Re-irradiation for intra-thoracic tumours and extra-thoracic breast cancer: dose accumulation, evaluation of efficacy and toxicity based on a literature review

The improvement seen in the diagnostic procedures and treatment of thoracic tumours means that patients have an increased chance of longer overall survival. Nevertheless, we can still find those who have had a recurrence or developed a secondary cancer in the previously treated area. These patients require retreatment including re-irradiation. We have reviewed the published data on thoracic re-irradiation which shows that some specific healthy tissues can tolerate a significant dose of irradiation and these patients benefit from aggressive treatment, however, there is a risk of damage to normal tissue under these circumstances. We analysed the literature data on re-irradiation in the areas of vertebral bodies, spinal cord, breast, lung and oesophagus. We evaluated the doses of primary and secondary radiotherapy, the treatment techniques, as well as the local control and median or overall survival in patients treated with re-radiation. The longest OS is reported in the case of re-irradiation after second breast-conserving therapy where the 5 year OS range is 81 to 100% and is shorter in patients with loco-reginal re-irradiation where the 5-y OS range is 18 to 60%. 2 year OS in patients re-irradiated for lung cancer and oesophagus cancer range from 13 to 74% and 18 to 42%, respectively. Majority grade ≥3 toxicity after second breast-conserving therapy was fibrosis up to 35%. For loco-regional breast cancer recurrences, early toxicity occurred in up to 33% of patients resulting in mostly desquamation, while late toxicity was recorded in up to 23% of patients and were mostly ulcerations. Early grade ≥3 lung toxicity developed in up to 39% of patients and up to 20% of Grade five hemoptysis. The most frequently observed early toxicity grade ≥3 in oesophageal cancer was oesophagitis recorded in up to 57% of patients, followed by hematological complications which was recorded in up to 50% of patients. The most common late complications included dysphagia, recorded in up to 16.7% of patients. We have shown that thoracic re-irradiation is feasible and effective in achieving local control in some patients. Re-irradiation should be performed with maximum accuracy and care using the best available treatment methods with a highly conformal, image-guided approach. Due to tremendous technological progress in the field of radiotherapy, we can deliver radiation precisely, shorten the overall treatment time and potentially reduce treatment-related toxicities.

Multifocality and Multicentrality in Breast Cancer: Comparison of the Efficiency of Mammography, Contrast-Enhanced Spectral Mammography, and Magnetic Resonance Imaging in a Group of Patients with Primarily Operable Breast Cancer

Background: The multifocality and multicentrality of breast cancer (MFMCC) are the significant aspects that determine a specialist’s choice between applying breast-conserving therapy (BCT) or performing a mastectomy. This study aimed to assess the usefulness of mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in women diagnosed with breast cancer before qualifying for surgical intervention to visualize other (additional) cancer foci. Methods: The study included 60 breast cancer cases out of 630 patients initially who underwent surgery due to breast cancer from January 2015 to April 2019. MG, CESM, and MRI were compared with each other in terms of the presence of MFMCC and assessed for compliance with the postoperative histopathological examination (HP). Results: Histopathological examination confirmed the presence of MFMCC in 33/60 (55%) patients. The sensitivity of MG in detecting MFMCC was 50%, and its specificity was 95.83%. For CESM, the sensitivity was 85.29%, and the specificity was 96.15%. For MRI, all the above-mentioned parameters were higher as follows: sensitivity—91.18%; specificity—92.31%. Conclusions: In patients with MFMCC, both CESM and MRI are highly sensitive in the detection of additional cancer foci. Both CESM and MRI change the extent of surgical intervention in every fourth patient.

The role of surgical clips in Breast Conserving Therapy: Systematic review of the Literature

Introduction Conservative breast therapy consists of wide local excision followed by local control of the breast cancer by boost radiotherapy. For radiologists, identification of breast tumor bed (TB) is an essential first step for them to start their radiotherapy. There is number of ways to identify the tumor bed, one of them is inserting the metallic clips in the tumor bed cavity intraoperative. They mark the tumor cavity against the whole breast normal tissue as they appear radioopaque during radiotherapy. Purpose The primary aim of this study is to investigate the need & validity of surgical clips insertion in breast tumor bed and its effect on further breast radiotherapy through a systematic review that includes all published studies which used clips for marking the breast tumor bed. The secondary aim is to define the needed number of surgical clips to define the breast tumor bed clearly and obviously and what are the best types of surgical clips to be used for this purpose. Methods The literature review was done by searching on different databases using the keywords for only English studies reporting using surgical clips for localization in breast surgeries. There was no restriction to specific period or study design. Assessment of included studies was done by 2 independent researchers. Results 54 articles (n = 3427 patients) were the total number of studies that met our inclusion criteria. These studies were of different study designs. Cohort studies were the most representing type about 40 articles. The most common used clips type (21 study, n = 1444 patient) was metallic hemostatic clips according to the sum of operated patients and count of studies. Although all studies confirmed the importance and effectiveness of using clips for tumor bed localization, there was no standard optimum number of clips that can be used for localization. However, most studies used definite number of clips as 4 or 5 clips or used number ranging from 1-5 clips. The same for inserted clips margins at tumor bed, only few studies mentioned definite cavity margins. The 4 main margins (anterior, posterior, superior, inferior) were the commonest reported sites. Conclusion Using surgical clips whatever their type is very helpful for radiologists to define breast tumor bed especially with the obvious increase in using oncoplastic techniques. It’s recommended to use more than 5 clips at tumor bed cavity with special concern to insert them at least 4 margins of tumor bed.

Breast cancer patient-reported outcome of factors influencing cosmetic satisfaction after breast-conserving therapy

Background The aim of this study was to investigate which factors patients considered to be important for determining the degree of cosmetic satisfaction with regards to perceived body image after previous breast-conserving therapy (BCT). Methods Outcomes considered relevant by the patients were first identified using interviews. A questionnaire based on this group input was then devised and added to the physician-based Sneeuw questionnaire. Next, a quantitative study using this questionnaire was conducted in Dutch patients treated at least 6 months earlier for (non-) invasive breast cancer by BCT. Exclusion criteria were: previous mastectomy or BCT of the contralateral breast, BCT with nipple resection, metastatic disease, local recurrence or (previous) plastic breast surgery. Descriptive statistics were used throughout. Results A total of 149 patients (aged 36–87 years) completed the questionnaire. From this focus group input, the top three factors in overall importance (important or very important) for satisfaction were: ‘wearability of bra’ (67%), ‘breast sensitivity’ (59%) and ‘asymmetry’ (51%). Younger patients (< 55 years) considered ‘breast size’ to be most important, whereas ‘wearability of bra’ was most frequently reported by older patients (> 55 years). Time since BCT did not significantly influence the rating of relevant factors. Conclusion Patients consider ‘wearability of bra’, ‘breast sensitivity’ and ‘asymmetry’ as the most important factors when assessing their satisfaction with regards to cosmetic outcome and body image. These factors should be addressed in routine clinical practice during (pre) counseling.