Radiodermatitis and Fibrosis in the Context of Breast Radiation Therapy: A Critical Review

Quantifying radiation-induced breast fibrosis by shear-wave elastography in patients with breast cancer: A 12-months-follow-up data of a prospective study

Purpose

To assess radiation-induced fibrosis (RIF) using shear-wave elastography (SWE) in patients with breast cancer who received radiotherapy (RT) after breast conserving surgery.

Methods

Forty-one patients were enrolled in a prospective study before RT. SWE and B-mode ultrasonography were performed to measure elasticity. For quantitative measurement, the maximum elasticity value was measured in the tumor bed and non-tumor bed of the treated breast, and contralateral breast before RT and at 3, and 12 months after RT. and RIF was recorded using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0.

Results

The mean ± standard deviation elasticity values for the tumor bed, non-tumor bed, and contralateral breast were 71.2 ± 74.9 kPa, 19.4 ± 9.8 kPa and 20.3 ± 10.0 kPa before RT; 28.7 ± 26.3 kPa, 15.1 ± 7.0 kPa, and 14.7 ± 6.3 kPa at 12 months after RT, respectively. The elasticity values for all three measurement areas before and 12 months after RT were significantly different (p < 0.001 for tumor bed, p = 0.002 for non-tumor bed, p = 0.001 for contralateral breast). At 12 months follow-up, the distribution of grades of RIF evaluated by CTCAE grade was grade 0 in 43.9 %, grade 1 in 48.8 %, and grade 2 in 7.3 %.

Conclusion

We demonstrated that SWE enables the evaluation of tissue stiffness to provide quantified information for the RIF of breast cancer. Further studies with long-term follow-up should provide more quantitative data.

CANTO skin: Evaluation of skin toxicity risk factors in patients treated for breast cancer

Skin reaction is a common toxicity during oncology management, especially followed during the radiotherapy. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients treated for an early breast cancer (BC). We evaluated 8561 patients during their overall management for a BC. We focus on specific skin toxicities: erythema, fibrosis, telangiectasia and changes of skin colour. These toxicities were assessed at the baseline defined as 0-3-6 (M0), 12 (M12), 36 (M36) and 60 (M60) months. The prevalence of toxicities of interest varied over time, so at M0, 30.4% of patients had erythema while 17.7% of patients had fibrosis. At M60, the prevalence of erythema was 2%, while fibrosis remained stable at about 19%. After adjustments, at M0, there was a significant association between the onset of cutaneous erythema and obesity, the presence of axillary dissection, the type of surgery and the tumour phenotype RH+/HER2+. Concerning fibrosis, a significant association was found, at M12, with the age of the patient, obesity, Charlson score and type of surgery. Concerning the modification of skin colour at M12, we find a link between the age of the patient, obesity, tobacco consumption and alcohol consumption. The prevention of this toxicity is a major issue for the quality of life. Our results allow us to understand the risk of developing skin toxicity in a patient, depending on her intrinsic, tumour or therapeutic characteristics and to implement adapted means of prevention and monitoring.

Predicting acute radiation dermatitis in breast cancer: a prospective cohort study

BACKGROUND

Acute radiation dermatitis (ARD) is one of the most common acute adverse reactions in breast cancer patients during and immediately after radiotherapy. As ARD affects patient quality of life, it is important to conduct individualized risk assessments of patients in order to identify those patients most at risk of developing severe ARD.

METHODS

The data of breast cancer patients who received radiotherapy were prospectively collected and analyzed. Serum ferritin, high-sensitivity C-reactive protein (hs-CRP) levels, and percentages of lymphocyte subsets were measured before radiotherapy. ARD was graded (0-6 grade), according to the Oncology Nursing Society Skin Toxicity Scale. Univariate and multivariate logistic regression analyses were used and the odds ratio (OR) and 95% confidence interval (CI) of each factor were calculated.

RESULTS

This study included 455 breast cancer patients. After radiotherapy, 59.6% and 17.8% of patients developed at least 3 (3+) grade and at least 4 (4+) grade ARD, respectively. Multivariate logistic regression analysis found that body mass index (OR: 1.11, 95% CI: 1.01-1.22), diabetes (OR: 2.70, 95% CI: 1.11-6.60), smoking (OR: 3.04, 95% CI: 1.15-8.02), higher ferritin (OR: 3.31, 95% CI: 1.78-6.17), higher hs-CRP (OR: 1.96, 95% CI: 1.02-3.77), and higher CD3 + T cells (OR: 2.99, 95% CI: 1.10-3.58) were independent risk factors for 4 + grade ARD. Based on these findings, a nomogram model of 4 + grade ARD was further established. The nomogram AUC was 0.80 (95% CI: 0.75-0.86), making it more discriminative than any single factor.

CONCLUSION

BMI, diabetes, smoking history, higher ferritin, higher hs-CRP, and higher CD3 + T cells prior to radiotherapy for breast cancer are all independent risk factors for 4 + grade ARD. The results can provide evidence for clinicians to screen out high-risk patients, take precautions and carefully follow up on these patients before and during radiotherapy.

Single Ultra-High Dose Rate Proton Transmission Beam for Whole Breast FLASH-Irradiation: Quantification of FLASH-Dose and Relation with Beam Parameters

Healthy tissue-sparing effects of FLASH (≥40 Gy/s, ≥4-8 Gy/fraction) radiotherapy (RT) make it potentially useful for whole breast irradiation (WBI), since there is often a lot of normal tissue within the planning target volume (PTV). We investigated WBI plan quality and determined FLASH-dose for various machine settings using ultra-high dose rate (UHDR) proton transmission beams (TBs). While five-fraction WBI is commonplace, a potential FLASH-effect might facilitate shorter treatments, so hypothetical 2- and 1-fraction schedules were also analyzed. Using one tangential 250 MeV TB delivering 5 × 5.7 Gy, 2 × 9.74 Gy or 1 × 14.32 Gy, we evaluated: (1) spots with equal monitor units (MUs) in a uniform square grid with variable spacing; (2) spot MUs optimized with a minimum MU-threshold; and (3) splitting the optimized TB into two sub-beams: one delivering spots above an MU-threshold, i.e., at UHDRs; the other delivering the remaining spots necessary to improve plan quality. Scenarios 1-3 were planned for a test case, and scenario 3 was also planned for three other patients. Dose rates were calculated using the pencil beam scanning dose rate and the sliding-window dose rate. Various machine parameters were considered: minimum spot irradiation time (minST): 2 ms/1 ms/0.5 ms; maximum nozzle current (maxN): 200 nA/400 nA/800 nA; two gantry-current (GC) techniques: energy-layer and spot-based. For the test case (PTV = 819 cc) we found: (1) a 7 mm grid achieved the best balance between plan quality and FLASH-dose for equal-MU spots; (2) near the target boundary, lower-MU spots are necessary for homogeneity but decrease FLASH-dose; (3) the non-split beam achieved >95% FLASH for favorable (not clinically available) machine parameters (SB GC, low minST, high maxN), but <5% for clinically available settings (EB GC, minST = 2 ms, maxN = 200 nA); and (4) splitting gave better plan quality and higher FLASH-dose (~50%) for available settings. The clinical cases achieved ~50% (PTV = 1047 cc) or >95% (PTV = 477/677 cc) FLASH after splitting. A single UHDR-TB for WBI can achieve acceptable plan quality. Current machine parameters limit FLASH-dose, which can be partially overcome using beam-splitting. WBI FLASH-RT is technically feasible.

The effect of antiperspirant and deodorant use on acute radiation dermatitis in breast cancer patients during radiotherapy: a systematic review and meta-analysis

PURPOSE

While some authors have investigated the impact of antiperspirant /deodorant on the development of acute radiation dermatitis (RD) among patients undergoing radiotherapy (RT) for breast cancer, recommendations supporting the use of antiperspirant/deodorant during breast RT remain highly variable. This systematic review and meta-analysis aims to evaluate the evidence investigating the effect of antiperspirant/deodorant on the development of acute RD during post-operative breast RT.

METHODS

A literature search has been performed using OVID MedLine, Embase, and Cochrane databases (1946 to September 2020) to identify randomized controlled trials (RCTs) that have investigated deodorant/antiperspirant use during RT. The meta-analysis was conducted using RevMan 5.4 to calculate pooled effect sizes and 95% confidence intervals (CI).

RESULTS

Five RCTs met the inclusion criteria. The use of antiperspirant/deodorant did not significantly affect the incidence of grade (G) 1 + RD (OR 0.81, 95% CI 0.54-1.21, p = 0.31). Prohibition of deodorant use did not significantly prevent the occurrence of G2 + acute RD (OR 0.90, 95%, CI 0.65-1.25, p = 0.53). No significant effect was reported in preventing G3 RD between the antiperspirant/deodorant and control groups (OR 0.54, 95%, CI 0.26-1.12, p = 0.10). There was no significant difference in pruritus and pain between patients undergoing skin care protocols with or without antiperspirant/deodorant (OR 0.73, 95% CI 0.29, 1.81, p = 0.50, and OR 1.05, 95% CI 0.43-2.52, p = 0.92, respectively).

CONCLUSIONS

The use of antiperspirant/deodorant during breast RT does not significantly affect the incidence of acute RD, pruritus, and pain. As such, the current evidence does not support recommendation against antiperspirant/deodorant use during RT.

Differential Radiomodulating Action of Olea europaea L. cv. Caiazzana Leaf Extract on Human Normal and Cancer Cells: A Joint Chemical and Radiobiological Approach

The identification of a natural compound with selectively differential radiomodulating activity would arguably represent a valuable asset in the striving quest for widening the therapeutic window in cancer radiotherapy (RT). To this end, we fully characterized the chemical profile of olive tree leaf polyphenols from the Caiazzana cultivar (OLC), autochthonous to the Campania region (Italy), by ultra-high-performance liquid chromatography–high-resolution mass spectrometry (UHPLC-HR-MS). Oleacein was the most abundant molecule in the OLC. Two normal and two cancer cells lines were X-ray-irradiated following 24-h treatment with the same concentration of the obtained crude extract and were assessed for their radioresponse in terms of micronucleus (MN) induction and, for one of the normal cell lines, of premature senescence (PS). Irradiation of pre-treated normal cells in the presence of the OLC reduced the frequency of radiation-induced MN and the onset of PS. Conversely, the genotoxic action of ionising radiation was exacerbated in cancer cells under the same experimental conditions. To our knowledge, this is the first report on the dual action of a polyphenol-rich olive leaf extract on radiation-induced damage. If further confirmed, these findings may be pre-clinically relevant and point to a substance that may potentially counteract cancer radioresistance while reducing RT-associated normal tissue toxicity.

Comparison of Breast Cancer Radiotherapy Techniques Regarding Secondary Cancer Risk and Normal Tissue Complication Probability - Modelling and Measurements Using a 3D-Printed Phantom

Background

Radiotherapy after breast-conserving therapy is a standard postoperative treatment of breast cancer, which can be carried out with a variety of irradiation techniques. The treatment planning must take into consideration detrimental effects on the neighbouring organs at risk-the lung, the heart, and the contralateral breast, which can include both short- and long-term effects represented by the normal tissue complication probability and secondary cancer risk.

Patients and Methods

In this planning study, we investigate intensity-modulated (IMRT) and three-dimensional conformal (3D-CRT) radiotherapy techniques including sequential or simultaneously integrated boosts as well as interstitial multicatheter brachytherapy boost techniques of 38 patients with breast-conserving surgery retrospectively. We furthermore develop a 3D-printed breast phantom add-on to allow for catheter placement and to measure the out-of-field dose using thermoluminescent dosimeters placed inside an anthropomorphic phantom. Finally, we estimate normal tissue complication probabilities using the Lyman-Kutcher-Burman model and secondary cancer risks using the linear non-threshold model (out-of-field) and the model by Schneider et al. (in-field).

Results

The results depend on the combination of primary whole-breast irradiation and boost technique. The normal tissue complication probabilities for various endpoints are of the following order: 1%-2% (symptomatic pneumonitis, ipsilateral lung), 2%-3% (symptomatic pneumonitis, whole lung), and 1%-2% (radiation pneumonitis grade ≥ 2, whole lung). The additional relative risk of ischemic heart disease ranges from +25% to +35%. In-field secondary cancer risk of the ipsilateral lung in left-sided treatment is around 50 per 10,000 person-years for 20 years after exposure at age 55. Out-of-field estimation of secondary cancer risk results in approximately 5 per 10,000 person-years each for the contralateral lung and breast.

Conclusions

In general, 3D-CRT shows the best risk reduction in contrast to IMRT. Regarding the boost concepts, brachytherapy is the most effective method in order to minimise normal tissue complication probability and secondary cancer risk compared to teletherapy boost concepts. Hence, the 3D-CRT technique in combination with an interstitial multicatheter brachytherapy boost is most suitable in terms of risk avoidance for treating breast cancer with techniques including boost concepts.

Efficacy of Epigallocatechin-3-Gallate in Preventing Dermatitis in Patients With Breast Cancer Receiving Postoperative Radiotherapy: A Double-Blind, Placebo-Controlled, Phase 2 Randomized Clinical Trial

Importance

Safe and effective prophylactic therapies for radiation-induced dermatitis (RID) remain an unmet need.

Objective

To determine if epigallocatechin-3-gallate (EGCG) solution reduces the incidence of RID in patients undergoing radiotherapy after breast cancer surgery.

Design, Setting, and Participants

This phase 2 double-blind, placebo-controlled randomized clinical trial enrolled 180 patients with breast cancer receiving postoperative radiotherapy at Shandong Cancer Hospital and Institute in Shandong, China, between November 2014 and June 2019. Data analysis was performed from September 2019 to January 2020.

Interventions

Participants were randomly assigned (2:1) to receive either EGCG solution (660 μmol/L) or placebo (0.9% NaCl saline) sprayed to the whole radiation field from day 1 of the radiation until 2 weeks after radiation completion.

Main Outcomes and Measures

The primary end point was incidence of grade 2 or worse RID, defined by the Radiation Therapy Oncology Group scale. The secondary end points included RID index (RIDI), symptom index, changes in the skin temperature measured by infrared thermal images, and safety.

Results

A total of 180 eligible patients were enrolled, of whom 165 (EGCG, n = 111; placebo, n = 54) were evaluable for efficacy (median [range] age, 46 [26-67] years). The occurrence of grade 2 or worse RID was significantly lower (50.5%; 95% CI, 41.2%-59.8%) in the EGCG group than in the placebo group (72.2%; 95% CI, 60.3%-84.1%) (P = .008). The mean RIDI in the EGCG group was significantly lower than that in the placebo group. Furthermore, symptom indexes were significantly lower in patients receiving EGCG. Four patients (3.6%) had adverse events related to the EGCG treatment, including grade 1 pricking skin sensation (3 [2.7%]) and pruritus (1 [0.9%]).

Conclusions and Relevance

In this randomized clinical trial, prophylactic use of EGCG solution significantly reduced the incidence and severity of RID in patients receiving adjuvant radiotherapy for breast cancer. It has the potential to become a new choice of skin care for patients receiving radiotherapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02580279.

CANTO-RT: Skin toxicities evaluation of a multicenter large prospective cohort of irradiated patients for early-stage breast cancer

Skin damage is the most common and most important toxicity during and after radiotherapy. Its assessment and understanding of the factors influencing its occurrence, is a major issue in the management of patients irradiated for an early breast cancer CANTO is a prospective clinical cohort study of 10 150 patients with stage I-III BC treated from 2012-2017 in 26 cancer centers. In this study, we used CANTO-RT, a sub-cohort of CANTO, including 3480 patients who received RT. We are focus on specifical skin toxicities: Erythema, fibrosis, telangiectasia, and cutaneous pigmentation The prevalence of toxicities of interest varied over time, so at M3-6, 41.1% of patients had erythema while 24.8% of patients had fibrosis. At M12 and M36, the prevalence of erythema decreased respectively while fibrosis remains stable. The prevalence of telangiectasia increases from 1% to 7.1% from M3-6 to M36. After adjustments, we showed an association between the occurrence of skin erythema and obesity; the type of surgery; the presence of axillary dissection; the use of taxane-based CT and the 3DvsIMRT irradiation technique. Regarding fibrosis, an association is found, at M3-6, with age at diagnosis, obesity, tobacco, and the use of boost. Only obesity and the type of surgery received by the patient remained statistically significant at M12 and M36. In this study we identified several risk factors for acute and late skin. The use of a boost was mainly related to the occurrence of fibrosis while the use of IMRT-type technique decreased the occurrence of skin erythema.