Effects of postmastectomy radiotherapy on prognosis in different tumor stages of breast cancer patients with positive axillary lymph nodes

Objective: To explore the effects of postmastectomy radiotherapy(PMRT) on the locoregional failure-free survival(LRFFS) and overall survival(OS) of breast cancer patients under different tumor stages and with one to three positive axillary lymph nodes(ALNs). Methods: We conducted a retrospective review of 527 patients with one to three positive lymph nodes who underwent modified radical or partial mastectomy and axillary dissection from January 2000 to December 2002. The patients were divided into the T1-T2 N1 and T3-T4 N1 groups. The effects of PMRT on the LRFFS and OS of these two patient groups were analyzed using SPSS 19.0, Pearson's χ2-test, Kaplan-Meier method, and Cox proportional hazard model. Results: For T1-T2 N1 patients, no statistical significance was observed in the effects of PMRT on LRFFS [hazard ratio(HR)=0.726; 95% confidence interval(CI): 0.233-2.265; P=0.582] and OS(HR=0.914; 95% CI: 0.478-1.745; P=0.784) of the general patients. Extracapsular extension(ECE) and high histological grade were the risk factors for LRFFS and OS with statistical significance in multivariate analysis. Stratification analysis showed that PMRT statistically improved the clinical outcomes in high-risk patients [ECE(+), LRFFS: P=0.026, OS: P=0.007; histological grade III, LRFFS: P<0.001, OS: P=0.007] but not in low-risk patients [ECE(–), LRFFS: P=0.987, OS: P=0.502; histological grade I-II, LRFFS: P=0.816, OS: P=0.296]. For T3-T4 N1 patients, PMRT effectively improved the local control(HR=0.089; 95% CI: 0.210-0.378; P=0.001) of the general patients, whereas no statistical effect was observed on OS(HR=1.251; 95% CI: 0.597-2.622; P=0.552). Absence of estrogen receptors and progesterone receptors(ER/PR)(–) was an independent risk factor. Further stratification analysis indicated a statistical difference in LRFFS and OS between the high-risk patients with ER/PR(–) receiving PMRT and not receiving PMRT [ER/PR(–), LRFFS: P=0.046, OS: P=0.039]. However, PMRT had a beneficial effect on the reduction of locoregional recurrence(LRR) but not in total mortality [ER/PR(+), LRFFS: P<0.001, OS: P= 0.695] in T3-T4 N1 patients with ER/PR(+) who received endocrine therapy. Conclusion: PMRT could reduce ECE(+), histological grade III-related LRR, and total mortality of T1-T2 N1 patients. T3-T4 N1 patients with ER/PR(–) could benefit from PMRT by improving LRFFS and OS. However, PMRT could only reduce LRR but failed to improve OS for T3-T4 N1 patients with ER/PR(+) who received endocrine therapy.

Postmastectomy Scar Boost Irradiation Using HDR Surface Mould Brachytherapy by 3D Image-Based Volume Optimization

Introduction: During postmastectomy radiotherapy (PMRT), it is recommended to boost the postmastectomy surgical scar with additional 10 Gy in 5 fractions in the patients with close or positive surgical margins. The electron beam therapy, though cumbersome, is usually preferred since it has the desired rapid fall of a dose beyond R85. An alternative but easier and reproducible treatment method for PMRT surgical scar boost using 3D CT image-based HDR surface mould brachytherapy is introduced and analyses of the target coverage and dose nearby organs-at-risk (OARs) using this method are evaluated in this study. Methods and Materials: This study includes twelve patients (five left-sided and seven right-sided chest wall), who were planned and treated with CT-image based surface mould HDR brachytherapy for chest wall scar boost (CWB) using Catheter Flap SetTM (Varian Medical Systems, USA) that were given concurrently during external beam radiotherapy (EBRT) treatments. Since no guidelines are available for delineating clinical target volume (CTV) structure to be used for postmastectomy scar boost, the CTV in this study was a uniform 5-mm thick volume drawn at 5 mm beneath the skin (CTVhdr_evl) and its extent was made conforming to the boost area marked on the skin and made visible in CT images by radiopaque wires. Results: Prescribed dose (PD) to CTVhdr_evl is 7.5 Gy in 3 fractions, and 2.5 Gy per fraction. The CTVhdr_evl volume receives the PD with mean V100%, V98% and V95% values which are 98.57%, 99.63% and 100% respectively. The mean dose for heart (MHD) is 2.71 Gy in left-sided CWB and 1.80 Gy in right-sided CWB plans. Mean lung dose (MLD) is 2.48 Gy for ipsilateral lung and 0.76 Gy for contralateral lung. Maximum dose to contralateral breast is 4.93 Gy and the mean dose is 0.79 Gy. The mean percent dose to the skin volume overlying the CTVhdr_evl is 138.6% and 3.7% of skin volume received 200% of the PD. Conclusion: The 3D image-based HDR surface mould achieved good CTV coverage with acceptable doses to OARs. Patient preparation, treatment planning, and execution in this method are less cumbersome and reproducible. Thus surface mould using flap applicator can be used whenever postmastectomy surgical scar boost is required.

Is Postmastectomy Radiation Therapy Indicated in Patients with Close or Positive Margins?

Background: The indications for Post Mastectomy Radiation Therapy (PMRT) for positive or close margins are unclear. We examined the indications for PMRT in mastectomy patients with close or positive margins and determined patterns for relapse and survival. Methods: The pathology reports of 610 patients treated with a mastectomy from 1999-2012 were reviewed. Of these, 72 patients had a positive or <2 mm margin. Demographic, tumor characteristics, treatments and survival were compared between women treated with and without PMRT. Results: The mean follow up was 4.1 years. Patients who received PMRT were younger (p = 0.03) and more likely to receive chemotherapy (p = 0.03). Patients with lymphovascular invasion (LVI) were more likely to undergo PMRT (p = 0.02). Seven patients who did not receive PMRT recurred. There was no correlation with locoregional failure. The disease free survival was better in the PMRT group (p = 0.03), but the overall survival was the same. Conclusion: We found that women with a close or positive margin who were younger, had LVI, and who received chemotherapy received PMRT. The disease free survival was better in the PMRT cohort, but the overall survival was similar. Long-term follow up of patients is warranted to see if PMRT offers a survival advantage.

Postmastectomy radiotherapy in breast reconstruction:Current controversies and trends

Breast cancer is the most common cancer among women worldwide.Postmastectomy radiotherapy(PMRT)is an essential component of combined therapy for early-stage,high-risk breast cancer.Breast reconstruction(BR)is often considered for patients with breast cancer who have undergone mastectomy.There has been a considerable amount of discussion about the optimal approach to combining PMRT with BR in the treatment of breast cancer.PMRT may increase the risk of complications and prevent good aesthetic results after BR,while BR may increase the complexity of PMRT and the radiation dose to surrounding normal tissues.The purpose of this review is to give a broad overview and summary of the current controversies and trends in PMRT and BR in the context of the most recent literature available.

Postmastectomy radiation in supraclavicular and internal mammary regions of patients with breast cancer of stage Ⅱ/Ⅲ

Adjuvant radiotherapy plays a vital role in the treatment of breast cancer, but irradiated area was not standardized. The ipsilateral chest wall and supraclavicular regions with or without internal mammary lymph nodes were reported in patients receiving postmastectomy radiotherapy. In our study, 133 consecutive patients with breast cancer of stage Ⅱ/Ⅲ who had received postmastectomy radiotherapy of supraclavicular and internal mammary regions at Cancer Hospital of Fudan University were analyzed for their survival and locoregional control as well as their relative prognostic predicator.

Effect of Transcranial Direct Current Stimulation of Motor Cortex versus Insula Cortex on Chronic Post-Mastectomy Pain: Randomized Sham-Controlled Trial

Background: Transcranial direct current stimulation (tDCS) across cortical brain areas appears to improve various forms of pain, yet evidence of tDCS efficiency and ideal stimulation target is lacking. This study aimed to compare the add-on analgesic efficacy of concentric electrode transcranial direct current stimulation (CE-tDCS) stimulation over the primary motor cortex versus the insular cortex on the management of chronic postmastectomy pain. Method: Prospective randomized double-blind sham-controlled study enrolled eighty patients with chronic postmastectomy pain that were randomly assigned to four groups: active motor (AM), sham motor (SM), active insula (AI) and sham insula (SI) group, each received 5 sessions for 20-minute duration with 2 mA tDCS over the targeted area of the contralateral side of pain. Our primary outcome was VAS score, the secondary outcomes were VDS score, LANSS score and depression symptoms by HAM-D scores, assessment was done at 4 time points (prestimulation, after 5th session, 15th day and one month after the last session). Results: Both active tDCS groups (motor and insula) showed reduction of VAS (P Conclusion: Active tDCS stimulation either targeting the primary motor cortex or the insula cortex has add-on analgesic effect for controlling neuropathic chronic post mastectomy pain and the maximum effect was at 15 days after the last session.

Modified partially wide tangents technique in post-mastectomy radiotherapy for patients with left-sided breast cancer

Background The role of internal mammary nodes （IMN） irradiation for breast cancer patients after mastectomy remains controversial. This study aimed to compare different techniques for radiation of the chest wall （CW） and IMN post-mastectomy for left-breast cancer patients in terms of dose homogeneity within planning target volume （PTV） and dose to critical structures.Methods Thirty patients underwent CT simulation, while CW, IMN, left lung, heart and contralateral breast were contoured. Three three-dimensional conformal radiotherapy （3D-CRT） techniques, namely, standard tangents, partially wide tangents （PWT）, and modified PWT techniques plus intensity modulated radiotherapy （IMRT） technique have been used to radiate CW and IMN. In addition to the target coverage and dose homogeneity, we also evaluated the dose to the critical structures including heart, left lung and contralateral breast.Results All three 3D-CRT techniques provided satisfactory coverage regarding total PTV. The PWT and the modified PWT gave better coverage of IMN PTV with V47.5 of （96.83±4.56）% and （95.19±3.90）% compared to standard tangents （（88.16±7.77）%）, P 〈0.05. The standard tangents also contributed the biggest IMN VD105%, VD110%, VD115% and VD120%. The lowest mean dose of the heart was achieved by the modified PWT （（8.47±2.30） Gy）, compared with PWT （（11.97±3.54）Gy） and standard tangents （（11.18±2.53） Gy）. The mean dose of lung and contralateral breast with the modified PWT was significantly lower than those with PWT. Comparing IMRT with the modified PWT, both techniques provided satisfactory coverage. The conformity indexes （CI） with IMRT （CI1： 0.71±0.02; CI2： 0.64±0.02） were better than those with the modified PWT （CI1： 0.50±0.02; CI2： 0.45±0.02）. The mean dose, V5, V10 and V5-10 of heart and left lung with the modified PWT were significantly lower than those with the IMRT. The mean dose and VD2% of contralateral breast with the modified PWT were not significantly different from the IMRT （P=0.868 and P=0.212）.Conclusions No single technique provides both the best CW and IMN coverage with minimum lung and heart dose.The modified PWT technique can be used as a clinical tool for the treatment of the left-sided post-mastectomy breast cancer patients to provide homogeneous target coverage while maintaining Iow doses to normal tissue.