breast cancer requires large radiation fields and high doses. This report examines the effectiveness and sequelae of superfractionated irradiation of cutaneous metastases of breast cancer with afterloading molds on preirradiated and nonirradiated skin.

METHODS AND MATERIALS

A flexible reusable skin mold was developed for use with a pulsed (PDR) afterloader. An array of 18 parallel catheters was sewn between two foam rubber slabs 5 mm in thickness to provide a defined constant distance to the skin. By selection of appropriate dwell positions, arbitrarily shaped skin areas can be irradiated up to a maximal field size of 17 x 23.5 cm2. Irradiations are performed with a nominal 37 GBq 192Ir stepping source in pulses of 1 Gy/h at the skin surface. The dose distribution is geometrically optimized. The 80 and 50% dose levels lie 5 and 27 mm below the skin surface. Sixteen patients suffering from metastases at the thoracic wall were treated with 18 fields (78-798 cm2) and total doses of 40-50 Gy applying two PDR split courses with a pause of 4-6 weeks. Eleven of the fields had been previously irradiated with external beam therapy to doses of 50-60 Gy at 7-22 months in advance.

RESULTS

For preirradiated fields (n = 10) the results were as follows: follow-up 4.5-28.5 months (median 17); local control (LC): 8 of 10; acute skin reactions: Grade 2 (moist desquamation) 2 of 10; intermediate/late skin reactions after minimum follow-up of 3 months: Grade 1 (atrophy/pigmentation): 2 of 10, Grade 2-3a (minimal/marked teleangiectasia): 7 of 10, Grade 4 (ulcer): 1 of 10; recurrencies: 2 of 10. For newly irradiated fields (n = 7) results were: follow-up: 2-20 months (median 5); LC: 6 of 7; acute reactions: Grade 1: 4 of 7, Grade 2: 3 of 7; intermediate/late skin reactions after minimum follow-up of 3 months (n = 5): Grade 2-3a: 2 of 5; recurrencies: 0 of 7. Local control could be achieved in 82% of the mold fields. Geometric optimization was mandatory to achieve a homogeneous dose distribution on the skin.

CONCLUSION

Superfractionated brachytherapy with skin molds is an effective alternative for the treatment of skin metastases of breast cancer even if the skin is preirradiated. This method is economically advantageous compared to external beam therapy, which would require several weeks. At the curved chest wall, optimized molds can provide better dose homogeneity than abutted electron fields. Skin reactions are comparable to the sequelae of orthovolt irradiation. In preirradiated areas, PDR doses should be restricted to 40-45 Gy. PDR doses of 50 Gy seem to be the limit for tolerance even in previously unirradiated fields.

Reirradiation for rectal cancer and surgical resection after ultra high doses

PURPOSE

Local recurrence of rectal cancer following high-dose pelvic radiation presents a difficult management challenge. Conventional wisdom suggests that reirradiation should be avoided and radical pelvic surgery is hazardous after ultra high-dose radiation.

METHODS AND MATERIALS

In a unique Phase I/II pilot study, 32 patients with recurrent rectal cancers following previous pelvic radiation underwent planned reirradiation to the pelvis. Initial radiation doses had ranged from 30-64.87 Gy (median dose 45 Gy). Seventeen patients underwent reirradiation followed by radical resection. Fifteen patients were reirradiated for palliative relief of symptoms. Treatment techniques consisted of two lateral fields (7 x 7 to 12 x 10 cm) encompassing the tumor with 2 cm margins. Reirradiation doses ranged from 19.80-47.66 Gy, (median 34.2 Gy). Patients also received concurrent low-dose continuous infusion chemotherapy, (5-FU 200-300 mg/day). Total cumulative radiation doses ranged from 70.6 to 111.6 Gy.

RESULTS

Treatment was well tolerated. Four patients had radiation interrupted/discontinued for diarrhea or leukopenia. Follow-up ranges from 6 months to 36 months. No late sequelae of radiation have been observed to date. Seventeen patients underwent surgical exploration 6-8 weeks following reirradiation. Two patients had extensive disease and were not resected. Fifteen patients underwent radical resection of residual tumor (4 posterior exenterations, 6 APR, 3 transanal abdominal transanal proctocolectomy with coloanal anastomosis (TAATA), and 2 LAR). No patients died postoperatively. No excessive edema, hemorrhage, or adhesions were observed. Two patients developed pelvic abscess and one developed a coloanal stricture. Eleven of 15 resected patients are alive from 6 to 36 months with a 2-year survival of 66%. Of the patients treated palliatively, symptomatic relief was observed in 13/15 patients. No objective complete response was observed, but 6/15 patients had measurable partial response. Median survival in this group was 14 months.

CONCLUSION

Based on this experience, we believe that in selected patients radical surgical resection after cumulative ultra high doses (70-90 Gy) of radiation can be performed safely. A viable anastomosis is also possible in spite of these high doses. Planned reirradiation for palliative relief of symptoms can be effective without unusual risks of complication. Long-term effects of such ultra high dose radiation and surgery continue to be monitored.

Thermoradiotherapy for residual microscopic cancer: elective or post-excisional hyperthermia and radiation therapy in the management of local-regional recurrent breast cancer

A Phase I/II study was undertaken to investigate the efficacy and side effects of combined hyperthermia and radiation therapy in the management of presumed or known microscopic residual tumors. Between February 1985 and March 1991, 262 fields in 89 patients with local-regional recurrent breast cancer were treated with externally administered hyperthermia and radiation therapy. Thirty-eight fields were treated for microscopic residual disease following excisional biopsy of nodular recurrences and 224 fields were treated electively for areas at high risk for local recurrences adjacent to fields with macroscopic residual disease. Mechanically mapped temperatures were monitored throughout the field in all treatments. All patients had at least one follow-up evaluation at three weeks or more following completion of treatment. The majority of the fields were in patients who had had extensive prior therapy including radiation therapy (54%), chemotherapy (71%), and hormonal therapy (51%). All fields received hyperthermia (1-6 treatments: average 1.74) and radiation therapy (average dose: 42.4 Gy); concurrent hormonal therapy was administered in 37% of the treatments and no fields received concurrent chemotherapy. The treatments were well tolerated, no life-threatening complications were noted. Averages for all fields of the minimum, maximum, and average measured interstitial temperatures were 40.2 degrees C, 45.3 degrees C, and 42.8 degrees C, respectively. The three-year actuarial local-control rate for all 262 treated fields was 68%. Parameters characterizing the initial breast cancer, the patient and tumor at the time of hyperthermia, and the treatment were studied in univariate and multivariate analysis for correlation with duration of local control within the hyperthermia treatment field. Parameters in the best five covariate model correlating with the duration of local control included: estrogen receptor status of the initial breast cancer; initial T-stage; time from initial breast cancer to first failure; age at hyperthermia; and concurrent radiation dose (p-value for model less than 0.000001). Six covariate models adding anatomic site of disease, field type, mean minimum temperatures, and mean percent temperatures greater than or equal to 40 degrees C all resulted in improved models. Randomized controlled studies stratifying for these pretreatment parameters are felt warranted to confirm the value of adjuvant hyperthermia in the elective treatment of areas of high risk for local-regional recurrent breast cancer and in fields following surgical excision of recurrent disease, particularly in patients in whom full dose radiation therapy cannot be safely administered.

Iridium 192 plesiocurietherapy using silicone elastomer plates for extensive locally recurrent breast cancer following chest wall irradiation

From July 1985 to October 1988, 11 patients with prior treatment for breast cancer, and presenting an isolated superficial widespread inoperable chest wall recurrence, underwent plesiocurietherapy for salvage. Most patients (91%) had had a mastectomy. The recurrences developed in tissue that had previously been irradiated to 45-55 Gy in three patients and 65 Gy in eight patients. Salvage was attempted using two or three courses of plesiocurietherapy at monthly intervals to decrease treatment complications. The position of the active sources was maintained parallel but slightly shifted at each application. A total dose of 60 Gy was delivered to a Reference Isodose (R.I.) located 2 to 4 mm under the skin surface. The guide system consisted of plastic tubes inserted at 1.5 cm intervals into flexible silicone plates that were applied to the skin surface to maintain the actives lines 0.5 cm above the skin surface. The high dose sleeves surrounding the actives lines (dose greater than 2 x R.I.) were contained within the thickness of the silicone plate. The mean surface treated was 480 cm2 (range 30-1030 cm2). Two patients had continued progression of the lesions within the treated volume during and after curietherapy and died rapidly of metastatic disease. Nine (89%) patients showed complete regression of treated lesions. But two patients developed a new recurrence outside the treated volume. Complications were acceptable: five patients experienced regressive moderate to severe radiation dermatitis and one had skin necrosis that healed in 2 months. These preliminary results have shown that even when tumor extension and previous treatment theorically counter-indicate further local therapy for locally recurrent breast cancer, it is possible to obtain immediate and, at times, lasting control of local disease using two or three courses of plesiocurietherapy with a source shift.

Prognosis following local or regional recurrence after conservative surgery and radiotherapy for early stage breast carcinoma

Factors which influence patient prognosis following a breast recurrence or regional nodal recurrence after initial treatment of early-stage invasive breast carcinoma with conservative surgery and radiotherapy are not well known. Ninety patients treated at the Joint Center for Radiation Therapy treated from 1968-1981 had a recurrence in the treated breast before (84) or simultaneous with (6) distant metastases. Sixty-five patients had salvage mastectomy (median subsequent follow-up in patients without further disease, 32 months; range, 1-123 months). The five-year rate of further recurrence in this group was 37%. The most important variable associated with subsequent outcome was the histology of the recurrent tumor. There were no further recurrences among 10 patients with purely non-invasive cancer or 10 patients with predominantly non-invasive disease and only focal areas of invasion. In contrast, 17/45 patients (38%) with predominantly infiltrating tumors suffered further local-regional recurrences (6) or distant metastases (11) following mastectomy (5-year actuarial rate, 55%) (p less than 0.05). Ten patients developed regional nodal failures without evidence of simultaneous breast recurrence (1 internal mammary, 3 supraclavicular, 1 both supraclavicular and axillary, and 5 axillary). Only 3 of these 10 (all with axillary node failures) did not have simultaneous distant metastases; they remain alive without evidence of further distant or local-regional recurrence following salvage treatment 1, 59, and 87 months after recurrence. We conclude that the great majority of the patients (88% in this series) who have a breast recurrence following initial conservative surgery and radiation therapy for early stage breast carcinoma will have disease limited to the breast clinically and tumors amenable to salvage mastectomy. Salvage mastectomy appears to be effective treatment for patients with an isolated breast recurrence, especially if the recurrence is predominantly or wholly non-invasive.

Low dose reirradiation in combination with hyperthermia: a palliative treatment for patients with breast cancer recurring in previously irradiated areas

Ninety-seven patients with breast cancer recurring in a previously irradiated area (mean dose 44 Gy) were reirradiated in combination with hyperthermia and had evaluable tumor responses. In the reirradiation series, radiotherapy was given twice weekly in most patients, with a fraction size varying from 200 to 400 cGy, the total dose varying from 8 to 32 Gy. Hyperthermia was given following the radiotherapy fractions. The combined treatment resulted in 35% complete and 55% partial responses. Duration of response was median 4 months for partial response and 26 months for complete response, respectively. The median survival time for all patients was 12 months. Acute skin reaction was mild, with more than moderate erythema in only 14/97 patients. Thermal burns occurred in 44/97 patients, generally at sites where pain sensation was decreased, and therefore they did not cause much inconvenience. In the 19 patients who survived more than 2 years, no late radiation damage was observed. When patients who received a "high dose" (greater than 29 Gy and hyperthermia) were compared with those who received a "low dose" (less than 29 Gy and hyperthermia), a higher complete response rate was observed in the high dose group (58% vs. 24%), whereas no difference in acute toxicity was found. We conclude that reirradiation with 8 x 4 Gy in combination with hyperthermia twice weekly is a safe, effective and well tolerated method for palliative treatment of patients with breast cancer recurring in previously irradiated areas.

Megavolt electron irradiation in the treatment of recurrent carcinoma of the breast on the chest wall

Low megavolt electron beam therapy was used to treat 68 women and one man with recurrent carcinoma of the breast on the chest wall. Photon irradiation had been used previously in 53 patients. Of the 63 patients who survived 2 months or longer after electron irradiation, 59 (94%) achieved a complete response. Persistent radiation ulcers developed in only 2 patients (3%). No other late radiation complications were observed. Nineteen patients (28%) survived 3 years after electron irradiation, with a median survival of 54 months. In this group, disease eventually recurred in all patients who received a calculated NSD of less than 1 400 ret; no disease recurred in the patients who received doses greater than 1 400 ret. It is concluded that megavolt electron irradiation is effective in the treatment of chest wall recurrence from carcinoma of the breast and is safe even in patients who have had a previous course of photon irradiation.

Major chest wall reconstruction after chest wall irradiation

In the last year, 12 patients have undergone extensive chest wall resection. Eight patients had recurrent cancer after prior resection and irradiation with an average defect of 160 square centimeters, usually including ribs and a portion of the sternum; four had radionecrosis of soft tissue and/or bone. Methods of reconstruction included latissimus dorsi musculocutaneous (MC) flap (five patients), pectoralis major MC flap (seven patients), and omental flap and skin graft (one patient). The donor site was usually closed primarily. All flaps survived providing good wound coverage. The only complication was partial loss of a latissimus dorsi MC flap related to an infected wound; this reconstruction was salvaged with a pectoralis major MC flap. The hospital stay ranged from 10-25 days with a median stay of 11 days. Use of the MC flap is a valuable tool which can be used to significantly decrease morbidity, hospital stay, and patient discomfort related to the difficult problem of chest wall reconstruction after radiation therapy.