Postmastectomy Patients Research Articles

A Case Study: Murotal Distraction to Reduce Pain Level among Post-Mastectomy Patients

Carcinoma mammae or breast cancer is a malignant disease that originates from the parenchyma. Women who suffer from this disease will choose treatment using mastectomy. Mastectomy treatment is a process of removing all breast tissue that can inhibit the development of cancer cells. Post-operative mastectomy pain can be relieved by non-pharmacological therapy, one of which is murotal therapy. This case study aims to present the results of applying evidence-based murotal treatment to reduce pain scales in post-mastectomy surgery patients. Physical examination was performed using the head-to-toe method in post-operative patients. The North American Nursing Diagnosis Association is used to determine nursing diagnoses. Meanwhile, nursing intervention refers to the Nursing Intervention Classification and Nursing Outcome Classification. The intervention was carried out in five stages of evidence-based nursing implementation in nursing practice, with complementary therapy in murotal therapy and progressive application for 6 days for post-mastectomy surgery patients. As a result, giving murotal therapy intervention for 6 days showed a reduction in the pain scale from a scale of 4 (1-10) to 1 (1-10). The implementation of EBN murotal therapy proved to be effective in reducing the intensity of the pain scale in post-mastectomy surgery patients

Redefining postmastectomy radiation contouring in the era of immediate breast reconstruction: An accurate assessment of local recurrence risk

IntroductionMost studies report post-mastectomy local recurrences as chest wall recurrences without clarifying whether the recurrence is in the subcutaneous tissue, muscle or underlying rib. Post-mastectomy chest wall radiation is recommended in patients at increased risk of locoregional recurrence. Chest wall radiation-related fibrosis has become an important clinical consideration in the era of immediate implant-based breast reconstruction. In patients with commonly performed subpectoral implant-based reconstruction, the pectoralis major becomes relocated anterior to the implant and just deep to skin, therefore raising the question of value in radiating deep chest wall structures. This study assessed the rate of recurrence in each anatomical region of chest wall in post-mastectomy patients. MethodsA comprehensive breast cancer database of 4287 patients at a single regional cancer center from 2006 to 2018 was retrospectively analyzed to identify 1571 mastectomy patients. Recurrences were classified as local skin/subcutaneous, pectoralis muscle (pectoralis major), deep chest wall (pectoralis minor, intercostal muscle or rib) or regional axillary recurrence. ResultsA total of 26 patients with locoregional recurrence were identified. Most recurrences were in the skin/subcutaneous level. Of 1571 mastectomy patients, only one patient developed a local recurrence posterior to pectoralis major. Our literature search and meta-analysis revealed that local recurrences post-mastectomy are much more likely to be in subcutaneous tissues/pectoralis major versus deeper chest wall. ConclusionA reduced clinical target volume which encompasses skin/subcutaneous and pectoralis muscle layers without treating deep chest wall may be more appropriate to reduce radiation-associated toxicity since avoiding circumferential radiation of an implant may prevent capsular contracture without compromising treatment benefit.

Nipple-Areola Complex Reconstruction Using a Skin Graft and Nipple Sharing after Wise-pattern Central Lumpectomy.

SummaryPatients with central breast cancers historically underwent mastectomy, as the aesthetic implications of removing the nipple–areola complex and central breast tissue left disfiguring defects after breast conservation. The introduction of oncoplastic techniques allowed for central lumpectomies in ptotic patients, as the excess skin and gland could be mobilized centrally to fill the defect and even immediately reconstruct a nipple and areola. These reconstructions used excess skin on the Wise pattern vertical limbs to create a nipple, or on a “neopedicle” where both the areola and nipple were reconstructed and then mobilized superiorly into position as would be performed for a conventional mastopexy or reduction. These techniques importantly allowed for the immediate reconstruction of a nipple and areola in patients who often imminently required radiotherapy and where subsequent surgery would be challenging. Here we describe another option for immediate nipple and areola reconstruction in these patients—nipple sharing and a skin graft—a well-established approach in post-mastectomy patients but never previously described for patients undergoing breast conservation.

Assessment of hand function in women with lymphadenopathy after radical mastectomy.

BackgroundBreast cancer related upper limb lymphedema (BCRL) is a common complication in post-mastectomy patients. It is known to cause upper limb disability, which subsequently may affect the grip strength and hand function. There is little evidence on the objective assessment of functional activities particularly hand function in women with BCRL. Therefore, this study objectively assesses the handgrip strength and hand functions in women with BCRL.MethodA cross-sectional study design was conducted on a sample of women with (n = 31) and without (n = 31) BCRL. The Handgrip strength and hand functions were measured using a dynamometer and Jebsen-Taylor hand function test, respectively.ResultsThe results showed a significantly reduced handgrip strength in women with BCRL as compared to age-matched healthy adult women for both right and left hands (p < 0.05). Similarly, hand functions were significantly impaired in women with BCRL as compared to healthy adult women (p < 0.05). Reduction in handgrip strength and hand function in women with BCRL were clinically meaningful as indicated by moderate to large effect sizes (Cohen’s d = 0.61 to 0.99 and 0.54 to 3.02, respectively) in all outcomes except power handgrip strength in left hand (Cohen’s d = 0.38).ConclusionThe results of this study indicate a significant reduction of hand grip strength and hand function in women with BCRL. Our findings suggest that objective measures of grip strength and function be included in the assessment of women with BCRL to better guide clinical decision making and patient care, which may include management of impairment associated with hand strength and function. Future studies that evaluate hand grip strength and function in a larger sample which includes a more diverse age group of women with BCRL are warranted to confirm the current findings.

THE RELATIONSHIP BETWEEN ARM EXERCISES AND THE INCIDENCE OF LYMPHEDEMA IN POST-MASTECTOMY BREAST CANCER PATIENTS IN RSUPH ADAM MALIK MEDAN

Breast cancer is a malignant neoplasm, an abnormal growth of breast tissue that does not see the surrounding tissue, grows infiltrative and destructive, and can metastasize. Every breast cancer patient experiences side effects from various treatment treatments. This is because the therapy that each patient gets varies and also that cancer patients have different genetic backgrounds and different environments. Mastectomy in breast cancer patients can cause many patients to suffer from decreased joint mobility, lymphedema, and limitation in daily activities. These complaints can be overcome with arm exercises. Arm exercises are done to improve circulation and muscle strength and to prevent joint stiffness, preventing lymphedema from occurring. The purpose of this study was to determine the effect of arm exercises on lymphedema prevention. The research design was a quasi-experimental study with a sample size of 64 respondents. The results of the study were p value = 0.001. It is hoped that this study can be used as an education for post-mastectomy patients to improve lymph flow so that lymph flow obstruction does not occur.

Abstract PS1-63: A survey of radiation oncologists on contemporary axillary management in post-mastectomy breast cancer patients

Abstract Background: Local-regional treatment (LRT) of the axilla in breast cancer has evolved over the past several decades. The AMAROS trial demonstrated that dedicated axillary radiation therapy (aRT) can provide local control and allow for less invasive axillary surgery in select patients. Since the AMAROS data was published in 2014, there are no large-scale studies specifically analyzing how this data has impacted clinical practice. Methods: An anonymous case-based survey was sent to 4,254 Radiation Oncologists (RO) who identified as practicing physicians in the US as of May 2020. Those who identified that they do not treat breast cancer patients were excluded. The survey was conducted through the Qualtrics™ platform. Descriptive analyses were performed by the survey software and analytical statistics were performed using R (v4.0.2) utilizing ANOVA, t-tests, and chi-squared analysis. Results: A total of 293 RO completed the survey. Mean years in practice was 18.4 and most were in private practice (41.4%), followed by academic practice (28.2%) and hospital-employed (25.7%). Most (65%) reported that the type of post-mastectomy breast reconstruction does not influence their axillary treatment algorithm. Cases and responses are as follows: Case 1: A 57-year-old female with a cT1N0, ER-positive, Her2-negative breast cancer undergoes mastectomy and sentinel node biopsy (SLNB). Pathology reveals a T1 tumor with 2 of 3 sentinel lymph nodes with 2mm tumor deposits. The majority (75.4%) of RO reported they would proceed with aRT, while 8.7% preferred ALND alone, 7.1% elected for both aRT and ALND, 3.3% chose no further axillary therapy, and 4.5% needed more case information to make a decision. Treatment decision was dictated by clinical trial evidence (62.2%) and national guidelines (26.4%), but 11.2% reported their decision was largely impacted by clinical experience. The ACOSOG Z11 and AMAROS trials had the largest impact on clinical decision-making. For RO who chose to treat with aRT, AMAROS and MA-20 had the highest impact in determining radiation fields, and 88.7% would give RT to both the chest wall and axilla. Choice of axillary treatment did not differ by years in practice (p=0.54), percentage of breast patients treated (p=0.22), or by clinical practice setting (p=0.44). Case 2: A 69-year-old female with a cT1N0 ER/PR-negative, Her2-positive breast cancer undergoes mastectomy and SLNB. Pathology demonstrates a T1 tumor and 4 of 4 sentinel nodes with disease but without extra-nodal extension. Treatment results were mixed: 45.5% recommended both ALND and aRT, 38.5% chose aRT alone, and 14.3% recommend ALND alone. Most (85%) cited that their decision was based upon clinical trial evidence and/or national guidelines. MA-20 and AMAROS were cited as having the highest impact on the decision to perform aRT and determining RT fields. 96.2% of those recommending RT would treat both the chest wall and axilla. On average, RO who were in practice for a shorter period of time preferred both ALND and aRT, while those in practice for more years preferred that patients undergo either ALND or aRT alone (mean 12.9 vs 20.3 years, p&amp;lt;0.001). Treatment decision to undergo dual or single LRT was not associated with percentage of breast patients treated (p=0.41), or by practice setting (p=0.92). Conclusion: There remains significant heterogeneity in axillary treatment patterns for N+ breast cancer patients amongst RO in the US. Those patients with significant nodal burden (≥4+ nodes) were more likely to receive additional axillary therapy, and with combination LRT when treated by RO in practice for a shorter number of years. Physician education on clinical trial inclusion criteria and development of clearer axillary treatment guidelines can aid in appropriate identification of axillary de-escalation opportunities. Citation Format: Chandler S Cortina, Carmen Bergom, Morgan Ashley Craft, British Fields, Adam Currey, Amanda L Kong. A survey of radiation oncologists on contemporary axillary management in post-mastectomy breast cancer patients [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-63.

Effect of Selected Factors on the Serum 25(OH)D Concentration in Women Treated for Breast Cancer.

Maintaining an optimal vitamin D concentration reduces the risk of recurrence and extends survival time in patients after breast cancer treatment. Data on vitamin D deficiency among Polish women after breast cancer therapy are limited. Thus, the aim of the study was the analysis of vitamin D status in post-mastectomy patients, considering such factors as seasons, social habits, vitamin D supplementation and its measurements. The study involved 94 women after breast cancer treatment. Serum vitamin D concentration was measured, and a questionnaire, gathering demographic and clinical data regarding cancer, diet, exposure to sun radiation, and knowledge of recommendations on vitamin D supplementation, was delivered twice, in both winter and in summer. The control group consisted of 94 age-matched women with no oncological history. In women after breast cancer treatment, 25-hydroxyvitamin D (25(OH)D) deficiency was much more frequent than in the general population. Only about half of the patients supplemented vitamin D at the beginning of the study. After the first test and the issuing of recommendations on vitamin D supplementation, the percentage of vitamin D supplemented patients increased by about 30% in study groups. The average dose of supplement also increased. None of the women that were not supplementing vitamin D and were tested again in winter had optimal 25(OH)D concentration. It was concluded that vitamin deficiency is common in women treated for breast cancer. Medical advising about vitamin D supplementation and monitoring of 25(OH)D concentration should be improved.

Incisional Hernia Incidence, Repair Techniques, and Outcomes Based on 1600 Consecutive Patients Receiving Abdominally Based Autologous Breast Reconstruction.

As the number of postmastectomy patients who receive abdominally based autologous breast reconstruction (ABABR) increases, the frequency of unique paramedian incisional hernias (IHs) at the donor site is increasing as well. We assessed incidence, repair techniques, and outcomes to determine the optimal treatment for this morbid condition. A total of 1600 consecutive patients who underwent ABABR at the University of Pennsylvania between January 1, 2009, and August 31, 2016, were retrospectively identified. Preoperative and operative information was collected for these patients. Incisional hernia incidence was determined by flap type and donor site closure technique. Repair techniques and postoperative outcomes for all patients receiving IH repair (IHR) after ABABR at our institution were also determined. Univariate and multivariate analyses were conducted. The incidence of IH after ABABR in our health system was 3.6% (n = 61). Fifteen additional patients were referred from outside hospitals for a total of 76 patients who received IHR. At the time of IHR, mesh was used in 79% (n = 60) of cases (13 biologic and 47 synthetic), with synthetics having significantly lower recurrent IH incidence (10.6% vs 38.5%, P = 0.017) when compared with biologics. Mesh position did not have any statistically significant effect on outcomes; however, sublay mesh position had zero adverse outcomes. Mesh should be used in all cases when possible. Although retrorectus repair with mesh is optimal, this plane is often nonexistent or too scarred in after ABABR. Thus, intraperitoneal underlay mesh with primary fascial closure or primary closure with onlay mesh placement should then be considered.

Total breast reconstruction using large-volume condensed and viable fat grafting after mastectomy

Autologous fat grafting (AFG) has become a third alternative for breast reconstruction after mastectomy. However, total breast reconstruction using AFG remains a great challenge. We performed breast reconstruction using large-volume condensed and viable fat grafting in 30 postmastectomy patients (irradiated, n = 9; nonirradiated, n = 21). The grafts were purified and condensed by the washing and cotton gauze rolling technique. The surgical maneuver is designed to preserve the grafts viability. Three-dimensional expansion was applied where strong adhesions were present. Seven patients wore the Brava device for the expansion of the recipient site. The mean (SD) volume of fat grafted in each procedure was 230.5 (57.8) mL. The average number of sessions was 3.3 (0.7). The irradiated patients required more sessions than the nonirradiated patients (p=.017). The mean follow-up period was 12.8 (4.3) months. One patient (3%) developed postoperative cellulitis. Cysts and palpable nodules occurred in eight patients (27%) and one patient (3%), respectively. Severe dermatitis and skin pigmentation change occurred in one patient wearing the Brava device. The esthetic scores significantly improved after the treatments (p<.001). Approximately 90% of the patients were satisfied. No local recurrence or remote metastasis was documented during the follow-up period. Our study showed the success of total breast reconstruction using AFG. As a third alternative for breast reconstruction, total breast reconstruction using large volume condensed and viable fat grafting is an effective and safe approach for postmastectomy patients.

Comparison of Skin Dose for 3-D Printed vs. Superflab Bolus in Postmastectomy Patients with Expanders Undergoing Radiation Therapy

Comparison of Skin Dose for 3-D Printed vs. Superflab Bolus in Postmastectomy Patients with Expanders Undergoing Radiation Therapy

Impact of Clinical-pathological Factors on Locoregional Recurrence in Mastectomy Patients with T1-2N1 Breast Cancer: Can We Omit Adjuvant Radiotherapy?

Post-mastectomy radiation (PMRT) in T1–T2 tumors with 1–3 positive axillary lymph nodes (ALNs) is controversial. This study was to identify prognostic clinical-pathological factors of locoregional control (LRC) following mastectomy and axillary dissection with or without adjuvant RT for patients with T1-2N1 breast cancer, and to discuss the selection of patients who might not benefit from PMRT. Between January 2006 and December 2010, the data of 839 post-mastectomy patients staged pT1-2N1M0 were analyzed. Radiotherapy was applied in 483 patients. LRC was assessed using the Kaplan-Meier method and log-rank test. At a median follow-up of 87 months (range, 1-167months), 47 (5.6%) patients developed locoregional recurrence (LRR). The 7-year LRC was 94.2% and 94.3% in the non-RT group and RT group respectively (P > .05). Multivariate analysis revealed that RT was an independent prognostic factor of LRC (HR, 0.46; 95% CI, 0.24-0.89; P = .02), meanwhile, age < 40 years, histological grade 3 tumor, and 3 involved lymph nodes were associated significantly with decreased LRC. The 7-year LRC for patients with 0, 1, and 2 or more risk factors was 97.3% / 95.7% (P = .97), 92.7% / 96.9% (P = .04), and 72.9% / 87.2% (P = .18) in the non-RT and RT group respectively. In patients with T1-2N1 breast cancer, clinical-pathological factors such as adjuvant RT, old age, grade 1-2, and 1-2 involved nodes were identified to be prognostic of decreased risk of LRR following mastectomy, and might be helpful in selecting candidates for whom adjuvant RT could be omitted.

Patient-centred communication for women with breast cancer: Relation to body image perception.

This study aimed to determine the predictive values of patient-centred communication (PCC) and patient's characteristics on the body image (BI) perception in postmastectomy patients. Patient-centred communication has been touted as a means of addressing BI issues, especially for postmastectomy patients. This predictive correlational study was conducted on 275 surgically treated breast cancer patients admitted to the Oncology Departments of two hospitals in Tabriz, Iran. These patients were selected using a convenience sampling method. The Body Image after Breast Cancer Questionnaire (BIBCQ) and patient-centred communication questionnaire (PCCQ) were used for collecting the data. Descriptive and inferential statistics were applied to the data. Reporting was in accordance with the STROBE guideline. A multivariable model significantly predicted BI perception in participants using surgery type and time elapsed following surgery. Participants' limitations were significantly affected by surgery type and participants' perception of the nurses' PCC skills. Arm concern was significantly affected by surgery type and nurses' PCC skills. Patient-centred skills in nurse-patient communication are critical for resolving BI difficulties such as arm concerns and limitations regarding the disease and its treatment. Patient-centred communication skills can be taught nurses in the clinical setting to help alleviate patients' BI problems.

Magnitude and dosimetric impact of inter-fractional positional variations of the metal port of tissue expanders in postmastectomy patients treated with radiation.

Postmastectomy breast reconstruction involves the insertion of a temporary tissue expander, which contains a metal injection port. The purpose of this study was to determine the magnitude and dosimetric impact of the inter-fractional positional variations of the port for patients treated with radiation. For nine breast cases treated on Tomotherapy, the deviation of the port in the daily MVCT from its reference position was measured in the three cardinal directions. The dosimetric effects of the measured errors were evaluated for two classes of error: Internal Port Error (IPE) and Patient Registration Error (PRE). For each class, dose accumulation was done for daily measured errors and a systematic error. Inter-fractional positional errors of the port were small, with 87% of the deviations below 5mm, but errors larger than 1.5cm were observed. The cumulative effect of the daily measured and systematic IPE decreased target coverage by as much as 2.8% and 3.5%, respectively. The cumulative effect of the daily measured PRE decreased target coverage by an average of 3.5%. The cumulative effect of a systematic PRE significantly decreased target coverage by an average of 16%. The presence of IPE over the course of treatment had minimal clinical impact while PRE had a greater impact on clinically-relevant regions. The robustness of treatment delivery can be improved by assigning the port its appropriate density during planning despite contouring uncertainties due to metal artefacts, and by prioritizing anatomical alignment over port alignment during daily registration.

Proprioceptive Neuromuscular Facilitation method in physiotherapy in patients after mastectomy

Rehabilitation in the course of breast cancer is an indispensable part of the treatment. The implementation of rehabilitation in the form of kinesitherapy should also take place in the pre-treatment period, so as to compensate for the possibility of complications associated with immobilisation of the patient after mastectomy. In most studies on post-mastectomy rehabilitation, emphasis is placed on anti-anginal prophylaxis and lymphedema therapy. The article aims to present treatment proposals that use the concept of PNF in improved postmastectomy patients. This method, known since the 90's, is often reserved for patients with neurological damage, but can also be successfully used in other patient groups using its main principles and philosophy of therapeutic goals. The article presents examples of activities that can be used in therapy in various phases. The paper presents the method of using the method associated with the upper limb dysfunction after mastectomy, which can be freely modified for the purposes of superior therapy. A review of available literature and own experience was used.

Proprioceptive Neuromuscular Facilitation method in physiotherapy in patients after mastectomy

Rehabilitation in the course of breast cancer is an indispensable part of the treatment. The implementation of rehabilitation in the form of kinesitherapy should also take place in the pre-treatment period, so as to compensate for the possibility of complications associated with immobilisation of the patient after mastectomy. In most studies on post-mastectomy rehabilitation, emphasis is placed on anti-anginal prophylaxis and lymphedema therapy. The article aims to present treatment proposals that use the concept of PNF in improved postmastectomy patients. This method, known since the 90's, is often reserved for patients with neurological damage, but can also be successfully used in other patient groups using its main principles and philosophy of therapeutic goals. The article presents examples of activities that can be used in therapy in various phases. The paper presents the method of using the method associated with the upper limb dysfunction after mastectomy, which can be freely modified for the purposes of superior therapy. A review of available literature and own experience was used.

Satisfacción con los resultados estéticos de la reconstrucción mamaria posmastectomía, en el Instituto Nacional de Oncología y Radiobiología (INOR) de Cuba, mediante el cuestionario BREAST-Q

IntroductionThe surgical treatment of breast cancer leaves deforming sequelae; therefore, breast reconstruction is considered an integral part of the treatment. Evaluating patient satisfaction with the aesthetic results of reconstruction is one way to assess the effectiveness of the surgical techniques used. ObjectivesTo evaluate satisfaction with aesthetic results in patients reconstructed after mastectomy and to compare these results with frontal breast symmetry after surgery. MethodsA case series study was conducted in 40 reconstructed post-mastectomy patients from 2013-2018 at INOR. Satisfaction with aesthetic results was evaluated using the modified Breast Q survey. Differences in satisfaction levels between groups of covariates were determined by the non-parametric Kruskal-Wallis test. The results were correlated with measurement of post-surgical global frontal symmetry using Spearman's correlation. ResultsHigh satisfaction levels were obtained in reconstructed patients in the evaluated scales, with medians above 95 points. Scores were significantly higher in patients aged between 35 and 54 years (p<0.05). Satisfaction with breast appearance correlated positively and significantly with post-surgical frontal symmetry. ConclusionsThe high satisfaction levels achieved suggest a high effectiveness of the reconstructive surgical techniques used, especially with latissimus dorsi plus implant technique; this statement is verified by the positive correlation between satisfaction with the appearance of the breasts and the overall post-surgical symmetry.

Cost-effectiveness analysis of advanced radiotherapy techniques for post-mastectomy breast cancer patients

BackgroundPrior cost-effectiveness studies of post-mastectomy radiotherapy (PMRT) only compared conventional radiotherapy versus no radiotherapy and only considered tumor control. The goal of this study was to perform cost-effectiveness analyses of standard of care (SOC) and advanced PMRT techniques including intensity-modulated radiotherapy (IMRT), standard volumetric modulated arc therapy (STD-VMAT), non-coplanar VMAT (NC-VMAT), multiple arc VMAT (MA-VMAT), Tomotherapy (TOMO), mixed beam therapy (MIXED), and intensity-modulated proton therapy (IMPT).MethodsUsing a Markov model, we estimated the cost-effectiveness of various techniques over 15 years. A cohort of women (55-year-old) was simulated in the model, and radiogenic side effects were considered. Transition probabilities, utilities, and costs for each health state were obtained from literature and Medicare data. Model outcomes include quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratio (ICER).ResultsFor the patient cohort, STD-VMAT has an ICER of $32,617/QALY relative to SOC; TOMO is dominated by STD-VMAT; IMRT has an ICER of $19,081/QALY relative to STD-VMAT; NC-VMAT, MA-VMAT, MIXED are dominated by IMRT; IMPT has an ICER of $151,741/QALY relative to IMRT. One-way analysis shows that the probability of cardiac toxicity has the most significant impact on the model outcomes. The probability sensitivity analyses show that all advanced PMRT techniques are more cost-effective than SOC at a willingness-to-pay (WTP) threshold of $100,000/QALY, while almost none of the advanced techniques is more cost-effective than SOC at a WTP threshold of $50,000/QALY.ConclusionAdvanced PMRT techniques are more cost-effective for breast cancer patients at a WTP threshold of $100,000/QALY, and IMRT might be a cost-effective option for PMRT patients.

Dosimetric comparison of TomoDirect, helical tomotherapy, and volumetric modulated arc therapy for postmastectomy treatment.

PurposeTo compare dose to the targets and organs at risk (OARs) in different situations for postmastectomy patients who require radiation to the chest wall with or without regional nodal irradiation when using three treatment techniques.Methods and materialsThirty postmastectomy radiotherapy (PMRT) patients previously treated by helical tomotherapy (HT) at our institution were identified for the study. The treatment targets were classified in three situations which consisted of, the chest wall (CW) only, the chest wall plus supraclavicular lymph nodes (CW + SPC), and the chest wall plus supraclavicular and whole axillary lymph nodes irradiation (CW + SPC+AXLN). The volumetric modulated arc therapy (VMAT) plans and Tomodirect (TD) plans were created for each patient and compared with HT treatment plans which had been treated. The target coverage, dose homogeneity index (HI), conformity index (CI), and dose to OARs were analyzed. The quality scores were used to evaluate the appropriate technique for each situation from multiparameter results.ResultsThe HT and VMAT plans showed the advantage of target coverage and OARs sparing for the chest wall with regional nodal irradiation with the higher plan quality scores when compared with TD plans. However, TD plans demonstrated superiority to contralateral breast sparing for the chest wall without regional nodal situation reaching the highest of planned quality scores. HT plans showed better HI, CI, and target coverage (P < 0.01) than TD and VMAT plans for all patient situations. Volumetric modulated arc therapy plans generated better contralateral breast and heart sparing at a lower dose than HT.ConclusionThe arc‐based techniques, HT and VMAT plans, provided an advantage for complex targets in terms of target coverage and OARs sparing. However, the static beam TD plan was superior for contralateral organ sparing meanwhile achieving good target coverage for the chest wall without regional node situations.

Dosimetric evaluation of 3 and/or 4 field radiation therapy of breast cancers: clinical experience

AbstractBackground:Breast cancer is the most commonly diagnosed cancer among women and the second leading cause of cancer-related death in Canadian women. Surgery is often the first line of treatment for low-risk early stage patients, followed by adjuvant radiation therapy to reduce the risk of local recurrence and prevent metastasis after lumpectomy or mastectomy. For high-risk patients with node positive disease or are at greater risk of nodal metastasis, radiation therapy will involve treatment of the intact breast or chest-wall as well as the regional lymph nodes.Materials and methods:We retrospectively evaluated the treatment plans of 354 patients with breast cancer with nodes positive or were at high risk of nodal involvement treated at our cancer centre. All patients were treated with a prescription dose of 50 Gy in 25 fractions to the intact breast or chest-wall and 50 Gy in 25 fractions to the supraclavicular region and, based on patient suitability and tolerance, were treated either using the deep inspiration breath hold (DIBH) or free-breathing (FB) techniques.Results:Based on patient suitability and tolerance, 130 (36·7%) patients were treated with DIBH and 224 (63·3%) with FB techniques. There were 169 (47·7%) patients treated with intact breast, whereas 185 (52·3%) were treated for post-mastectomy chest-wall. The mean PTV_eval V92%, V95%, V100% and V105% for all patients are 99·4 ± 0·7, 97·6 ± 1·6, 74·8 ± 7·9 and 1·5 ± 3·2%, respectively. The mean ipsilateral lung V10Gy, V20Gy and V30Gy are 30·0 ± 5·3, 22·4 ± 4·7 and 18·4 ± 4·3% for intact breast and 30·9 ± 5·8, 23·5 ± 5·4 and 19·4 ± 5·0% for post-mastectomy patients with FB, respectively. The corresponding values for patients treated using DIBH are 26·3 ± 5·9, 18·9 ± 5·0 and 15·6 ± 4·7% for intact breast and 27·5 ± 6·5, 20·6 ± 5·7 and 17·1 ± 5·2% for post-mastectomy patients, respectively. The mean heart V10Gy, V20Gy, is 1·8 ± 1·7, 0·9 ± 1·0 for intact breast and 3·1 ± 2·2, 1·7 ± 1·6 for post-mastectomy patients with FB, respectively. The corresponding values with the DIBH are 0·5 ± 0·7, 0·1 ± 0·4 for intact breast and 1·1 ± 1·4, 0·4 ± 0·7 for post-mastectomy patients, respectively.Conclusion:The use of 3 and/or 4 field hybrid intensity-modulated radiation therapy technique for radiation therapy of high-risk node positive breast cancer patients provides an efficient and reliable method for achieving superior dose uniformity, conformity and homogeneity in the breast or post-mastectomy chest-wall volume with minimal doses to the organs at risk. The development and implementation of a consistent treatment plan acceptability criteria in radiotherapy programmes would establish an evaluation process to define a consistent, standardised and transparent treatment path for all patients that would reduce significant variations in the acceptability of treatment plans.

&lt;p&gt;Patterns of Chest Wall Recurrence and Suggestions on the Clinical Target Volume of Breast Cancer: A Retrospective Analysis of 121 Postmastectomy Patients&lt;/p&gt;

PurposeRadiotherapy is a powerful strategy to prevent chest wall recurrence (CWR) of postmastectomy breast cancer (BC). This retrospective study aims at analyzing patterns of CWR to explore the delineation of clinical target volume.Patients and MethodsDetailed clinicopathological information of postmastectomy BC patients with CWR was collected from our single cancer center based on clear criteria. To describe recurrent positions more accurately, the chest wall was divided into three layers: skin layer (skin and subcutaneous tissues), pectoralis layer (pectoralis major and minor), and rib layer (rib and intercostal muscle). The frequency distribution of recurrence location and its association with clinical pathological factors were analyzed.ResultsA total of 121 postmastectomy BC with CWR were included in this study. The percentages of breast tumor located in the upper outer quadrant, upper inner quadrant, lower inner quadrant, lower outer quadrant, overlapping quadrant, and areola area were 31.0% (35/113), 26.5% (30/113), 12.4% (14/113), 5.3% (6/113), 21.1% (25/113), and 2.7% (3/113), respectively. HER2-positive BC (51/113, 45.1%) is the most common BC subtype. Analysis on the patterns of CWR showed that recurrences locating in the skin layer, pectoralis layer, rib layer, mixed layers, and incision periphery accounted for 58.6% (68/116), 9.5% (11/116), 1.7% (2/116), 30.2% (35/116), and 60.5% (46/76), respectively. Rates of recurrences located in the skin and/or pectoralis layers for all BC patients, patients with concomitant distance metastasis, and patients without concomitant distance metastasis were 82.8% (96/116), 85.9% (49/57), and 81.0% (47/58), respectively.ConclusionFor BC patients receiving mastectomy, skin, subcutaneous tissues, pectoralis, and area around incision have a high risk of recurrence, which should be paid more attention in chest wall radiotherapy.