Concurrent administration of adjuvant chemotherapy and radiotherapy after breast-conserving surgery enhances late toxicities: Long-term results of the ARCOSEIN multicenter randomized study

Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

Experimental determination of breast skin dose using volumetric modulated arc therapy and field-in-field treatment techniques

Introduction:

The use of volumetric modulated arc therapy (VMAT) on the breast has several dosimetric advantages but its impact on skin dose should be evaluated and compared to well-established treatment techniques using tangential fields. The aim of this work is to contrast the skin dose for VMAT and field-in-field (FIF) and to estimate the magnitude of the skin dose involved.

Method:

The skin dose was measured, without build-up, using thermoluminescent dosimeter (TLD) and optically stimulated luminescence dosimeter (OSLD) in breast radiotherapy by an in-house anthropomorphic phantom. Two different treatment techniques were used: FIF and VMAT, based on the planning strategy proposed by Nicolini et al. The dose levels were 4300 cGy, 4600 cGy and 5600 cGy in 20 fractions. In vivo dosimetry with TLD for VMAT was performed for different breast sizes in the same locations as phantom measurements.

Results:

The ipsilateral phantom breast skin dose using both treatment techniques was equivalent. TLD measured doses by the VMAT technique were up to 5% higher than OSLD, although they agree if we consider the geometry uncertainty of the TLD. In accordance with in vivo dosimetry, the mean dose of the ipsilateral breast skin was 62 ± 6% (51%, 75%) relative to the prescribed dose, regardless of the breast size for the volumes considered with this small population (n = 9) as shown by Mann–Whitney U-test (Z = 1·9, 95% confidence). The uncertainty expected in this region due to geometry (volume) changes is up to 9% higher for volumes from 225·9 cc to 968·8 cc. According to the treatment techniques and in vivo dosimetry, the contralateral breast skin dose was 1·0% in FIF and 2·5% in VMAT concerning the prescribed dose.

Conclusion:

There is no difference in skin dosimetry between VMAT and FIF techniques on the ipsilateral breast. It provides useful support for the use of VMAT as a planning technique for breast irradiation. The work describes the importance of quantifying potential differences in skin dosimetry.

Safety of pre- or postoperative accelerated radiotherapy in 5 fractions: A randomized pilot trial

OBJECTIVE

Neo-adjuvant radiotherapy (NART) for breast cancer has shown promising survival results in retrospective trials. However, there are some obstacles such as a chemotherapy delay, an increased overall treatment time (OTT) and the risk of increasing surgical morbidity. Accelerated radiotherapy (RT) in 5 fractions allows to deliver NART in a very short time span and minimizes the delay of surgery and chemotherapy. This trial investigates this NART schedule for safety, feasibility and OTT.

MATERIAL AND METHODS

Twenty patients eligible for neo-adjuvant chemotherapy (NACT) and breast conserving surgery, were randomized between NART before NACT or NACT and postoperative RT. In both arms, RT treatment was given in 5 fractions to the whole breast with a simultaneously integrated boost (SIB) on the tumor(bed). Lymph node irradiation was given concomitantly in case of lymph node involvement. OTT was defined as the time from diagnosis to last surgery in the intervention group, while in the control group the time between diagnosis and last RT-fraction was used. In the intervention group NACT-delay was defined as time between diagnosis and start of chemotherapy.

RESULTS

20 patients were included, and 19 patients completed treatment. OTT was significantly shorter in the intervention group (mean 218 days, range 196-253) compared to the control group (mean 237, range 211-268, p = 0.001). The difference in mean duration from diagnosis to the first treatment was a non-significant 4 days longer (31 vs 27 days, p = 0.28), but the start of NACT after diagnosis was delayed by 21 days (48 vs 27 days, p < 0.001). NART did not result in additional surgery complications.

CONCLUSION

This pilot trial is the first to report on accelerated NART in 5 fractions with SIB. NART before NACT resulted in a shorter OTT with good safety results.

Toxicity of Hypofractionated Whole Breast Radiotherapy Without Boost and Timescale of Late Skin Responses in a Large Cohort of Early-Stage Breast Cancer Patients

AIM

To report toxicity of hypofractionated whole-breast radiotherapy in a large cohort of early-stage breast cancer (BCaients.

MATERIALS AND METHODS

From 02/2009-05/2017, 1325 consecutive BCa patients were treated with 40.05 Gy/15 fractions, without boost. Median age was 62 (IQR:51.1-70.5) years. Chemotherapy was prescribed for 28% of patients, hormonal therapy for 80.3%, monoclonal antibodies for 8.2%.

RESULTS

Median follow-up was 72.4 (IQR: 44.6-104.1) months. Acute RTOG toxicity was: 69.8% Grade (G) 1, 14.3% G2 and 1.7% G3. Late SOMA-LENT toxicities were: edema-hyperpigmentation (E-H): G1 28.67%, G2 4.41%, G3 0.15%; fibrosis-atrophy-telangiectasia-pain (F-A-T-P): G1 14.6%, G2 3.2%, G3 0.8%, G4 0.1%. Median time to first occurrence was 6 and 18 months, respectively. Aesthetic result after surgery was excellent in 28.7%, good in 41.5%, acceptable in 20.3% and poor in 9.5% of patients. Change in breast appearance after radiotherapy was mild in 6.9%, moderate in 2.3% and marked in 1.3% of patients. Concomitant chemotherapy, obesity, smoking, use of bolus and planning target volume (PTV) were associated with higher acute toxicity. Patients ≥55 years old were less likely to experience acute toxicity. PTV and acute G2 toxicity were associated with ≥G2 E-H. PTV, concomitant chemotherapy, hypertension and ≥G2 acute toxicity were associated with increased risk of F-A-T-P.

CONCLUSION

Hypofractionated whole-breast radiotherapy without boost demonstrated mild acute and late toxicity in a large cohort of consecutive patients. Moderate and marked changes in breast appearance were registered for 3.6% of patients and occurred between 18 to 42 months.

SKIN AND SUBCUTANEOUS ADIPOSE TISSUE DAMAGE AFTER RADIATION THERAPY IN BREAST CANCER PATIENTS

The analysis of long-term researches of the pathological changes arising in soft tissues at patients with a breast cancer as a result of radical surgical treatment and adjuvant radiotherapy is carried out in work. The article shows that the standard approach to postoperative radiation therapy, which is based only on the prevalence of the primary tumor process is not always justified. Very often it leads to excessive radiation load on the patient's body and the development of local acute and chronic radiation reactions of the skin, subcutaneous tissue and other soft tissues.In this regard, the question of differentiated purpose of radiotherapy acquires special value first of all at patients with small primary prevalence of tumor process. The paper presents the results of studies to study changes in the anterior chest wall in patients with breast cancer. In relation to the conduct of adjuvant radiotherapy more often need to use the concept of personalized radiation therapy. Radical operation, post-radiation early and late pathological changes in soft tissues, disturbance of microcirculation of lymph and blood, disturbance of innervation of vessels of an upper extremity, peripheral nerves in system of a cervical and plexus plexus, leads to intensive degen-erative and dystrophic changes in soft tissues of the upper. and causes morphological changes in them and further progression of reflex neurovascular and neurodystrophic disorders. Based on the data of adverse effects of radio-therapy on the skin and surrounding tissues, as well as to reduce excessive radiation exposure to the patient's body, a differentiated approach to the appointment of adjuvant radiation therapy.

Breast edema, from diagnosis to treatment: state of the art

Introduction

Breast edema can arise from different etiologies; however, it is mostly seen after breast conserving surgery and/or radiotherapy. Combining breast conserving surgery and radiotherapy can cause damage to the lymphatic system and reactions to surrounding tissues, which can lead to breast edema; hereby, the breast size can increase by more than one cup size. Swelling of the breast is not the only criterion associated with breast edema. Other common criteria found in literature are peau d’orange, heaviness of the breast, skin thickening, breast pain, redness of the skin, hyperpigmented skin pores and a positive pitting sign. Despite the benefits of breast conserving surgery, breast edema can be uncomfortable, and can negatively influence quality of life in suffering patients. In contrast to lymphedema of the arm, which is well known in clinical practice and in research, breast edema is often underestimated and far less explored in literature. Currently, many aspects still need to be reviewed.

Purpose and importance to practice

This masterclass aims at providing the state of the art of breast edema for all health care workers and researchers involved in the treatment and monitoring of breast cancer patients. It includes current and future perspectives on its diagnosis, longitudinal course and treatment. Furthermore, recommendations for clinical practice and future research are discussed.

Clinical implications

It is recommended to closely monitor those patients in whom breast edema symptoms do not decline within 6 months after termination of radiotherapy and provide them with the appropriate therapy. Since evidence concerning the treatment of breast edema is currently lacking, we recommend the complex decongestive therapy (CDT) to the utmost extent, by analogy with the lymphedema treatment of the extremities. This treatment involves skin care, exercise therapy and compression. Additionally, all patients should be informed about the normal course of breast edema development.

Future research priorities

A consensus should be reached among clinicians and researchers concerning the definition, assessment methods and best treatment of breast edema. Furthermore, high quality studies are necessary to prove the effectiveness of the CDT for breast edema.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00103-4.

The effect of hyperbaric oxygen treatment on late radiation tissue injury after breast cancer: A case-series of 67 patients

INTRODUCTION

Late radiation tissue injury (LRTI) after breast cancer may benefit from hyperbaric oxygen treatment (HBOT). This study aimed to report the LRTI symptom scores up to 12 months after HBOT and identify risk factors for poor scores.

METHODS

A case-series of 67 patients who underwent a mean of 44 sessions of HBOT was analysed. LRTI symptoms were scored at four time points using the LENT-SOMA scale (Late Effects in Normal Tissues - Subjective, Objective, Management, and Analytic), a visual analog scale for pain, and the range of shoulder motion.

RESULTS

Between starting HBOT and 12 months after HBOT 57 patients (85%) reported at least one point improvement in their LENT-SOMA score. Median pain and fibrosis scores improved significantly between the start and end of HBOT (P < 0.001), and remained stable three and 12 months after HBOT. The median breast oedema score improved significantly 12 months after HBOT (P = 0.003). Median shoulder abduction increased significantly from 90 to 165 degrees (P = 0.001) and median shoulder anteflexion increased significantly from 115 to 150 degrees (P = 0.004). Various risk factors were identified for poor scores despite HBOT; the most common risk factor was a poor score at start of HBOT.

CONCLUSIONS

In this case-series, patients who underwent HBOT for LRTI after breast cancer reported significant improvement in pain, fibrosis, oedema, and shoulder movement. The improvement persisted up to 12 months after HBOT. A poor score at the start of HBOT was predictive for a poor score 12 months after HBOT.

Dermatologic toxicities associated with radiation therapy in women with breast cancer

Breast-conserving surgery with adjuvant radiation therapy has become the standard of care for women with early stage breast cancer, and as a result, a large number of patients are affected by the cutaneous sequelae of radiation therapy. These dermatologic toxicities may present during treatment or years later and can significantly impact patients’ quality of life. In this review, we discuss the clinical presentation, prevention, and management of radiation-induced cutaneous toxicities in women with breast cancer, including radiation dermatitis, radiation recall, radiation-induced morphea, radiation-induced fibrosis, and cutaneous malignancies in irradiated skin.

Development and clinimetric properties of the Dutch Breast Edema Questionnaire (BrEQ-Dutch version) to diagnose the presence of breast edema in breast cancer patients

PURPOSE

To develop a diagnostic tool, the Breast Edema Questionnaire (BrEQ) and to determine its clinimetric properties.

METHODS

The BrEQ was developed based on information from literature, experts and breast edema patients. Content validity, construct validity, test-retest reliability, internal consistency and cut-off point were investigated in a group of breast cancer patients. Construct validity made up two parts; convergent and known-groups validity. Convergent validity was tested by correlating the BrEQ with skin thickness measured with ultrasound (US).

RESULTS

In part 1 of the BrEQ, symptoms of breast edema were scored from 0 to 10: pain, heaviness, swelling, tensed skin, redness, pitting sign, enlarged skin pores and hardness. Taking into account the International Classification of Functioning, Disability and Health, several activity limitations and participation restrictions were scored from 0 to 10 in part 2. Clinimetric properties of part 1 were examined in 55 patients. US showed that 35 women had breast edema. Content validity was good. Regarding convergent validity, all breast symptoms correlated moderately with skin thickness. The total symptom score had a strong correlation with skin thickness. Concerning known-groups validity, patients with breast edema had a higher total symptom score. Test-retest reliability ranged between moderate and strong. The internal consistency was good for all items and the total symptom score. We identified that a score cut-off point of ≥ 8.5 discriminates between patients with breast edema and those without.

CONCLUSION

Part 1 of the BrEQ-Dutch version is a valid and reliable tool for assessing clinical indicators of breast edema.

Quantitative background parenchymal enhancement to predict recurrence after neoadjuvant chemotherapy for breast cancer

Breast background parenchymal enhancement (BPE) is an increasingly studied MRI parameter that reflects the microvasculature of normal breast tissue, which has been shown to change during neoadjuvant chemotherapy (NAC) for breast cancer. We aimed at evaluating the BPE in patients undergoing NAC and its prognostic value to predict recurrence. MRI BPE was visually and quantitatively evaluated before and after NAC in a retrospective cohort of 102 women with unilateral biopsy-proven invasive breast cancer. Pre-therapeutic BPE was not predictive of pathological response or recurrence. Quantitative post-therapeutic BPE was significantly decreased compared to pre-therapeutic value. Post-therapeutic quantitative BPE significantly predicted recurrence (HR = 6.38 (0.71, 12.06), p < 0.05).

Are mammographic density phenotypes associated with breast cancer treatment response and clinical outcomes? A systematic review and meta-analysis

Mammographic density (MD) increases breast cancer (BC) risk, however, its association with patient outcomes is unclear. We examined the association of baseline MD (BMD), and MD reduction (MDR) following BC treatment with patient outcomes. Six databases (CINAHL, Scopus, PubMed, Web of Science, MEDLINE, and Embase) were used to identify relevant articles. The PRISMA strategy was used to extract relevant details. Study quality and risk of bias were assessed using the "Quality In Prognosis Studies" (QUIPS) tool. A Meta-analysis and pooled risk estimates were performed. Results showed that BMD is associated with contralateral breast cancer (CBC) risk (HR = 1.9; 95%CI: 1.3-3.0, p = 0.0007), recurrence (HR = 2.0; 95%CI: 1.0-4.0, p = 0.04), and mortality (HR = 1.4; 95%CI: 1.1-1.9, p = 0.003). No association was found between BMD and prognosis (HR = 3.2; 95%CI: 0.9-11.2, p = 0.06). Data on risk estimates (95%CI) from BMD for survival [RR: 1.75; 0.99-3.1 to 2.4; 1.4-4.1], ipsilateral BC [HR: 1; 0.6-1.6 to 3; 1.2-7.5], and treatment response (OR, 1.8; 0.98-3.3) are limited. MDR showed no association with mortality (HR = 0.5; 95%CI: 0.2-1.2, p = 0.13). MDR is associated with a reduced risk of recurrence [HR/RR: 0.35; 0.17-0.68 to 1.33; 0.67-2.65)], however data on MDR and outcomes such as mortality [HR/RR: 0.5; 0.27-0.93 to 0.59; 0.22-0.88], and CBC risk [RR/HR: 0.53; 0.24-0.84 to 1.3; 0.6-2.7] are limited. Evidence, although sparse, demonstrates that high BMD is associated with an increased risk of recurrence, CBC, and mortality. Conversely, MDR is associated with a reduced risk of BC recurrence, CBC, and BC-related mortality.

Evaluation of a 3D surface imaging system for deep inspiration breath-hold patient positioning and intra-fraction monitoring

PURPOSE

To determine the accuracy of a surface guided radiotherapy (SGRT) system for positioning of breast cancer patients in breath-hold (BH) with respect to cone-beam computed tomography (CBCT). Secondly, to evaluate the thorax position stability during BHs with SGRT, when using an air-volume guidance system.

METHODS AND MATERIALS

Eighteen left-sided breast cancer patients were monitored with SGRT during CBCT and treatment, both in BH. CBCT scans were matched on the target volume and the patient surface. The setup error differences were evaluated, including with linear regression analysis. The intra-fraction variability and stability of the air-volume guided BHs were determined from SGRT measurements. The variability was determined from the maximum difference between the different BH levels within one treatment fraction. The stability was determined from the difference between the start and end position of each BH.

RESULTS

SGRT data correlated well with CBCT data. The correlation was stronger for surface-to-CBCT (0.61) than target volume-to-CBCT (0.44) matches. Systematic and random setup error differences were ≤ 2 mm in all directions. The 95% limits of agreement (mean ± 2SD) were 0.1 ± 3.0, 0.6 ± 4.1 and 0.4 ± 3.4 mm in the three orthogonal directions, for the surface-to-CBCT matches. For air-volume guided BHs, the variability detected with SGRT was 2.2, 2.8 and 2.3 mm, and the stability - 1.0, 2.1 and 1.5 mm, in three orthogonal directions. Furthermore, the SGRT system could detect unexpected patient movement, undetectable by the air-volume BH system.

CONCLUSION

With SGRT, left-sided breast cancer patients can be positioned and monitored continuously to maintain position errors within 5 mm. Low intra-fraction variability and good stability can be achieved with the air-volume BH system, however, additional patient position information is available with SGRT, that cannot be detected with air-volume BH systems.

Breast Edema Following Breast-Conserving Surgery and Radiotherapy: Patient-Reported Prevalence, Determinants, and Effect on Health-Related Quality of Life

Background

The association between lymphedema of the arm and impaired health-related QoL (HR-QoL) has led to changes in clinical practice. However, data on lymphedema of the breast (ie, breast edema) are lacking. We prospectively evaluated patient-reported prevalence and determinants of breast edema and its effect on patient-reported HR-QoL and breast pain.

Methods

We prospectively included 836 patients undergoing breast-conserving surgery followed by radiotherapy between October 2013 and October 2016 (UMBRELLA cohort). Patient-reported breast edema, HR-QoL, and breast pain were assessed by means of European Organisation for Research and Treatment of Cancer-C30/BR23 before starting radiotherapy and at 3, 6, 12, and 18 months thereafter. We assessed which patient, tumor, and treatment characteristics were associated with breast edema. With mixed-effects models, we assessed the impact of breast edema on patient-reported HR-QoL domains and breast pain over time, adjusting for confounders.

Results

Within a median follow-up of 28 months (interquartile range [IQR] = 15), 207 (24.8%) patients reported breast edema at some point in time. Prevalence of breast edema was highest at 6 months (12.4%, 95% confidence interval [CI] = 10.0 to 14.7). Larger tumor size, oncoplastic surgery, axillary lymph node dissection, locoregional radiotherapy, radiotherapy boost on the tumor bed, and adjuvant chemotherapy were associated with breast edema. Breast edema was independently associated with more breast pain and with poorer QoL, physical functioning, and body image.

Conclusions

Breast edema occurs frequently within the first year after breast-conserving surgery and radiotherapy and is independently associated with impaired HR-QoL and more breast pain. This information is important for use in clinical practice and should be discussed with patients during shared decision making.

Radiation-induced fibrosis in breast cancer: A protocol for an observational cross-sectional pilot study for personalised risk estimation and objective assessment

•

Radiation-induced fibrosis is a side-effect after treatment for breast cancer.

•

An important question is the best plan for breast reconstructive surgery.

•

Objective measures of radiation-induced fibrosis are needed.

•

Patient reported outcome measures will provide a more comprehensive assessment.

Introduction

About 30% of patients request breast reconstruction following surgery for breast cancer, but radiation therapy negatively influences the outcome. Post-reconstruction radiotherapy is associated with more complications, including more severe capsular contracture and inferior cosmetic results. In general, less fibrosis is seen if autologous reconstruction is performed after radiotherapy, so surgeons will often delay reconstruction until after radiotherapy is complete. Drawbacks to this approach include additional surgery, recuperation, cost, and an extended reconstructive process. Randomised clinical trials are required to determine the best approach.

Methods and analysis

The aim of this cross-sectional pilot study is to see if it is feasible to recruit women, and gather the required data. This information will be used to design a subsequent, larger study whose aim is to identify factors that increase the risk of radiation-induced fibrosis, and use these to develop a personalised risk-prediction tool, to enable the clinician and patient to have a more informed discussion when treatment for breast cancer is being discussed. Identification of the risk factors will also enable the development of methods to minimise the risk, which would have applications in other medical conditions where fibrosis is a problem. In addition, the project will develop objective methods of assessing fibrosis, and will determine the psychological and economic impacts that fibrosis has affected individuals. A better understanding of the long-term effects of radiotherapy on normal tissues such as the heart and lungs may also have applications in other medical conditions where fibrosis is a problem.

Ethics and dissemination

The study has been submitted for ethical approval (REC reference). Findings will be made available to patients and clinicians through presentations at national and international meetings, peer-reviewed publications, social media and patient support groups.

Trial registration

Registered on ClinicalTrials.gov (after REC approval).

Radiation Fibrosis Syndrome: the Evergreen Menace of Radiation Therapy

Fibrosis is a descriptive appellation referring to the obliteration of normal tissue components replaced by matrix and disorganized and varied collagen fibrils that result in the loss of organ function and frequent tissue contraction leading to death or significant deterioration in the quality of life. Radiation fibrosis syndrome (RFS) is a progressive fibrotic tissue sclerosis with various clinical symptoms in the irradiation field. It is usually a late complication of radiation therapy and may occur weeks or even years after treatment. It may affect the musculoskeletal, soft tissue, neural tissue, and cardiopulmonary systems. RFS is a serious and lifelong disorder that, nevertheless, may often be prevented when identified and rehabilitated early. Genetic factors likely play a significant role in the development of chronic fibrotic response to radiation injury that persists even after the initial insult is no longer present. Management of this syndrome is a complex process comprising medication, education, rehabilitation, and physical and occupational therapy. A bibliographical search was carried out in PubMed using the following keywords: "radiation fibrosis," "radiation fibrosis syndrome," and "radiation-induced fibrosis." We also reviewed the most relevant and recent series on the current management of RFS, and the reviewed data are discussed in this article. This review discusses the pathophysiology, evaluation, and treatment of neuromuscular, musculoskeletal, and functional disorders as late effects of radiation treatment.

Lysophosphatidic acid (LPA) as a pro-fibrotic and pro-oncogenic factor: a pivotal target to improve the radiotherapy therapeutic index

Radiation-induced fibrosis is widely considered as a common but forsaken phenomenon that can lead to clinical sequela and possibly vital impairments. Lysophosphatidic acid is a bioactive lipid involved in fibrosis and probably in radiation-induced fibrosis as suggested in recent studies. Lysophosphatidic acid is also a well-described pro-oncogenic factor, involved in carcinogenesis processes (proliferation, survival, angiogenesis, invasion, migration). The present review highlights and summarizes the links between lysophosphatidic acid and radiation-induced fibrosis, lysophosphatidic acid and radioresistance, and proposes lysophosphatidic acid as a potential central actor of the radiotherapy therapeutic index. Besides, we hypothesize that following radiotherapy, the newly formed tumour micro-environment, with increased extracellular matrix and increased lysophosphatidic acid levels, is a favourable ground to metastasis development. Lysophosphatidic acid could therefore be an exciting therapeutic target, minimizing radio-toxicities and radio-resistance effects.

Concurrent use of capecitabine with radiation therapy and survival in breast cancer (BC) after neoadjuvant chemotherapy

PURPOSE

Capecitabine has been studied as a radiosensitizer, and our study seeks to examine the association of concurrent capecitabine/radiation therapy (RT) on event-free- (EFS) and overall survival (OS) in women with breast cancer (BC) with residual disease after neoadjuvant chemotherapy (NAC).

METHODS/PATIENTS

In a retrospective study of women with BC who received adriamycin/taxane-based NAC from 2004-2016, we identified 21 women administered concurrent capecitabine/RT. To assess differences in survival, we selected a clinical control cohort (n = 57) based on criteria used to select patients for capecitabine/RT. We also created a matched cohort (2:1), matching on tumor subtype, pathological stage and age (< 50 or 50+ years). Differences in EFS, using STEEP criteria, and OS, using all-cause mortality, between those who received capecitabine/RT and controls were assessed.

RESULTS

Of the 21 women who received capecitabine/RT, median age was 52 years. The majority were pathologic stage III (n = 15) and hormone receptor-positive/HER2-negative BC (n = 20). In those receiving capecitabine/RT, there were 9 events, compared with 14 events in clinical and 10 events in matched controls. Capecitabine/RT was associated with worse OS in clinical (HR 3.83 95% CI 1.12-13.11, p = 0.03) and matched controls (HR 3.71 95% CI 1.04-13.18, p = 0.04), after adjusting for clinical size, pathological stage and lymphovascular invasion. Capecitabine/RT was also associated with a trend towards worse EFS in clinical (HR 2.41 95% CI 0.86-6.74, p = 0.09) and matched controls (HR 2.68 95% CI 0.91-7.90, p = 0.07) after adjustment.

CONCLUSION

Concurrent capecitabine/RT after NAC is associated with worse survival and should be carefully considered in BC.

Concurrent versus sequential administration of CMF chemotherapy and radiotherapy after breast-conserving surgery in early breast cancer

Aims and background

To compare the outcome of concurrent versus sequential administration of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy and radiotherapy after breast-conserving surgery in early breast cancer.

Methods

From February 1992 to January 2002, 156 patients underwent CMF chemotherapy and radiotherapy, either concurrently (CCRT group, 88 patients) or sequentially (SCRT group, 68 patients). There was a predilection of patients with a larger tumor (P = 0.0035), with more frequent nodal involvement (P = 0.0686), and younger age (P = 0.0776) in the CCRT group.

Results

The planned radiotherapy was completed in every patient. No grade 3 or 4 late treatment-related toxicity was observed in the CCRT or SCRT group. Compliance to the treatment as well as cosmetic outcome of the two groups were comparable. Despite more adverse factors for local-regional recurrence in the CCRT group, the 5-year local-regional control rate of the CCRT group was similar to that of the SCRT group (97.7% vs 93.8%, respectively, P = 0.1688). On multivariate analysis, concomitant administration of chemotherapy and radiotherapy was associated with improved local-regional control (P = 0.0463).

Conclusions

Concurrent administration of CMF chemotherapy and radiotherapy resulted in improved local-regional control over sequential administration without an increase in significant toxicity. Concurrent CMF chemoradiotherapy may serve as a viable option for patients at high-risk of local-regional relapse not suitable for anthracycline or taxane-based chemotherapy.

Radiation-Induced Alopecia after Endovascular Embolization under Fluoroscopy

Radiation-induced alopecia after fluoroscopically guided procedures is becoming more common due to an increasing use of endovascular procedures. It is characterized by geometric shapes of nonscarring alopecia related to the area of radiation. We report a case of a 46-year-old man presenting with asymptomatic, sharply demarcated rectangular, nonscarring alopecic patch on the occipital scalp following cerebral angiography with fistula embolization under fluoroscopy. His presentations were compatible with radiation-induced alopecia. Herein, we also report a novel scalp dermoscopic finding of blue-grey dots in a target pattern around yellow dots and follicles, which we detected in the lesion of radiation-induced alopecia.

Chronic radiation-induced dermatitis: challenges and solutions

Chronic radiation dermatitis is a late side effect of skin irradiation, which may deteriorate patients’ quality of life. There is a lack of precise data about its incidence; however, several risk factors may predispose to the development of this condition. It includes radiotherapy dose, fractionation, technique, concurrent systemic therapy, comorbidities, and personal and genetic factors. Chronic radiation dermatitis is mostly caused by the imbalance of proinflammatory and profibrotic cytokines. Clinical manifestation includes changes in skin appearance, wounds, ulcerations, necrosis, fibrosis, and secondary cancers. The most severe complication of irradiation is extensive radiation-induced fibrosis (RIF). RIF can manifest in many ways, such as skin induration and retraction, lymphedema or restriction of joint motion. Diagnosis of chronic radiation dermatitis is usually made by clinical examination. In case of unclear clinical manifestation, a biopsy and histopathological examination are recommended to exclude secondary malignancy. The most effective prophylaxis of chronic radiation dermatitis is the use of proper radiation therapy techniques to avoid unnecessary irradiation of healthy skin. Treatment of chronic radiation dermatitis is demanding. The majority of the interventions are based only on clinical practice. Telangiectasia may be treated with pulse dye laser therapy. Chronic postirradiation wounds need special dressings. In case of necrosis or severe ulceration, surgical intervention may be considered. Management of RIF should be complex. Available methods are rehabilitative care, pharmacotherapy, hyperbaric oxygen therapy, and laser therapy. Future challenges include the assessment of late skin toxicity in modern irradiation techniques. Special attention should be paid on genomics and radiomics that allow scientists and clinicians to select patients who are at risk of the development of chronic radiation dermatitis. Novel treatment methods and clinical trials are strongly needed to provide more efficacious therapies.

Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy

Ionizing radiation is an important treatment modality for a variety of malignant conditions. However, development of radiation-induced skin changes is a significant adverse effect of radiation therapy (RT). Cutaneous repercussions of RT vary considerably in severity, course, and prognosis. When they do occur, cutaneous changes to RT are commonly graded as acute, consequential-late, or chronic. Acute reactions can have severe sequelae that impact quality of life as well as cancer treatment. Thus, dermatologists should be informed about these adverse reactions, know how to assess their severity and be able to determine course of management. The majority of measures currently available to prevent these acute reactions are proper skin hygiene and topical steroids, which limit the severity and decrease symptoms. Once acute cutaneous reactions develop, they are treated according to their severity. Treatments are similar to those used in prevention, but incorporate wound care management that maintains a moist environment to hasten recovery. Chronic changes are a unique subset of adverse reactions to RT that may develop months to years following treatment. Chronic radiation dermatitis is often permanent, progressive, and potentially irreversible with substantial impact on quality of life. Here, we also review the etiology, clinical manifestations, pathogenesis, prevention, and management of late-stage cutaneous reactions to radiotherapy, including chronic radiation dermatitis and radiation-induced fibrosis.

Impact of Sequencing Radiation Therapy and Chemotherapy on Long-Term Local Toxicity for Early Breast Cancer: Results of a Randomized Study at 15-Year Follow-Up

PURPOSE

To compare long-term late local toxicity after either concomitant or sequential chemoradiation therapy after breast-conserving surgery.

METHODS AND MATERIALS

From 1997 to 2002, women aged 18 to 75 years who underwent breast-conserving surgery and axillary dissection for early breast cancer and in whom CMF (cyclophosphamide, methotrexate, and 5-fluorouracil) chemotherapy was planned were randomized between concomitant and sequential radiation therapy. Radiation therapy was delivered to the whole breast through tangential fields to 50 Gy in 20 fractions over a period of 4 weeks, followed by an electron boost. Surviving patients were tentatively contacted and examined between March and September 2014. Patients in whom progressive disease had developed or who had undergone further breast surgery were excluded. Local toxicity (fibrosis, telangiectasia, and breast atrophy or retraction) was scored blindly to the treatment received. A logistic regression was run to investigate the effect of treatment sequence after correction for several patient-, treatment-, and tumor-related covariates on selected endpoints. The median time to cross-sectional analysis was 15.7 years (range, 12.0-17.8 years).

RESULTS

Of 206 patients randomized, 154 (74.8%) were potentially eligible. Of these, 43 (27.9%) refused participation and 4 (2.6%) had been lost to follow-up, and for 5 (3.2%), we could not restore planning data; thus, the final number of analyzed patients was 102. No grade 4 toxicity had been observed, whereas the number of grade 3 toxicity events was low (<8%) for each item, allowing pooling of grade 2 and 3 events for further analysis. Treatment sequence (concomitant vs sequential) was an independent predictor of grade 2 or 3 fibrosis according to both the National Cancer Institute Common Terminology Criteria for Adverse Events (odds ratio [OR], 4.05; 95% confidence interval [CI], 1.34-12.2; P=.013) and the SOMA (Subjective, Objective, Management and Analytic) scale (OR, 3.75; 95% CI, 1.19-11.79; P=.018), as well as grade 2 or 3 breast atrophy or retraction (OR, 3.87; 95% CI, 1.42-10.56; P=.008). No effect on telangiectasia was detected.

CONCLUSIONS

At long-term follow-up, concomitant chemoradiation therapy has a detrimental effect on both fibrosis and retraction with an approximately 4-fold increase in the odds of grade 2 or 3 toxicity.

Bone marrow derived macrophages fuse with intestine stromal cells and contribute to chronic fibrosis after radiation

BACKGROUND AND PURPOSE

Bone marrow-derived cells (BMDC) have been demonstrated to play a critical role in intestine regeneration. However, organ fibrosis was one of the major side effects of bone marrow (BM) transplantation. It warrants further investigation on the mechanisms of BM cell therapy in radiation induced intestine damage.

MATERIALS AND METHODS

We established three murine models to evaluate BMDC within intestines after radiation, including cre-loxP system of transgenic mice. In vitro co-culture between murine BM with human intestine stromal cells was also performed to measure the level of fusion and fibrosis after treatment with anti-fibrotic agents or after macrophage depletion.

RESULTS

Despite complete recovery of epithelial mucosa from radiation damage, we found persistent proliferation and repopulation of BMDC within the lamina propria. Fusion between BM derived monocytic and intestine stromal cells correlated with the level of fibrosis and proliferation index. Depleting macrophages genetically using CD11b-DTR mouse model or pharmacologically using clodronate liposome reduced the level of cell fusion and intestine fibrosis.

CONCLUSIONS

Fibrotic cues from intestine enhance fusion between BM-derived monocytes/macrophages with intestine stromal cells. The fusion hybrids promote cell cycle re-entry, proliferation and reinforce fibrosis signal. Depleting macrophages interferes with cell fusion and ameliorates radiation-induced intestine fibrosis.

Radiation-induced fibrosis: mechanisms and implications for therapy

PURPOSE

Radiation-induced fibrosis (RIF) is a long-term side effect of external beam radiation therapy for the treatment of cancer. It results in a multitude of symptoms that significantly impact quality of life. Understanding the mechanisms of RIF-induced changes is essential to developing effective strategies to prevent long-term disability and discomfort following radiation therapy. In this review, we describe the current understanding of the etiology, clinical presentation, pathogenesis, treatment, and directions of future therapy for this condition.

METHODS

A literature review of publications describing mechanisms or treatments of RIF was performed. Specific databases utilized included PubMed and clinicaltrials.gov, using keywords "Radiation-Induced Fibrosis," "Radiotherapy Complications," "Fibrosis Therapy," and other closely related terms.

RESULTS

RIF is the result of a misguided wound healing response. In addition to causing direct DNA damage, ionizing radiation generates reactive oxygen and nitrogen species that lead to localized inflammation. This inflammatory process ultimately evolves into a fibrotic one characterized by increased collagen deposition, poor vascularity, and scarring. Tumor growth factor beta serves as the primary mediator in this response along with a host of other cytokines and growth factors. Current therapies have largely been directed toward these molecular targets and their associated signaling pathways.

CONCLUSION

Although RIF is widely prevalent among patients undergoing radiation therapy and significantly impacts quality of life, there is still much to learn about its pathogenesis and mechanisms. Current treatments have stemmed from this understanding, and it is anticipated that further elucidation will be essential for the development of more effective therapies.

Concurrent chemoradiotherapy for locally advanced breast cancer-time for a new paradigm?

BACKGROUND

In cases of locally advanced breast cancer (labc), preoperative ("neoadjuvant") therapy was traditionally reserved to render the patient operable. More recently, neoadjuvant therapy, particularly chemotherapy, is being used in patients with operable disease to increase the opportunity for breast conservation. Despite the increasing use of preoperative chemotherapy, rates of pathologic complete response, a surrogate marker for disease-free survival, remain modest in patients with locally advanced disease and particularly so when the tumour is estrogen or progesterone receptor-positive and her2-negative. A new paradigm for labc patients is needed. In other solid tumours (for example, rectal, esophageal, and lung cancers), concurrent chemoradiotherapy (ccrt) is routinely used in neoadjuvant and adjuvant treatment protocols alike.

RESULTS

The literature suggests that ccrt in labc patients with inoperable disease is associated with response rates higher than would be anticipated with systemic therapy alone.

CONCLUSIONS

Ongoing trials in this field are eagerly awaited to determine if ccrt should become the new paradigm.

Treatment-related symptom severity and occurrences among oncology adults in Australia

Objective:

Cancer treatments cause a range of distressing symptoms that can be well managed with pharmacological and nonpharmacological interventions. Treatment-related symptom screening and management by health care professionals is required to provide appropriate guidance to help patients to complete successfully their treatment regimen and achieve the best possible outcomes for patients. The aims of this study were to explore treatment-related symptom severity and occurrences among oncology adults in Australia and compare the results with the Chinese and Filipino studies.

Methods:

A cross-sectional descriptive survey of 84 adult patients over 18 years of age undergoing chemotherapy (CT) and/or radiotherapy (RT) in the Radiation Oncology and Medical Oncology Departments in one public teaching hospital in Canberra, Australia using the 25-item treatment-related symptom checklist (TRSC) was used in this study.

Results:

Six symptom clusters emerged from combining the 25 symptoms. Patients receiving CT experienced highest fatigue symptom occurrences (95.8%) and greater symptom severity (mean = 2.59) for fatigue symptom cluster for patients receiving a combination of CT-RT. Australians treatment-related symptom severity and occurrences were higher compared with the Filipino and Chinese adult cancer patients.

Conclusions:

Nurses in oncology settings are uniquely placed to assess patients’ therapy-related symptoms that will assist them to target education to cancer patients’ individual needs. For all types of cancer, it is important to assess treatment-related symptoms and to provide the most appropriate interventions in consideration to the patients’ preferences.

Breast edema in breast cancer patients following breast-conserving surgery and radiotherapy: a systematic review

Breast-conserving surgery (BCS) is commonly used in breast cancer treatment. Despite its benefits, some women will be troubled by breast edema. Breast edema may cause an unsatisfactory cosmetic result, influencing the quality of life. The purpose of this systematic review is to investigate the incidence of breast edema and to identify risk factors of breast edema in breast cancer patients following BCS and radiotherapy. A systematic literature search was performed using different electronic databases (PubMed, Web of Science, Cochrane, Embase) until June 2014. Inclusion criteria were as follows: (1) research studies that included female breast cancer patients who were treated with BCS and radiotherapy and (2) studies that investigated the incidence of breast edema and/or risk factors of breast edema. Exclusion criteria were (1) reviews or case studies and (2) studies published before 1995. We identified in total 28 papers which represented 4,011 patients. There was a great variation in the incidence of breast edema (0-90.4 %). We identified several possible risk factors for breast edema namely increasing irradiated breast volume, increasing boost volume, the use of a photon boost, increasing breast separation, a higher density of the breast tissue, a large tumor, a higher specimen weight, postoperative infection, acute postoperative toxicity, and diabetes mellitus. However, their prognostic value remains uncertain. Breast edema is a common complaint after BCS and radiotherapy. A number of possible risk factors associated with breast edema were identified, but further research is warranted.

The impact of intermediate time between chemotherapy and hypofractionated radiotherapy to the radiation induced skin toxicity for breast adjuvant treatment

To evaluate the impact of intermediate time between chemotherapy and radiotherapy (ITCR) to skin toxicity for a hypofractionated irradiation schedule. Forty-four patients with stage I-II invasive breast cancer receiving postoperative radiotherapy (RT) after lumpectomy and axillary dissection were studied. All patients received RT with 6 MV linear accelerator (LINAC) with a total tumor dose of 53 Gy (Equivalent dose-EQD2- 60 Gy), 2.65 Gy per fraction, in 20 fractions. All patients received six cycles of cyclophosphamide methotrexate fluorouracil chemotherapy i.v. every 21 days. Acute and late effects and cosmetic results were assessed using the European Organization for Research and Treatment of Cancer and Radiation Therapy Oncology Group (EORTC/RTOG) Rating System. The mean follow-up was 7 years. The spearman rho test showed that there was a significant correlation between short ITCR and acute skin toxicity 3 months post RT, by means of acute radiation induced morbidity. None of the related late-toxicity parameters was correlated with the ITCR. However, there was significantly higher acute toxicity when the ITCR was less than 20 days (p < 0.05). We may suggest that when a hypofractionated irradiation schedule is used for breast cancer patients, then the ITCR should be more than 20 days from chemotherapy.

Sequencing of chemotherapy and radiotherapy for early breast cancer

BACKGROUND

After surgery for localised breast cancer, radiotherapy (RT) improves both local control and breast cancer-specific survival. In patients at risk of harbouring micro-metastatic disease, adjuvant chemotherapy (CT) improves 15-year survival. However, the best sequence of administering these two types of adjuvant therapy for early-stage breast cancer is unclear.

OBJECTIVES

To determine the effects of different sequencing of adjuvant CT and RT for women with early breast cancer.

SEARCH METHODS

An updated search was carried out in the Cochrane Breast Cancer Group's Specialised Register (20 May 2011), MEDLINE (14 December 2011), EMBASE (20 May 2011) and World Health Organization (WHO) International Clinical Trials Registry Platform (20 May 2011). Details of the search strategy and methods of coding for the Specialised Register are described in the Group's module in The Cochrane Library. We extracted studies that had been coded as 'early', 'chemotherapy' and 'radiotherapy'.

SELECTION CRITERIA

We included randomised controlled trials evaluating different sequencing of CT and RT.

DATA COLLECTION AND ANALYSIS

We assessed the eligibility and quality of the identified studies and extracted data from the published reports of the included trials. We derived odds ratios (OR) and hazard ratios (HR) from the available numerical data. Toxicity data were extracted, where reported. We used a fixed-effect model for meta-analysis and conducted analyses on the basis of the method of sequencing of the two treatments.

MAIN RESULTS

Three trials reporting two different sequencing comparisons were identified. There were no significant differences between the various methods of sequencing adjuvant therapy for local recurrence-free survival, overall survival, relapse-free survival and metastasis-free survival based on 1166 randomised women in three trials. Concurrent chemoradiation increased anaemia (OR 1.54; 95% confidence interval (CI) 1.10 to 2.15), telangiectasia (OR 3.85; 95% CI 1.37 to 10.87) and pigmentation (OR 15.96; 95% CI 2.06 to 123.68). Treated women did not report worse cosmesis with concurrent chemoradiation but physician-reported assessments did (OR 1.14; 95% CI 0.42 to 3.07). Other measures of toxicity did not differ between the two types of sequencing. On the basis of one trial (244 women), RT before CT was associated with an increased risk of neutropenic sepsis (OR 2.96; 95% CI 1.26 to 6.98) compared with CT before RT, but other measures of toxicity did not differ.

AUTHORS' CONCLUSIONS

The data included in this review, from three well-conducted randomised trials, suggest that different methods of sequencing CT and RT do not appear to have a major effect on recurrence or survival for women with breast cancer if RT is commenced within seven months after surgery.

Relationship between irradiated breast volume and late normal tissue complications: a systematic review

The concept of radiation dose-volume effect has been exploited in breast cancer as boost treatment for high risk patients and more recently in trials of Partial Breast Irradiation for low risk patients. However, there appears to be paucity of published data on the dose-volume effect of irradiation on breast tissue including the recently published report on Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC). This systematic review looks at the current literature for relationship between irradiated breast volume and normal tissue complications and introduces the concept of dose modulation.

Simultaneous integrated boost irradiation after breast-conserving surgery: physician-rated toxicity and cosmetic outcome at 30 months' follow-up

PURPOSE

To evaluate toxicity and cosmetic outcome (CO) in breast cancer survivors treated with three-dimensional conformal radiotherapy with a hypofractionated, simultaneous integrated boost (3D-CRT-SIB) and to identify risk factors for toxicity, with special focus on the impact of age.

METHODS AND MATERIALS

Included were 940 consecutive disease-free patients treated for breast cancer (Stage 0-III) with 3D-CRT-SIB, after breast-conserving surgery, from 2005 to 2010. Physician-rated toxicity (Common Terminology Criteria for Adverse Events version 3.0) and CO were prospectively assessed during yearly follow-up, up to 5 years after radiotherapy. Multivariate logistic regression analyses using a bootstrapping method were performed.

RESULTS

At 3 years, toxicity scores of 436 patients were available. Grade ≥ 2 fibrosis in the boost area was observed in 8.5%, non-boost fibrosis in 49.4%, pain to the chest wall in 6.7%, and fair/poor CO in 39.7% of cases. Radiotherapy before chemotherapy was significantly associated with grade ≥ 2 boost fibrosis at 3 years (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.3-6.0). Non-boost fibrosis was associated with re-resection (OR 2.2, 95% CI 1.2-4.0) and larger tumors (OR 1.1, 95% CI 1.0-1.1). At 1 year, chest wall pain was significantly associated with high boost dosage (OR 2.1, 95% CI 1.2-3.7) and younger age (OR 0.4, 95% CI 0.2-0.7). A fair/poor CO was observed more often after re-resection (OR 4.5, 95% CI 2.4-8.5), after regional radiotherapy (OR 2.9, 95% CI 1.2-7.1), and in larger tumors (OR 1.1, 95% CI 1.0-1.1).

CONCLUSIONS

Toxicity and CO are not impaired after 3D-CRT-SIB. Fibrosis was not significantly associated with radiotherapy parameters. Independent risk factors for fibrosis were chemotherapy after radiotherapy, re-resection, and larger tumor size. Re-resection was most predictive for worse CO. Age had an impact on chest wall pain occurrence.

Radiotherapy of early breast cancer in scleroderma patients: our experience with four cases and a short review of the literature

PURPOSE

Connective vascular diseases (CVD), including scleroderma, are reported to represent for some researchers a relative contraindication and for others absolute contraindication for radiotherapy. The purpose of our study is to add four new cases to the existing body of international literature and to determine whether women with pre-existing scleroderma who have been surgically treated for early breast cancer could undergo postsurgical radiotherapy without serious early and late complications.

PATIENTS AND METHODS

From May 1998 to November 2010, we irradiated for early breast cancer four patients suffering from pre-existing scleroderma; after conservative surgery, we performed whole breast postoperative radiotherapy of 50.4 Gy total dose to the whole breast plus a 9 Gy boost to the tumor bed. We reviewed the records of all four patients and evaluated the early and late reactions using acute radiation morbidity scoring criteria (Radiation Therapy Oncology Group [RTOG], American College of Radiology, Philadelphia, PA) and late radiation morbidity scoring scheme (European Organisation for Research and Treatment of Cancer [EORTC], Brussels, Belgium and RTOG).

RESULTS

After a median follow-up of 105 months (range 12-155 months) the early and late toxicity concerning the skin, the subcutaneous tissues, the lungs, and the heart have been acceptable and are in full accordance with what have been reported in international literature.

CONCLUSION

This study matches global experience, which shows that patients with scleroderma and breast cancer must be discussed by the multidisciplinary tumor board in order for a personalized treatment strategy to be formulated. Radiation therapy can be proposed as a postsurgical therapeutic option in selected cases.

Decrease in breast density in the contralateral normal breast of patients receiving neoadjuvant chemotherapy: MR imaging evaluation

PURPOSE

To investigate the change of breast density with quantitative magnetic resonance (MR) imaging in the contralateral normal breast of patients receiving neoadjuvant chemotherapy.

MATERIALS AND METHODS

This study was approved by the institutional review board and was HIPAA compliant. Informed consent was obtained. Fifty-four patients with breast cancer (mean age, 47 years; age range, 30-74 years) treated with NAC protocol and enrolled in a breast MR imaging research study were studied. The density in the contralateral normal breast was analyzed by using an MR imaging-based segmentation method. The effect of chemotherapy on the change of density following the doxorubicin and cyclophosphamide (AC) and the AC and taxane regimen was evaluated. The dependence on age was investigated by using a multivariate regression model.

RESULTS

In patients who underwent both AC and taxane follow-up, the mean percentage of change from the individual's baseline density was -10% (95% confidence interval: -12.8%, -7.2%) after AC and -12.7% (95% confidence interval: -16%, -9.4%) after AC and taxane. In patients who underwent both follow-up studies after one to two and four cycles of AC, the mean percentage of change was -9.4% (95% confidence interval: -13.5%, -5.3%) after one to two cycles of AC and -14.7% (95% confidence interval: -20.6%, -8.7%) after four cycles of AC. The percentage reduction of density was significantly dependent on age. Patients younger than 40 years had a greater reduction after chemotherapy than patients older than 55 years (P = .01).

CONCLUSION

By using three-dimensional MR imaging, patients receiving chemotherapy showed reduction of breast density, and the effects were significant after initial treatment with one to two cycles of the AC regimen.

Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair

Most advice currently available with regard to fluoroscopic skin reactions is based on a table published in 1994. Many caveats in that report were not included in later reproductions, and subsequent research has yielded additional insights. This review is a consensus report of current scientific data. Expected skin reactions for an average patient are presented in tabular form as a function of peak skin dose and time after irradiation. The text and table indicate the variability of reactions in different patients. Images of injuries to skin and underlying tissues in patients and animals are provided and are categorized according to the National Cancer Institute skin toxicity scale, offering a basis for describing cutaneous radiation reactions in interventional fluoroscopy and quantifying their clinical severity. For a single procedure performed in most individuals, noticeable skin changes are observed approximately 1 month after a peak skin dose exceeding several grays. The degree of injury to skin and subcutaneous tissue increases with dose. Specialized wound care may be needed when irradiation exceeds 10 Gy. Residual effects from radiation therapy and from previous procedures influence the response of skin and subcutaneous tissues to subsequent procedures. Skin irradiated to a dose higher than 3-5 Gy often looks normal but reacts abnormally when irradiation is repeated. If the same area of skin is likely to be exposed to levels higher than a few grays, the effects of previous irradiation should be included when estimating the expected tissue reaction from the additional procedure.

Radiation-induced complications after breast cancer radiation therapy: a pictorial review of multimodality imaging findings

The purpose of this pictorial essay is to illustrate the multimodality imaging findings of a wide spectrum of radiation-induced complications of breast cancer in the sequence of occurrence. We have classified radiation-induced complications into three groups based on the time sequence of occurrence. Knowledge of these findings will allow for the early detection of complications as well as the ability to differentiate tumor recurrence.

Effect of adjuvant systemic treatment on cosmetic outcome and late normal-tissue reactions after breast conservation

To investigate whether adjuvant treatment with CMF or tamoxifen predisposes to an unfavorable cosmetic outcome or increased breast morbidity after radiotherapy in breast conservation. Data from 266 patients who entered a randomized breast conservation trial (DBCG-82TM protocol) was analyzed. The patients were treated with lumpectomy and axillary dissection followed by external beam radiotherapy to the residual breast. High-risk patients (n = 94), as well as 31 low-risk patients, received additional radiation to the regional lymph nodes. Adjuvant systemic treatment was given to all high-risk patients: premenopausal patients (n = 67) received eight cycles of CMF intravenously (600/40/600 mg per m2) every fourth week; postmenopausal patients (n = 27) received 30 mg of tamoxifen daily for one year. Clinical assessments included cosmetic outcome, breast fibrosis, skin telangiectasia, and dyspigmentation which were scored on a 4-point categorical scale after median 6.6 years. The observations were analyzed in multivariate logistic regression analysis which included potential risk factors on outcome related to systemic treatment, surgery, radiation technique, tumor, and patient characteristics. In premenopausal patients, systemic treatment with CMF independently predicted a fair/poor cosmetic outcome, RR = 2.2 (95% CI 1.2-4.2), as well as increased skin telangiectasia, RR = 3.3 (1.4-8.2). There was no impact of tamoxifen treatment on cosmetic outcome in postmenopausal patients (p = 0.32). However, univariate analysis showed that tamoxifen was significantly associated with breast fibrosis (p < 0.004), as was radiation to the regional lymph nodes (p < 0.0001). A strong interaction between axillary irradiation and tamoxifen treatment occurred since 26 of 27 high-risk postmenopausal patients had received both tamoxifen and axillary irradiation. In multivariate regression analysis, axillary irradiation independently predicted moderate/severe breast fibrosis with a relative risk of 5.0 (2.0-12.5) and 9.6 (3.3-27.7) in premenopausal and postmenopausal patients, respectively. To circumvent the strong interaction between tamoxifen treatment and axillary irradiation, a subsequent analysis omitting axillary treatment from the multivariate regression showed a significant effect of both tamoxifen and CMF on the occurrence of breast fibrosis with relative risks of 5.3 (CI 1.8-15.8) and 4.4 (1.8-10.3), respectively. Adjuvant systemic treatment with CMF given sequentially to radiotherapy independently predicted an adverse cosmetic outcome as well as increased skin telangiectasia after breast conserving treatment. Due to a strong interaction between tamoxifen administration and radiation to the regional lymph nodes, the effect of tamoxifen on the development of fibrosis could not be fully discerned in this study. Axillary irradiation increased the incidence of moderate to severe breast fibrosis in both premenopausal and postmenopausal patients.