Postmastectomy Breast Cancer Research Articles

Comparison of Treatment Outcome between Hypofractionated Radiotherapy and Conventional Radiotherapy in Postmastectomy Breast Cancer

Objective:The aim of this study was to compare Conventional fractionated radiotherapy (CFRT) and Hypofractionated radiotherapy (HFRT) in terms of treatment outcomes, such as in 5-year loco-regional recurrence free survival, disease free survival, overall survival, and distant metastatic free survival rates as well as toxicity. Materials and Methods:We retrospectively analyzed the data obtained from 462 breast cancer patients who received complete adjuvant radiotherapy treatment between January 2012 and December 2014. One hundred twenty eight patients received CFRT 2 Gy daily fractions at a total dose of 48-60 Gy (group 1), while 334 patients received HFRT 2.65-2.67 Gy daily for 15-19 fractions at a total dose of 39.7-47.8 Gy 9 (grup 2). Treatment outcome such as 5-year loco-regional recurrence free survival, disease free survival, overall survival, and distant metastatic free survival rates as well as toxicity were measured and compared between two groups. Results:Median follow-up was 65.7 months (ranging from 45.1 to 95.2 months). Five-year loco-regional recurrence free survival rate was 96.1% in both CFRT and HFRT groups (p=0.993). Five-year disease-free survival rate of CFRT group was higher (68.8%), but this difference was not significant (HFRT =63.5%) (p=0.396). These were complied with 5-year overall survival rate (71.9% and 64.7%, p=0.385). Five-year distant metastatic free survival rate was 85.9% in CFRT group and 79.6% in HFRT group (p=0.169). No difference was observed between two groups in terms of toxicities, including changes in chest wall appearance, skin fib rosis, brachial plexopathy, arm edema, pulmonary fibrosis, and cardiovascular events. Conclusion:The treatment outcomes of hypofractionated radiotherapy in the postmastectomy breast cancer patients is comparable to the outcomes of conventional treatment at the Chonburi Cancer Hospital as previously reported from other studies, and HFRT can be implemented in resource-limited settings.

Optimization of autogenerated chest-wall radiation treatment plans developed for postmastectomy breast cancer patients in underserved clinics

Over the past decade, several strides have been made to improve the management of breast cancer in developing countries; however, there are still obstacles present. In the area of radiation therapy, these hurdles include limited access to radiotherapy treatment and scarcity of oncology specialists. In an effort to reduce inequities in cancer care while improving patient outcomes, our research is focused on developing automated postmastectomy radiation therapy (PMRT) plans for breast cancer patients in these underserved communities that can be further improved upon through treatment planning system (TPS) specific optimization guidelines. The automated planning tool utilized algorithms integrated with Varian's Eclipse TPS. The tool created PMRT plans that used monoisocentric tangents and supraclavicular (SCV) fields with a mix of high and low energy photon beams along with field-in-field (FIF) segments. The completed autogenerated PMRT plans were imported into Phillip's Pinnacle 9.10 and Varian's Eclipse 13.6 TPSs to be further improved through manual optimization; the time required to complete this step was measured and assessed. A senior dosimetrist, physicist, and physician evaluated the optimized plans for clinical acceptability. Guidelines were developed for the planning systems that can be implemented by personnel with either limited experience in radiation treatment planning or those with limited time to produce treatment plans. The autogenerated plans in conjunction with our guidelines have shown to significantly reduce the time required to produce a clinically acceptable PMRT plan from approximately 120 ± 60 minutes to just 13 ± 11 (Pinnacle) and 12 ± 7 (Eclipse) minutes, reducing the total uninterrupted treatment planning time by an average of 108 ± 51 minutes. The results from this research indicate that the autogenerated PMRT plans along with the optimization guidelines are a viable option to provide quality and clinically acceptable PMRT plans that are more efficient and consistent for postmastectomy breast cancer patients in severely underserved communities.

A comparison between phantom breast syndrome and phantom limb: A systematic review

Phantom Breast Syndrome (PBS) is a post mastectomy condition in which patients experience both non painful sensations as well as phantom breast pain in the area of the amputated breast. Studies into phantom breast arose decades after the term “phantom limb” was introduced. However, the aetiology of the phantom phenomenon is yet to be fully understood. Furthermore, there are fewer documented cases and researches done into PBS in comparison with phantom limb. PBS and phantom limb are believed to develop under the same neurological basis; however, differences exist. For instance, the concept of proprioception is proposed as a possible contribution to phantom pain, incorporated into the mirror box therapy used to treat phantom limb, was proven effective, based on various studies. This review, draws comparison between Phantom Limb and PBS and also aims at highlighting the proposed causes to phantom phenomenon, the risk factors and possible treatment of PBS in breast cancer patients. The PRISMA methodology was implemented; random articles were evaluated, drawn from electronic databases such as PUBMED, Scopus, MEDLINE, HINARI, EBSCO, Science Direct and Google Scholar. In conclusion, there is limited studies into PBS in relation to phantom limb and thus questions arise which evoke curiosity. Is it possible that PBS is the key to unlocking the mystery to the phantom phenomenon? Does PBS have an effect on post-mastectomy recovery and breast cancer prognosis? If so, PBS deems worthy of further research as there is a rising global cancer epidemic.

Dosimetric comparison between volumetric-modulated arc therapy and a hybrid volumetric-modulated arc therapy and segmented field-in-field technique for postmastectomy chest wall and regional lymph node irradiation

Decreasing radiotoxicity to the heart, lungs, and contralateral breast has proven to lower the risk of secondary malignancy and improve overall outcomes when treating chest wall (CW) and regional lymph nodes in postmastectomy breast cancer patients. In this retrospective study, 11 postmastectomy patients were selected and planned with a novel hybrid treatment method and a traditional volumetric arc therapy (VMAT) approach for comparison. This hybrid technique was able to optimize tangential beams to minimize heart dose and the VMAT contribution to improve dose conformity around the planning target volume (PTV). Overall, this hybrid technique produced more homogenous target dose coverage and demonstrated a decrease of integral dose to organs at risk (OAR), while the VMAT technique demonstrated a higher affinity for maintaining dose conformity. Further observation of dose distributions also revealed that the hybrid plans were more effective in sparing low-dose spread to healthy tissue in both right- and left-sided cases. This observation was made evident by the reduction in heart V5 and Dmean, decreases in all parameters regarding the contralateral lung, as well as all values other than the V20 of the ipsilateral lung. This unique hybrid planning technique could present an alternative to standard intensity-modulated radiation therapy (IMRT) planning when treating postmastectomy CW and regional lymph nodes, as it has shown the capacity to decrease cardiac, lung, and contralateral breast toxicity while maintaining quality PTV coverage.

PD-L1 expression is a predictive biomarker for CIK cell-based immunotherapy in postoperative patients with breast cancer

BackgroundA sequential combination of radiochemotherapy/endocrinotherapy and cytokine-induced killer cell (CIK) infusion has been shown to be an effective therapy for post-mastectomy breast cancer based on statistical analysis of the patient population. However, whether an individual could obtain an improved prognosis from CIK cell-based treatment remains unknown. In the present study, we focused on immune microenvironment regulation and specifically investigated the relationship between PD-L1 expression and survival benefit from CIK immunotherapy in breast cancer.MethodsA total of 310 postoperative breast cancer patients who received comprehensive treatment were enrolled in this retrospective study, including 160 patients in the control group (received chemotherapy/radiotherapy/endocrinotherapy) and 150 patients in the CIK cell treatment group (received chemotherapy/radiotherapy/ endocrinotherapy and subsequent CIK infusion).ResultsWe found that overall survival (OS) and recurrence-free survival (RFS) were significantly better in the CIK group than that in the control group. PD-L1 expression in tumor tissue sections was showed to be an independent prognostic factor for patients in the CIK treatment group using multivariate survival analysis. Further survival analysis in the CIK group showed that patients with PD-L1 tumor expression exhibited longer OS and RFS. In addition, among all patients who were enrolled in this study, only the patients with PD-L1 expression experienced survival benefits from CIK treatment.ConclusionsOur study showed the relationship between PD-L1 expression and CIK therapy and revealed that PD-L1 expression in the tumor is as an indicator of adjuvant CIK therapy for postoperative breast cancer.

The 8th edition of the American Joint Committee on Cancer staging system provide improved prognostic accuracy in T1-2N1M0 postmastectomy breast cancer patients

Objective: To validate whether the prognostic stage groups by the 8th edition of the American Joint Committee on Cancer (AJCC) staging system provides improved prognostic accuracy in T1-2N1M0 postmastectomy breast cancer patients compared to 7th edition. Methods: a total of 1 823 female patients with T1-2N1M0 breast cancer who underwent mastectomy and axillary lymph node dissection without neoadjuvant chemotherapy were analyzed and restaged according to 8th edition. Univariate analysis of prognostic factors was evaluated by using log-rank test. Multivariate analysis was estimated by using the Cox proportional hazards model. The prognostic accuracy of the two staging systems was compared using receiver operating characteristic (ROC) analyses and the concordance index (C-index). Results: 5-year locoregional recurrence rate (LRR) for the whole group was 6.0%, 5-year distant metastasis (DM) rate was 11.5%, 5-year disease-free survival (DFS) was 85.0%, and 5-year overall survival (OS) was 93.1%. Cox analysis showed that 7th edition of the AJCC staging system and progesterone receptor status were independent risk factors for LRR, DM, DFS and OS (P<0.05). Compared with stage by 7th edition, 1 278(70.1%) were assigned to a different prognostic stage group: 1 088 (85.1%) to a lower stage and 190 (14.9%) to a higher stage. LRR, DM, DFS and OS were significantly different between prognostic stage ⅠA, ⅠB, ⅡA, ⅡB and ⅢA according to 8th edition of the AJCC staging system(P<0.001). Prognostic stage had significantly higher C-indexes and provided better estimation of prognosis compared to stage by 7th edition of the AJCC staging system (P<0.001). Conclusion: The prognostic stage groups of 8th edition AJCC staging system has superior prognostic accuracy compared to 7th edition in T1-2N1M0 breast cancer, and has better clinical therapeutic guidance value.

An atlas-based method to predict three-dimensional dose distributions for cancer patients who receive radiotherapy

Due to the complexity of advanced radiotherapy techniques, treatment planning process is usually time consuming and plan quality can vary considerably among planners and institutions. It is also impractical to generate all possible treatment plans based on available radiotherapy techniques and select the best option for a specific patient. Automatic dose prediction will be very helpful in these situations, while there were a few studies of three-dimensional (3D) dose prediction for patients who received radiotherapy. The purpose of this work was to develop a novel atlas-based method to predict 3D dose prediction and to evaluate its performance. Previously treated nineteen left-sided post-mastectomy breast cancer patients and sixteen prostate cancer patients were included in this study. One patient was arbitrarily chosen as the reference for each type of cancer and all the remaining patients’ computed tomography (CT) images and contours were aligned to it using deformable image registration (DIR). Deformable vector field (DVF) for each patient i (DVFi-ref) was used to deform the original 3D dose matrix of that patient. CT scan of a test patient was also registered with the same reference patient using DIR and both direct DVF (DVFtest-ref) and inverse DVF () were derived. Similarity of atlas patients to the test patient was determined based on the similarity of DVFtest-ref to atlas DVFs (DVFi-ref) and appropriate weighting factors were calculated. Patients’ doses in the atlas were deformed again using to transform them from the reference patient’s coordinates to the test patient’s coordinates and the final 3D dose distribution for the test patient was predicted by summing the weighted individual 3D dose distributions. Performance of our method was evaluated and the results revealed that the proposed method was able to predict the 3D dose distributions accurately. The mean dose difference between clinical and predicted 3D dose distributions were 0.9 ± 1.1 Gy and 1.9 ± 1.2 Gy for breast and prostate plans. The proposed dose prediction method can be used to improve planning quality and facilitate plan comparisons.

Development and impementation of the psychophysiological well-being assessment tool based on roy's adaptation model for breast cancer patients: A pilot study

Breast cancer is a chronic illness affecting a vast number of females globally. During the illness and after mastectomy they have disturbed physiological and psychological wellbeing. No tool based on RAM (Roy's Adaptation Model) was there to assess their physiological and psychological wellbeing. The purpose of the present study was to develop the valid and reliable Psycho physiological Well-being Assessment Tool (PWAT) based on Roy's Adaptation Model and implement the tool on post mastectomy breast cancer patients who were under radiation therapy or chemotherapy or both to assess their Psycho physiological Well-being. Methodology: A Methodological research design was adopted to conduct the study. Item analysis and Modified Delphi survey were done to develop PWAT. It was implemented on 20 post mastectomy breast cancer patients who were selected by convenient sampling technique in Amer Hospital Patiala. Results: Common consensus of experts was obtained from 72 pooled items to 38 items of PWAT. The reliability of instrument was estimated by using split half Chronbachs alpha which was r=0.73. Statistically all the items of PWAT were found inter correlated and were compatible to each other. The mean value of physiological wellbeing was 60.45 with stand red deviation of 6.637 and median value 61.5as compared to Psychological wellbeing mean value 80.60 with standard deviation 15.689 and median value 80.5 which revealed that post mastectomy breast cancer patients were having better psychological wellbeing rather than physiological wellbeing Conclusion: The empowered nurses with PWAT will do quick assessment of psycho physiological wellbeing of post mastectomy breast cancer patients. Their timely intervention will help in decreasing re-hospitalizations of patients and help in cost containment for the health care industry which is the essence of quality care management.

Dose-volume Analysis of Heart and Lung during 3D Planning of Tangential Breast Cancer Irradiation

Introduction: Breast cancer is becoming more frequently diagnosed at early stages with improved long-term outcomes. Radiation-related heart disease and lung cancer can occur following radiotherapy for breast cancer. The aim of this study was to evaluate some dosimetric parameters of heart and lung during whole breast radiotherapy. Materials and Methods: Twenty-five consecutive patients with breast cancer who underwent radiotherapy were included in this study. Plans that employed the 3D conventional radiotherapy technique (Tangential Technique) were generated for each patient. Dose-volume histograms (DVHs) were calculated and dosimetric parameters such as, mean dose/volume receiving a dose 30 Gy (V30), mean dose/ volume receiving a dose 20 Gy (V20) for heart and lung were assessed, respectively. Results: The average of mean dose of heart on left and right side irradiation was 9.68±5.10 Gy and 1.23±1.51 Gy, respectively. The average of mean dose of ipsilateral lung on left and right-sided irradiation was 14.49±4.07 Gy and 11.69±3.37 Gy, respectively. The percentage of heart volume that received at least 30 Gy was 16.32±9.56% for left-sided treatment. The percentage of lung volume that received at least 20 Gy was 23.47±11.05% and 24.12±7.77% respective on the left and right-sided breast irradiation. Conclusion: Tangential beam conventional radiotherapy of the chest wall of postmastectomy breast cancer patients provides the potential to significantly keep the DVH parameters of heart and lung as low as the QUANTEC constrains.

Using Time Management and Quality Improvements to Decrease the Incidence of Unexpected Skin Defects in Post-Mastectomy Breast Cancer Patients

When patients with breast cancer undergo radical mastectomy, seromas are often caused due to the large area of excised breast tissue and the resulting cavity that fills with blood and water. Therefore, strong adhesive elastic tape and large amounts of gauze are needed to compress the wound. Our clinical experience shows that repeatedly removing dressings during dressing changes significantly increases the risk of unexpected skin defects. However, the increased duration of hospital stays required for these patients with skin defects exposes them to high risk environments, which may result in nosocomial infections and even longer hospitalization durations. This project aimed to decrease the incidence of unexpected skin defects in patients after mastectomy to below 15%. After a review of the literature, we implemented this project to: (1) build up a standard operating procedure for post-mastectomy wound compression; (2) use narrow girdles instead of strong adhesive elastic tape; (3) use soft elastic bandages to replace the single layer of gauze for wound compression; (4) use a skin examination form as a continuous monitoring tool. We expected that these measurements would effectively decrease the incidence of unexpected skin defects in post-mastectomy patients. After implementing this project, the incidence of unexpected skin defects in post-mastectomy patients decreased from 100% to 13% and the time required by clinical nursing staff to perform wound dressing care decreased from 25 mins to 15 mins per care instance. We hope that this project helps effectively improve postoperative wound care quality in post-mastectomy patients and decreases the time spent by clinical nursing staff on wound dressing care.

Molecular determinants of post-mastectomy breast cancer recurrence

Breast cancer (BC) adjuvant therapy after mastectomy in the setting of 1–3 positive lymph nodes has been controversial. This retrospective Translational Breast Cancer Research Consortium study evaluated molecular aberrations in primary cancers associated with locoregional recurrence (LRR) or distant metastasis (DM) compared to non-recurrent controls. We identified 115 HER2 negative, therapy naïve, T 1–3 and N 0-1 BC patients treated with mastectomy but no post-mastectomy radiotherapy. This included 32 LRR, 34 DM, and 49 controls. RNAseq was performed on primary tumors in 110 patients; with no difference in RNA profiles between patients with LRR, DM, or controls. DNA analysis on 57 primary tumors (17 LRR, 15 DM, and 25 controls) identified significantly more NF1 mutations and mitogen-activated protein kinase (MAPK) pathway gene mutations in patients with LRR (24%, 47%) and DM (27%, 40%) compared to controls (0%, 0%; p < 0.0001 and p = 0.0070, respectively). Three patients had matched primary vs. LRR samples, one patient had a gain of a NF1 mutation in the LRR. There was no significant difference between the groups for PTEN loss or cleaved caspase 3 expression. The mean percentage Ki 67 labeling index was higher in patients with LRR (29.2%) and DM (26%) vs. controls (14%, p = 0.0045). In summary, mutations in the MAPK pathway, specifically NF1, were associated with both LRR and DM, suggesting that alterations in MAPK signaling are associated with a more aggressive tumor phenotype. Validation of these associations in tissues from randomized trials may support targeted therapy to reduce breast cancer recurrence.

Nursing intervention in women who developed lymphedema after undergoing a modified radical mastectomy: a pre-experimental study.

The aim of this study was to analyse the effect of a nursing intervention in increasing the therapeutic self-care demand in patients with breast cancer-related lymphedema after a mastectomy. The pre-experiment was carried out on women in the State Cancer Institute in Colima, Mexico. Thirty women who had undergone a mastectomy were included in this study. Each woman received a nursing intervention to increase her knowledge, skills and motivation, which are the components of therapeutic self-care demand. Students’ t and P values were calculated for paired means, and the McNemar X2 test was performed for paired categorical variables. It was found that Students’ t values for therapeutic self-care demand, knowledge, skills and motivation were significant (all with P = 0.00001). It was also found that McNemar X 2 values for the same criteria paired categorically were significant (P = 0.0002, P = 0.003, P= 0.0002, P = 0.00001, respectively). It was concluded that the nursing intervention was effective in increasing the therapeutic self-care demand of patients with post-mastectomy breast cancer.

Abstract P3-04-01: Molecular determinants of post-mastectomy breast cancer recurrence

Abstract Introduction The management of breast cancer (BC) patients who undergo mastectomy in the setting of 1-3 positive lymph nodes has been controversial. This retrospective Translational Breast Cancer Research Consortium study evaluated the molecular aberrations associated with locoregional recurrence (LRR) or distant metastasis (DM) compared to controls in an effort to identify molecular predictors associated with recurrence. Methods/Materials We identified 115 HER2 negative, therapy naïve, T 1-3 and N 0-1 BC patients treated with mastectomy and no post mastectomy radiation therapy from 1997 to present with available FFPE tissue blocks. The cohort included 32 patients with LRR, 34 with DM, and 49 controls (without recurrence) who were matched for stage, grade, hormone receptor status, age ≤ or &amp;gt; 50, chemotherapy receipt, and margin status. Matched primary and recurrent LRR samples were available for 3 patients. Hybrid capture next generation sequencing (NGS) of 142 cancer related genes and RNAseq were performed to identify DNA/RNA alterations associated with LRR or DM. The frequency of common alterations on NGS was compared with Fisher's exact test. Expression of each gene from mRNA-Seq was treated as an explanatory variable. Immunohistochemistry (IHC) was performed for PTEN, Ki-67 and cleaved caspase 3 (CC3). PTEN loss and percentage of Ki-67 and CC3 positive cells were compared between groups with Fisher's exact test and nonparametric methods, respectively. Results RNAseq was performed on 115 patients; there was no difference in RNA expression levels between the groups. DNA analysis was performed on 57 patients (17 LRR, 15 DM and 25 controls), NF1 mutation rate was significantly elevated in both the LRR (24%) and DM (27%) samples compared to controls 0%; (p=0.0070). The mitogen activated protein kinase (MAPK) pathway was significantly mutated in both LRR (47%) and DM (40%) samples compared to the controls 0%; (p&amp;lt;0.0001). There was no significant difference in the rate of alterations of the PI3K/Akt/mTOR pathway among the three groups. Of three patients with matched primary vs LRR samples, one had concordant mutations. The second patient had additional mutations in the LRR, including gain of a NF1 mutation. The third patient had complete discordance of mutations identified in primary and LRR and had gain of HER2 amplification, suggestive of a new primary. There was no significant association between the groups and the loss of PTEN expression or CC3 expression. There was a significant difference between Ki 67 positive cells in patients with LRR (mean 29%), DM (mean 26%) versus controls (mean 14%, p= 0.0011). HR+ patients were significantly more likely to have a positive PTEN, lower Ki-67 and lower CC3 expression, p=0.0004, p&amp;lt;0.0001, and p&amp;lt;0.0001 respectively. Conclusions In this matched cohort analysis, mutations in the MAPK pathway, specifically NF1, were associated with both LRR and DM, suggesting that alterations in this pathway are associated with a more aggressive tumor phenotype. However, there were no molecular features that discriminated between those likely to recur locally alone versus distantly. Further study is needed to validate these findings, and to determine whether targeting alterations in this pathway could decrease the risk of recurrence. Citation Format: Keene KS, King T, Hwang ES, Peng B, McGuire K, Tapia C, Zhang H, Bae S, Nakhlis F, Klauber-Demore N, Meszoely I, Sabel MS, Willey SC, Eterovic KA, Hudis C, Wolff A, De Los Santos J, Thompson A, Mills GB, Meric-Bernstam F. Molecular determinants of post-mastectomy breast cancer recurrence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-04-01.

Hypofractionated versus Conventionally Fractionated Radiotherapy in Post-Mastectomy Breast Cancer Patients

Background & Objective: Hypofractionation has been used in curative setting in breast conservative surgery, but still no adequate information about its application in the adjuvant setting after mastectomy in breast cancer patients. The aim of this trial was to assess the efficacy and toxicity of hypofractionation radiotherapy (40 Gy in 15 fractions) in post mastectomy breast cancer patients and to compare these results with those of post mastectomy patients treated retrospectively by conventional radiotherapy (50 Gy in 25 fractions) as regard overall survival (OS), disease free survival (DFS), locoregional disease free survival (LDFS), and toxicities. Patients & Methods: One hundred post mastectomy breast cancer patients were included into this study, they were divided into 2 groups, the 1st included 50 patients treated prospectively with hypofractionated radiotherapy regimen (40 Gy in 15 fractions), and the 2nd (control group) included 50 patients treated retrospectively with conventionally fractionated radiotherapy regimen (50 Gy in 25 fractions). Results: The 2 year overall survival were 96% & 94% respectively (p = 0.7), while the disease free survival were 91% & 89.8%, respectively (p = 0.9), and the LDFS were 95.8% & 93.3%, respectively (p = 0.9), G1 acute dermatitis was observed in 22 (44%) & 25 (50%) patients in group I & II respectively, G2 in 8 (16%) & 10 (20%) patients respectively, no G4 skin toxicity was detected. Radiation pneumonitis was observed in 2 patients (4%) only in group II. Conclusion: post-mastectomy hypofractionated radiation therapy achieved comparable survival and toxicity to the conventionally fractionated radiotherapy with the advantage of reducing overall treatment time, treatment burden & cost.

A comparative study of hypofractionated and conventional radiotherapy in postmastectomy breast cancer patients

Objective:The aim of this study was to compare toxicity and locoregional control of short duration hypofractionated (HF) radiotherapy (RT) with conventional RT in breast cancer patients.Methods:A total of 100 postmastectomy breast cancer patients were randomized for adjuvant RT in control group (comprising fifty patients who received the standard conventional dose of 50 Gy in 25 fractions with 2 Gy per fraction) and study group (comprising fifty patients who received HF RT with dose of 42.72 Gy in 16 fractions with 2.67 Gy per fraction). All patients were treated on linear accelerator with 3-dimensional conformal RT technique. Outcome was analyzed in terms of toxicity, tolerability, and locoregional control.Results:In the present study, at a median follow-up of 20 months, almost similar results were seen in both the groups in terms of toxicity, tolerability, and locoregional control. Adjuvant postmastectomy HF RT was found to be well tolerated with mild-to-moderate side effects that neither reached statistical significance nor warranted any treatment interruption/hospitalization.Conclusions:HF postmastectomy RT is comparable to conventional RT without evidence of higher adverse effects or inferior locoregional tumor control and has an added advantage of increased compliance because of short duration; hence, it can help in accommodating more breast cancer patients in a calendar year, ultimately resulting in decreased waiting list, increased turnover, and reduced cost of treatment.

Field-In-Field Plan Versus Tangential Wedged Beam Plan in Chest Wall Radiotherapy of Post-Mastectomy Patients: Treatment Planning Study

Introduction: In this study, dose distribution of the chest wall in post-mastectomy breast cancer patients was evaluated and compared in the tangential wedged beam (TWB) and field-in-field (FIF) plans. Materials and Methods: Thirty-six patients with left-sided breast cancer were enrolled in this study. The FIF and TWB plans were generated for each patient to compare dosimetric parameters of the chest wall. The maximum dose (Dmax), homogeneity index (HI), conformity index (CI), and uniformity index (UI) were defined and used for comparison of the dosimetric parameters of the planning target volume (PTV) in both FIF and TWB plans. The percentage of volumes receiving at least 10, 20, 30, and 40 Gy of the left lung and 5, 10, 20, 25 and 30 Gy of the heart were used to compare the dosimetric results of the organs at risk. Statistical analysis was performed using SPSS, version 20. Results: The FIF plan had significantly lower HI (P=0.000) than the TWB plan, indicating that the FIF plan was better than the TWB plan in PTV. The V40lung (15.36±4.35 vs. 18.37±4.42) and V30heart (8.15±3.75 vs. 10.94±3.94; P=0.000) were significantly lower in the FIF plan than in the TWB plan. In addition, the monitor unit (MU) was significantly lower in the FIF plan than in the TWB plan (227.76 vs. 323.59; P=0.000). Conclusion: The FIF plan significantly reduced the dose volume of the left lung and heart in post-mastectomy radiotherapy compared to the TWB plan. Therefore, the FIF plan is recommended for this purpose.

Association of Anxiety, Depression, and Body Image Disorder with Pain-Related Disability in Post-Mastectomy Breast Cancer Patients

Association of Anxiety, Depression, and Body Image Disorder with Pain-Related Disability in Post-Mastectomy Breast Cancer Patients

Dosimetric comparison of Volumetric Modulated Arc Therapy and Three-Dimensional Conformal Radiotherapy during Post Mastectomy left chest wall Irradiation

Aims: To dosimetrically evaluate the Volumetric Modulated Arc Therapy (VMAT) technique and compare it with Three-Dimensional Conformal Radiotherapy (3D-CRT) for postmastectomy breast cancer therapy. Methods and Material: Ten consecutively treated left sided breast cancer patients were selected for this study. VMAT plans were generated from each of the patients planning CT and compared with 3D-CRT plans. Statistical analysis used: Two tailed paired t test Results: The VMAT technique provided statistically significant homogenous and conformal dose distribution with mean HI of (0.1±0.02) and mean CI of (1.1±0.06) when compared mean HI of (0.3±0.02) and mean CI of (1.7±0.2) in the 3D-CRT technique. VMAT plans showed reduced V30 of the heart (10±4.54) when compared to 3D-CRT plans (15.1±8.53). Except V30, VMAT plans resulted in higher doses to heart. The mean doses received by left lung was (17.50±6.27) and was significantly higher than that of 3D-CRT plans (10.20±3.72). VMAT plans also gave higher doses to the contralateral lung and the opposite breast. Conclusions: VMAT plans in post mastectomy breast cancers provide more homogenous and conformal plans as compared to 3DCRT plans but higher doses to normal tissues.

Migration of Metallic Breast Expander Ports During Post-mastectomy Radiation Therapy

Adjuvant radiotherapy (RT) is often indicated in post-mastectomy breast cancer patients, many of whom have temporary tissue expanders. However, the metallic breast expander ports (MBEP) are known to cause RT dose attenuation, often impacting dosimetry planning. Given MBEP migration is typically not monitored, we sought to determine if the MBEP shifts over the course of RT. We conducted a retrospective review of 20 post-mastectomy patients who received RT with an inflated tissue expander in place from 2015-2016. We assessed MBEP migration in sequential port films taken with lateral and medial tangential fields using the image analysis software ImageJ. Translational migration was measured relative to both a superimposed landmark (apparent migration due to patient setup or breathing, i.e. horizontal and vertical distances from the MBEP to inside gridlines and outer field boundaries) and an anatomic landmark (true migration in the tissue, i.e. horizontal distance from the MBEP to ribcage). Rotational migration was assessed by measuring the angle of the MBEP frame relative to the horizontal axis. Measurement consistency was assessed by recording the MBEP center coordinates in triplicate. All measurements were recorded in pixels, converted to mm using the grid axis scale, and normalized to the average for a given patient and field. Patients were subdivided into ABC (active breathing coordinator) and non-ABC groups. Each patient had 5-7 port films for each lateral and medial tangential field (216 total films). Triplicate measurements to confirm consistency had an average standard deviation of 0.24mm and with no variation >1.5mm. Apparent migration had an average deviation of 2.0 ± 1.6mm from the mean for a given patient and field, with 11/432 (2.5%) exceeding a max deviation of 10mm within a given port film series, thus exceeding our port film-determined setup of ± 5mm relative to the DRR. True migration and rotational migration were both minimal, with an average deviation of 0.9 ± 0.8mm and 1.2 ± 0.9 degrees from the mean, respectively. No significant migration difference was observed between ABC (n=5) and non-ABC (n=15) patients. Using this novel port film based method to assess MBEP migration over the course of RT, we only rarely observed significant apparent migration, with no significant true translational or rotational migration observed in this study. Given that tissue is radiated relative to the grid axis, apparent MBEP migration, as opposed to true migration, is a better metric of dosing accuracy. Our data suggest that apparent MBEP migration that could alter RT dosing is uncommon but does occur and should be accounted for, particularly with the use of multi-segmentation technique to compensate for MBEP attenuation. More research is needed to better understand how MBEP migration impacts dosage and to develop strategies to monitor migration during RT.

An alternative option to reduce lung dose for electron scar boost irradiation in post-mastectomy breast cancer patients with a thin chest wall

AbstractAimWe evaluated water-equivalent slabs as an alternative to a bolus to reduce radiation dose to the underlying lungs during electron scar boost irradiation in breast cancer patients with a thin chest wall undergoing post-mastectomy radiation therapy.Materials and methodsPercent depth doses (PDDs) and attenuation factors were obtained for 6 MeV (the lowest electron energy in most clinics) with solid water slabs (1–10 mm by 1 mm increments) placed on top of electron cones. Scatter dose to contralateral breast caused by the solid water slabs was measured on a human-like phantom using two selective scar boost patient setups.ResultsThe PDD plots showed that the solid water slabs had similar dosimetric effects to the bolus with lower skin dose to ipsilateral breast for the same thickness. Slab attenuation and scatter dose to the contralateral breast were increased by ~220% and by a factor of 3 with a 5 mm slab, respectively.FindingsOur results demonstrate the feasibility of using water-equivalent slabs to reduce lung dose for electron scar boost treatment in mastectomy patients with a thin chest wall. However, the increases in treatment time and scatter dose to the contralateral breast are the disadvantages of this approach.