Chest Wall Recurrence Rate Research Articles

Outcomes in Patients Treated with Post-mastectomy Chest Wall Radiotherapy without the Routine Use of Bolus

AimsThe use of bolus in post-mastectomy radiotherapy (PMRT) varies significantly between institutions. We report on chest wall recurrence and acute toxicity rates for PMRT patients treated with selective use of bolus. Materials and methodsWe analysed PMRT patients who received adjuvant chest wall radiotherapy for invasive breast cancer between 2004 and 2009. Patient, tumour and cancer outcomes were collected from a prospective database, with additional radiotherapy and acute toxicity details supplemented retrospectively. Chest wall bolus was reserved for patients considered at high risk of local recurrence. ResultsThere were 314 patients suitable for analysis: 52 received bolus, 262 did not. The mean age was 53.2 years. The median follow-up was 4.2 years. The most common T stage was T2 (37%), followed by T3/T4 (33%). There were 229 patients (73%) who had N+ disease; 213 (68%) patients had grade 3 cancer. Oestrogen receptor was positive in 176 (56%) cases, progesterone receptor was positive in 134 (43%) and HER2 receptor was positive in 24 (8%). Lymphovascular space invasion was present in 146 patients (46%), dermal invasion in 30 patients (10%) and positive margin in 14 patients (4%). The 4 year chest wall recurrence rate was 14% (95% confidence interval 5.4–26.8%) in the bolus group and only 3.5% (95% confidence interval 1.6–6.4%) in the non-bolus group. On univariate analysis, use of bolus was associated with a significant difference in chest wall recurrence (hazard ratio 3.09; 1.15–8.33; P = 0.025). However, when taking into account margin status, this significance was lost (hazard ratio = 2.45; 95% confidence interval 0.80–7.50, P = 0.12). There was a higher rate of acute grade 2 skin toxicity in patients receiving bolus compared with those without, 40% versus 21% (P = 0.01). ConclusionsThe selective use of bolus resulted in a small risk of chest wall recurrence rates for low-risk patients. This suggests that the routine use of bolus in PMRT patients may be unnecessary.

Local failure and acute radiodermatological toxicity in patients undergoing radiation therapy with and without postmastectomy chest wall bolus: Is bolus ever necessary?

PurposePostmastectomy chest wall radiation therapy has historically used bolus to increase dose at the skin surface. Despite the theoretical benefits of bolus, the clinical implications of locoregional tumor control, cosmesis, and the incidence of radiodermatitis are less well characterized. We hypothesized that treatment in the presence or absence of bolus results in equivalent chest wall recurrence rates, but its presence results in more severe acute dermatologic toxicity. Methods and materialsLocally advanced breast cancer patients undergoing chest wall radiation therapy were retrospectively reviewed from 2005 to 2015 (n = 106; 53 with bolus, 53 without). Outcomes including local failure, acute skin toxicity, and treatment interruptions were recorded. Median age was 59 years (range, 28-91) and median follow-up was 34 months. Histology was invasive ductal carcinoma (73%), invasive lobular carcinoma (20%), inflammatory (6%), and neuroendocrine (1%). Fifty-nine percent were T3/T4 primary tumors and 29.2% had clinical/pathologic skin involvement. Node-positive patients accounted for 80.2%. Chemotherapy was administered in 84.0%. All patients had 3-dimensional conformal radiation therapy and received a median dose of 61Gy (range, 50-63 Gy). ResultsLocal failure was 6.6% (n = 7) overall, with 4 failures in the bolus group and 3 in the no bolus group. No pathological factors were associated with local failure. Acute grade 2 and 3 skin toxicities (37 vs 22) and treatment interruptions (20 vs 3) were more common in the bolus group (P < .05). Mean treatment interruption (14.5 vs 5 days) was longer for patients receiving bolus. Patients undergoing treatment interruption were more likely to fail locally than patients not requiring a treatment interruption (17.4% vs 3.6%, P = .0322). ConclusionsBolus omission in adjuvant chest wall radiation therapy may be a reasonable approach to avoid acute skin toxicity and treatment interruptions while preserving local control; however, further study will be needed to reach a definitive conclusion.

Chest Wall Recurrence Rates for Low Risk Patients With Close/Positive Margins After Mastectomy for Breast Cancer, Treated With Reexcision and No Postmastectomy Radiation Therapy (PMRT)

treatments. Patients then received salvage hyperthermia, weekly or twice weekly, with radiation (median 35.5 Gy). Results: Twenty-six (87%) patients received prior radiation therapy (median 60.4 Gy). Median follow-up was 7.7 months. Complete response (CR) was observed in 15 patients (50%), partial response (PR) in 4 patients (13%), and stable disease (SD) in 11 patients (37%). Twenty-two patients experienced acute grade 1 and 2 toxicities, primarily pain and erythema, and twenty-two experienced long-term grade 1 and 2 toxicities, mainly lymphedema and hyperpigmentation. Conclusion: Hyperthermia and radiation provide good local control with a favorable side effect profile in heavily pretreated patients. Thermoradiation therapy should be considered for patients with locally recurrent breast cancer. Author Disclosure: J.S. Yu: None. S. Dharmaiah: None. V. Rao: None. A.R. Godley: None.

Electron-beam chest-wall irradiation in breast cancer patients after mastectomy

Objective To evaluate the effcacy of electron-beam chest-wall irradiation in patients with breast cancer after mastectomy.Methods From June 1999 to December 2007,280 women with localized breast cancer received postmastectomy radiotherapy using electron beam to chest wall.The effcacy and toxicity of these 280 women was compared with 118 women treated during the same period using tangential field with photon beam.Results The follow-up rate was 93.2%.140 patients had a minimum followed up time of 5 years and 12 patients had a minimum follow up time of 10 years.The 5-year and 10-year chest wall recurrence rates were 6.8%and 5.0%.14.8%and 10.1%for patients irradiated with electron and photon(X2=1.12,P=0.290).The corresponding 5-year and 10-year disease-free survival rates were 60.6%and 65.5%,47.6%and 57.3%(X2=0.97,P=0.325).The 5-year and 10-year overall survival rates were 77.5%and 79.6%,48.4%and 53.3%(X2=0.37,P=0.545).Grade Ⅱ or more acute skin toxicity occurred in 10.4%and 16.9%of patients irradiated with electron and photon(X2=3.34.P=0.090).Pulmonary fibrosis developed in 28.8%and 22.1% of patients irradiated with electron and photon(X2=1.27,P=0.300).Conclusion Electron-beam chest-wall irradiation is as effective as photon-beam irradiation in breast cancer after mustectomy. Key words: Breast neoplasms/radiotherapy; Radiotherapy,electron-beam; Prognosis

Prognostic factors for skin-involved inflammatory and non-inflammatory breast cancer

Objective To analyze the prognostic factors and the role of postmastectomy radiotherapy (PMRT) in skin-involved breast cancer.Methods Fifty-three skin-involved breast cancer patients treated with mastectomy and axillary dissection were retrospectively analyzed.Ten patients had inflammatory breast cancer (IBC).Of the 43 non-inflammatory breast cancer (NIBC) patients, 19(36%) had clinical signs of skin involvement and 24(45%) had pathological skin infiltration without clinical signs.Thirty-three patients (62%) received PMRT with a median dose of 50 Gy, 45 received chemotherapy and 27 received hormone therapy.Results The median follow up time for alive patients was 42 (7 -83) months.The overall 5-year locoregional recurrence (LRR),disease-free survival (DFS) and overall survival (OS) rates were 18%,45% and 64%.Patients with NIBC had a significantly better 5-year DFS (49% vs.30% ,χ2=4.29,P=0.038) and OS (71% vs.37% ,χ2=5.92,P=0.015) than those with IBC.In patients with NIBC, those with primary tumor ≤5 cm had a lower 5-year LRR (11% vs.33% ,χ2= 3.75 ,P =0.053) and a higher 5-year OS (90% vs.38% ,χ2=4.44,P=0.035) as compared to those >5 cm.No significant difference in terms of LRR, DFS or OS was observed between patients with clinical signs of skin involvement and those without.Patients with 0 - 3 positive nodes had an improved 5-year DFS (80% vs.29%, χ2= 6.71, P =0.010) and OS (93% vs.52% ,χ2=6.00,P=0.014) than those with ≥4 positive nodes.Patients with Rec + / Her2 - had a lower5 - year LRR (7 % vs.3 4 % , χ2= 5.70, P= 0.017) and a higher DFS (54% vs.32% ,χ2=8.82 ,P =0.003) than those with triple-negative or Her2 +.There was no significant difference in 5-year LRR (12% vs.30%, χ2= 2.45, P = 0.118) between patients with PMRT and without PMRT.However, the 5-year chest wall recurrence rate was 0% and 50% (χ2= 9.15 ,P =0.002) for patients with chest wall bolus dose > 20 Gy and 20 Gy.Conclusions Skin-involved breast cancer is a heterogeneous group of diseases.Patients with NIBC, small tumor (≤5 cm), less positive nodes (0 -3) or rec +/Her2-have favorable prognosis.Patients with pathologically proven skin involvement without clinical signs have similar prognosis to those with clinical signs.PMRT with chest wall bolus dose >20 Gy is recommended. Key words: Breast neoplasms/radiotherapy; Radiotherapy,postoperation; Skin-involvement; Prognosis

Eleven‐Year Follow‐Up of a Randomized Study of Pectoral Fascia Preservation After Mastectomy for Early Breast Cancer

The present study reports results of a randomized trial in which breast cancer patients operated with preserved pectoral fascia compared to removal of the pectoral fascia showed a trend toward an increased risk for chest wall recurrence The aim of the study was to assess whether the different procedural modes had any impact on survival or local control in breast cancer patients followed in the long term. The trial included 247 patients with breast cancer who underwent modified radical mastectomy in five Swedish hospitals between 1993 and 1997. The median follow-up time was 11years. The patients were randomized between removal (n=122) versus preservation (n=125) of the pectoral fascia. The breast-cancer-specific survival at 10years was 73%. Removal or preservation of the pectoral fascia had no significant impact on chest-wall recurrence rate or breast-cancer-specific survival. A total of 18 patients with chest-wall recurrence were seen in the group allocated to pectoral fascia preservation versus a total of 10 in patients allocated to pectoral fascia removal (hazard ratio=1.8, 95% confidence interval=0.8-4.0). The majority of the chest-wall recurrences were detected 0-5years postoperatively. The cumulative chest-wall recurrence rates at 5 and at 10years were 13 and 15%, respectively, in patients allocated to pectoral fascia preservation and 8 and 9% in patients allocated to pectoral fascia removal. With long-term follow-up neither the chest wall recurrence rate nor the breast-cancer-specific survival was significantly influenced by the preservation of the pectoral fascia. A trend toward an increased risk for chest wall recurrence was observed in patients with preserved pectoral fascia. A hazard ratio of 1.8 for a chest-wall recurrence in patients with preserved fascia indicates that fascia-sparing mastectomy may negatively affect prognosis.

Is Radiation Indicated in Patients With Ductal Carcinoma In Situ and Close or Positive Mastectomy Margins?

Resection margin status is one of the most significant factors for local recurrence in patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery with or without radiation. However, its impact on chest wall recurrence in patients treated with mastectomy is unknown. The purpose of this study was to determine chest wall recurrence rates in women with DCIS and close (<5 mm) or positive mastectomy margins in order to evaluate the potential role of radiation therapy. Between 1985 and 2005, 193 women underwent mastectomy for DCIS. Fifty-five patients had a close final margin, and 4 patients had a positive final margin. Axillary surgery was performed in 17 patients. Median follow-up was 8 years. Formal pathology review was conducted to measure and verify margin status. Nuclear grade, architectural pattern, and presence or absence of necrosis was recorded. Median pathologic size of the DCIS in the mastectomy specimen was 4.5 cm. Twenty-two patients had DCIS of >5 cm or diffuse disease. Median width of the close final margin was 2 mm. Nineteen patients had margins of <1 mm. One of these 59 patients experienced a chest wall recurrence with regional adenopathy, followed by distant metastases 2 years following skin-sparing mastectomy. The DCIS was high-grade, 4 cm, with a 5-mm deep margin. A second patient developed an invasive cancer in the chest wall 20 years after her mastectomy for DCIS. This cancer was considered a new primary site arising in residual breast tissue. The risk of chest wall recurrence in this series of patients is 1.7% for all patients and 3.3% for high-grade DCIS. One out of 20 (5%) patients undergoing skin sparing or total skin-sparing mastectomy experienced a chest wall recurrence. This risk of a chest wall recurrence appears sufficiently low not to warrant a recommendation for postmastectomy radiation therapy for patients with margins of <5 mm. There were too few patients with positive margins to draw any firm conclusions.

Eleven-Year Follow-Up of a Randomised Study of Pectoral Fascia Preservation after Mastectomy for Early Breast Cancer.

Abstract Background: In a previous report with 6 years follow-up a trend towards an increased risk for chest wall recurrence was seen in breast cancer patients operated with preserved pectoral fascia compared to removal of the pectoral fascia. The aim of the present study was to assess whether the preservation or removal of the pectoral fascia in the modified radical mastectomy procedure had any impact on survival or local control in breast cancer patients when followed long term.Method: The trial included 247 patients with breast cancer who underwent modified radical mastectomy in five Swedish hospitals 1993-1997. The median follow-up time was 11 years. The patients were randomised between removal (n=122) versus preservation (n=125) of the pectoral fascia.Results: The breast cancer specific survival at 10 years was 75%. Removal or preservation of the pectoral fascia had not any significant impact on the chest-wall recurrence and on breast cancer specific survival. A total of 18 patients with chest-wall recurrence were seen in the group allocated to pectoral fascia preservation versus 10 in patients allocated to pectoral fascia removal (hazard ratio=1.8, 95%CI = 0.8-4.0). The majority of the chest-wall recurrences were detected 0-5 years postoperatively. The cumulative chest-wall recurrence rates at 5 and at 10 years were 13 and 15% respectively in patients allocated to pectoral fascia preservation and 8 and 9% in patients allocated to pectoral fascia removalConclusion: Neither the chest-wall recurrence rate nor the breast cancer specific survival is significantly influenced by the preservation of the pectoral fascia when the tumor macroscopically does not involve the muscle. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3109.

Selective use of post-mastectomy flap irradiation in high-risk breast cancer patients

The incidence of local recurrence after mastectomy can be reduced by chest wall radiotherapy. However, only a minority of patients are at substantial risk. No UK national guidelines exist for the use of mastectomy flap radiotherapy. This study evaluated a protocol, whereby only high-risk patients were treated with post-mastectomy flap radiotherapy; identified histologically by grade, vascular invasion and nodal status. All women treated by simple mastectomy for invasive breast cancer at the Nottingham Breast Unit from January 1993 to December 1995 were studied (n=292). Postoperative flap radiotherapy was given to 147 high-risk women (50.3%). Median follow-up was 76 months. Overall, 12 women (4.1%) developed a chest wall recurrence; six were single spot recurrences and the remaining six were either multiple spot (n=3) or field change (field change dermal invasion, n=3). The chest wall recurrence rate was 2.7% in those treated with radiotherapy. A low rate of local recurrence has been achieved with selective use of mastectomy flap radiotherapy.

A randomised study of axillary drainage and pectoral fascia preservation after mastectomy for breast cancer

Background. To reduce the risk of seroma after modified radical mastectomy in breast cancer patients, the use of suction axillary drainage is a standard procedure. The optimal time to remove the drain is not established. Whether the removal or preservation of the pectoral fascia influences the risk of seroma formation or loco-regional recurrence rate remains unclear.Method. The trial included 247 patients with breast cancer who underwent modified radical mastectomy in five Swedish hospitals 1993–1997. The median follow-up time was 6 years. One hundred and twenty-two and 125 patients, respectively, were randomised between removal versus preservation of the pectoral fascia. Of these 247 patients a total of 198 patients were also randomised to have the drain removed 24 h postoperatively or to keep the drain in until discharge had decreased to less than 40 ml/24 h.Results. Early removal of the axillary drain was associated with significantly more seromas and a shorter average postoperative hospital stay. There were no differences between the two groups regarding the rate of wound infections and/or hematoma formation. Removal or preservation of the pectoral fascia did not influence the formation of seroma or the amount of peroperative bleeding. A trend towards an increased risk for chest wall recurrence was observed in patients with preserved pectoral fascia (16/125 compared with 8/122; hazard ratio=2.0, 95% confidence interval=0.9–4.7).Conclusion. Early removal of axillary drain shortened the duration of hospital stay without any increase in wound complications. However, it yielded a significantly higher incidence of seroma. Seroma formation and the chest wall recurrence rate was not significantly influenced by the preservation of the pectoral fascia or not.

The rates and CT patterns of locoregional recurrence after resection surgery of lung cancer: correlation with histopathology and tumor staging.

The purpose of our study was to assess the rates and CT patterns of locoregional recurrence after resection surgery of lung cancers according to histopathology and tumor staging. Three hundred and seventy nine patients who underwent lung resection surgery due to lung cancer in a recent 6 year period were followed up with CT (at 3, 6, 12, 18, 24 months, and then annually after surgery) for evaluation of locoregional tumor recurrence (analysis of hilar or mediastinal lymph nodes and surgical margin including bronchial stump, pleura, and chest wall). The recurrence rates and CT patterns were compared in terms of underlying histopathology and tumor staging. Of 379 patients, 75 (20%) patients had locoregional recurrences. The recurrence rates were higher in squamous cell carcinoma (39/190, 21%) than adenocarcinoma (24/140, 17%) (P = 0.012). The patterns of recurrence in 75 patients were hilar-mediastinal lymph node enlargement (n = 39, 52%), ipsilateral pleural lesion (n = 24, 32%), chest wall lesion (n = 13, 17%), bronchial stump lesion (n = 8, 11%), and bronchial extension including the trachea (n = 3, 4%). Bronchial stump recurrence was seen only in squamous cell carcinoma. Bronchioloalveolar carcinoma did not show any evidence of locoregional recurrence. Pleural (P = 0.0016) and mediastinal nodal (P = 0.001) recurrence, respectively, were more common in N2 than N0 cancers. Chest wall recurrence rates were higher with higher T staging (P < 0.001). The locoregional recurrence of lung cancer occurs in about one fifth of patients who undergo curative resection and is more common in squamous cell carcinoma than in adenocarcinoma. Recurrent patterns are diverse and different according to histopathologic type and pathologic staging of lung cancer.

Radiotherapy following mastectomy: indication and contraindication of chest wall irradiation

Purpose: To determine in which cases radiotherapy of the chest wall following mastectomy is indicated, based on the local recurrent rate in patients with locally advanced breast cancer. Methods and Materials: From 1984 until 1994, 105 patients who had four or more histopathologically confirmed axillary nodes metastases, or T3-4Nany, were subjected to mastectomy and were administered radiotherapy postoperatively using the hockey-stick field, which included the ipsilateral supraclavicular fossa and internal mammary nodes, except the chest wall. Median age was 51 years old (range, 23 to 82 years old). Eighty-five patients underwent radical mastectomy, 18 modified radical mastectomy, and 2 extended radical mastectomy. Fraction size was 2 Gy/day, the weekly fraction size was 10 Gy and the total dose ranged from 44 Gy to 54 Gy (median 50 Gy). Seventy-four patients were administered adjuvant chemotherapy, and 61 patients were administered hormone therapy. Results: The 5-year disease-free survival rates of the whole study population were 66%. The 5-year chest wall recurrence rates were 10%. The 5-year chest wall recurrence rates of the patients who had no vascular invasion ( n = 19) and the patients who had definite vascular invasion ( n = 38) were 0% and 24%, respectively ( p = 0.036). All the patients who presented chest wall recurrence had four or more axillary nodes metastases. Nine of the 10 patients who presented chest wall recurrence had definite vascular invasion, while there was no information about vascular invasion for the remaining patient. Factors such as age, pathological subtypes, tumor location, estrogen receptors, extent of resection, chemotherapy, and hormone therapy did not influence the development of chest wall recurrence. Conclusion: Among patients with breast cancer who have four or more positive axillary nodes or T3-4Nany, those who have no vascular invasion or less than 4 axillary nodes metastases do not need to be subjected to chest wall irradiation after radical mastectomy.

Stage I and II Breast Cancer: What Type of Surgery?-Reply

In Reply. —The comment by Dr Quattlebaum regarding recurrence represents a frequent misconception regarding surgical treatment of breast cancer, namely, that more extensive surgery is better than tumor resection with conservation of the breast. However, three large randomized controlled trials comparing BCS and mastectomy have now shown no advantage of mastectomy over BCS for women with tumors up to 4 cm. 1-3 Based on these studies, local recurrence rates 8 to 10 years after treatment range from 2% to 10% among women undergoing BCS and radiation therapy, compared with 2% to 9% chest wall recurrence rates among women with mastectomy. While the US study provides evidence of substantial local recurrence in an unirradiated breast (39%) following BCS, even these women are at no disadvantage for overall survival compared with women undergoing mastectomy. 3 These trials are the basis for the National Institutes of Health recommendation calling for breast preservation for

Prognostic significance of residual disease after radiation therapyof stage III breast cancer

239 Consecutive women with stage III carcinoma of the breast were treated by primary radiation therapy (RT) from 1977 to 1985. The response rate was 89%, the 5-year survival 40% and the local-regional tumor control (LTC) 59%. For the 27 non-responders, postirradiation chemotherapy was initiated but they died within 3 years. 105 Patients were subjected to mastectomy and axillary dissection after RT. In 107 cases, the RT was not followed by surgery. Systemic treatment consisted of hormonal therapy in both groups. The RT plus surgery group had better survival rate, 58% vs. 35% at 5 years. However, the incidence of less favorable cases was higher in the RT alone group. Histological findings in the operated group are analysed to determine prognostic significance of residual disease. No residual or only damaged microscopic disease was found in the breast in 36% of the cases. The axillary lymph nodes (ALN) were free of disease in 42% of the women. Patients with negative ALN after RT had significantly better 5-year survival (82% vs. 43%) and LTC (85% vs. 60%) rates. Decreased chest wall recurrence rate was associated with no residual or damaged microscopic disease in the breast (5% vs. 21%). The disease-free ALN were more common after 50-80 Gy telecobalt than after 40-50 Gy kV irradiation (51% vs. 33%). Primary tumor size (phi less than 5 cm vs. phi greater than 5 cm) had no significant impact on histological findings or on prognosis. Residual disease is mainly a marker of tumor-host relationship which indicates the biological aggressiveness of the disease.

The role of postoperative irradiation in carcinoma of the breast

Chest wall and regional nodal recurrences, and survival following postmastectomy radiation therapy, were analyzed in 352 patients. Patients with T1 and T2 central and medial breast lesions, negative axillary nodal findings, and no evidence of skin or chest wall extension received irradiation to the peripheral lymphatics alone. There were no chest wall recurrences among these patients. The remainder of the patients, including those with axillary nodal involvement, regardless of the site of the primary breast lesion received irradiation by a three-field technique directed to both chest wall and regional nodes. The chest wall recurrence rate was 1.9% when axillary nodes were negative for metastatic disease, 1.3% when the axillary nodes showed less than 50% positivity, and 14.2% when axillary nodes showed greater than 50% involvement. The overall chest wall recurrence rate was 5.1%. A possible mechanism of chest wall recurrence is discussed. Cumulative 5-year survival for stage I is 76%, for stage II, 79%, and for stage III, 57%. If chemotherapy proves to be effective in controlling distant microscopic disease local control may become an equally critical issue in long-term survival of patients with breast carcinoma.