Postoperative irradiation following immediate breast reconstruction using a temporary tissue expander.

Ten consecutive patients at Howard University Hospital underwent modified radical mastectomy with immediate breast reconstruction using a temporary tissue expander. Postoperative irradiation was delivered to the breast mound encompassing the tissue expander. The effects of expansion on the delivery of postoperative irradiation was assessed. Dosimetric measurements with thermoluminescent dosimeters revealed that the saline-filled expander attenuated the photon beam 3% less than tissue-equivalent material of equal volume. This dose variation was negligible, so no adjustments were made. Postoperative treatment consisted of 5040 cGy to 5220 cGy delivered in 5 to 10 weeks using 4 mV photon tangentials. Cosmesis was assessed over a 2-year period. Six patients completed reconstruction and irradiation without complications. Cosmesis was good in five and fair in one. One patient developed a moist reaction secondary to postoperative irradiation; however, final cosmesis was good. Three patients developed complications leading to the loss of the reconstructed breast. Successful final reconstruction can be achieved with careful patient selection and close follow-up by the plastic surgeon and radiation oncologist.     

野中野调强放疗在左乳腺癌改良根治术后胸壁放疗的剂量学研究

目的:研究采用野中野调强放疗（FIF-IMRT）进行左乳腺癌改良根治术后胸壁放疗的剂量学特点。方法:回顾性分析 2014年9月至2019年8月以来行左乳腺癌改良根治术后予胸壁及锁骨区放疗的77例患者资料。患者均接受胸壁及锁骨区 行整体化IMRT，胸壁行FIF-IMRT及锁骨区行IMRT这两种治疗方案，采集并比较靶区相关剂量参数、适形度指数、均匀性 指数，肺、心脏及右侧乳腺的剂量体积参数的差异。结果:两种治疗方案均达到放疗计划剂量学要求。两种治疗方案的靶区 均匀性指数和适形度指数、PTV-Dmax、PTV-Dmean、PTV-V105%，左肺V5、V10、V20、V30、Dmean，右肺V30，全肺V30以及心脏Dmean相比 较，均无统计学意义（P>0.05），而PTV-Dmin、PTV-V95%、PTV-V110%、右肺Dmean、V5、V10、V20，全肺Dmean、V5、V20，心脏V5、V30、V40， 右侧乳腺Dmean相比较，均有统计学意义（P<0.05）。结论:乳腺癌根治术后胸壁采取FIF-IMRT结合锁骨区IMRT的治疗方案 在降低正常组织的剂量照射和受照体积方面优势明显。     

Predictors for contralateral prophylactic mastectomy in breast cancer patients

Background: In recent years, radical breast cancer surgery has been largely replaced by breast conservation treatment, due to early diagnosis and more effective adjuvant treatment. While breast conservation is mostly preferred, the trend of bilateral mastectomy has risen in the United States. The aim of this study is to determine factors influencing patients’ choice for having contralateral prophylactic mastectomy (CPM). Methods: This is a retrospective study of 373 patients diagnosed with primary invasive breast cancer who were treated by bilateral or unilateral mastectomy (BM or UM) at the Revlon/UCLA Breast Center between Jan. 2002 and Dec. 2010. In the BM group, only those with unilateral breast cancer who chose CPM were included in the analysis. Results: When compared with the UM group, the following factors were found to be associated with BM: younger age, pre-menopausal, a family history of breast/ovarian cancer, BRCA mutation, more breast biopsies, history of breast augmentation, having MRI study within 6 months before the surgery, more likely to have reconstruction and sentinel lymph node biopsy (SLNB) and fewer had neoadjuvant/adjuvant chemotherapy/radiation. When patients with bilateral breast cancer were excluded, multivariate logistic regression analysis indicated younger patients with negative nodes, SLNB as the only nodal surgery and positive family history were significant factors predicting CPM and immediate reconstruction using tissue expanders or implants. Conclusion: Younger age, lower TN stage, requiring only SLNB and high risk family history predict contralateral prophylactic mastectomy. Tissue expander/implant-based reconstructions were more frequently chosen by patients with BM.     

Comparison of two radiation dose schedules in post mastectomy carcinoma of the breast

In 108 histopathologically proved breast cancer patients, after surgical treatment with modified radical mastectomy, two radiation dose schedules have been compared. Radiation therapy was given on a 60Co teletherapy machine using gent pair technique for chest wall irradiation and direct fields for lymphatic drainage areas. The patients were randomly divided into two groups (Group A and Group B). 54 patients were given external radiotherapy 40 Gy/17 F/3.2 weeks and remaining 54 patients were given 45 Gy/20 F/4 weeks. Results of treatment in Group A versus Group B were as follows; chest wall failure 5/50(10%) versus 3/54 (5.6%), axillary lymphnods failure 3/50(6%) versus 4/54(7%), distant metastasis 16/50(32%) versus 15/54(28%). Radiation reactions were almost similar in both the groups. Skin reactions were most common radiation effects [45/50 (90%) in Group A and 43/54 (79.6% in Group B]. Thus no statistically significant difference in local control and efficacy of these two radiation dose schedules was observed in postmastectomy carcinoma of the breast.     

Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer

In 1976 we began a randomized trial to evaluate breast conservation by a segmental mastectomy in the treatment of Stage I and II breast tumors less than or equal to 4 cm in size. The operation removes only sufficient tissue to ensure that margins of resected specimens are free of tumor. Women were randomly assigned to total mastectomy, segmental mastectomy alone, or segmental mastectomy followed by breast irradiation. All patients had axillary dissections, and patients with positive nodes received chemotherapy. Life-table estimates based on data from 1843 women indicated that treatment by segmental mastectomy, with or without breast irradiation, resulted in disease-free, distant-disease-free, and overall survival at five years that was no worse than that after total breast removal. In fact, disease-free survival after segmental mastectomy plus radiation was better than disease-free survival after total mastectomy (P = 0.04), and overall survival after segmental mastectomy, with or without radiation, was better than overall survival after total mastectomy (P = 0.07, and 0.06, respectively). A total of 92.3 per cent of women treated with radiation remained free of breast tumor at five years, as compared with 72.1 per cent of those receiving no radiation (P less than 0.001). Among patients with positive nodes 97.9 per cent of women treated with radiation and 63.8 per cent of those receiving no radiation remained tumor-free (P less than 0.001), although both groups received chemotherapy. We conclude that segmental mastectomy, followed by breast irradiation in all patients and adjuvant chemotherapy in women with positive nodes, is appropriate therapy for Stage I and II breast tumors less than or equal to 4 cm, provided that margins of resected specimens are free of tumor.     

The START trial-measurements in semi-anatomical breast and chest wall phantoms

This paper describes dosimetry measurements performed prior to departments entering patients into the START Trial, a breast fractionation trial. Absolute and relative doses were measured in semi-anatomical breast and chest wall phantoms, as part of a quality assurance programme visit. Doses were measured using an ionization chamber and the resulting distributions were compared with those calculated by the department. The mean ratio of measured to calculated dose at the START reference point was found to be 0.981 for the breast phantom and 0.978 for the chest wall phantom. This average measured dose was significantly less than the prescribed dose (p < 0.001). Differences were found between 2D and 3D planning systems and for departments using cobalt 60 beams. A number of departments had deviations of greater than 4%, which was the tolerance applied for this trial. It is essential for dose measurements of this type to be performed for randomized clinical trials involving radiotherapy, particularly where dose fractionation regimes are being compared.     

Radiation-associated extraskeletal osteosarcoma of the chest wall

Radiation-associated sarcoma is a rare but potential complication of radiation therapy. Most reported cases of osteosarcoma of the chest wall following radiation therapy for breast cancer arise from the chest wall skeletal structures. In contrast, few cases of extraskeletal osteosarcomas have been reported. We report a rare example of an extraskeletal osteosarcoma involving the pectoralis major muscle occurring after radiation therapy for breast cancer. Extraskeletal osteosarcomas are rare soft tissue tumors with a high rate of local recurrence and a poor prognosis.     

256层CT灌注成像和三维重建对乳腺疾病诊断的临床价值

目的　探讨256层CT灌注成像和三维重建技术对乳腺疾病诊断和术前评估的意义。 方法　采用256层CT对50例经彩超或钼靶发现有乳腺肿物的患者进行灌注扫描,结合术后病理结果,分析不同性质乳腺肿瘤组织和正常乳腺组织的灌注成像指标,以及乳腺三维重建对临床手术的指导作用。 结果　256层CT灌注成像指标值对鉴别诊断乳腺良恶性肿瘤具有重要的参考价值;三维重建模型可以全方位地观察病灶情况,为术前评估提供了依据。 结论　256层CT灌注成像能从血流动力学方面鉴别诊断乳腺良恶性肿瘤;三维重建可为临床诊断、治疗提供更多的信息,有助于乳腺癌的术前评估。     

两种皮肤通量外扩方法在乳腺癌根治术后调强放疗计划中的剂量学比较

目的:比较两种皮肤通量外扩方法在乳腺癌调强放疗计划中的剂量学差异。方法:对20例左乳腺癌根治术后患者的调强放疗计划分别采用瓦里安Eclipse治疗计划系统（11.0版）提供的Nearest cell（NC）和Erosion-dilation（ED）两种方法进行皮肤通量外扩,生成8FIMRT-NC和8FIMRT-ED计划。比较两组治疗计划的剂量体积直方图、靶区和危及器官的剂量分布、计划验证通过率和单次总机器跳数。结果:两种计划的通量和剂量线均已向胸壁皮肤外扩,两组计划的靶区剂量分布均达到临床处方剂量要求。PTV的最大剂量、平均剂量、大于110%处方剂量受照的体积、适形度指数、均匀性指数、梯度测量值等差异均无统计学意义。主要危及器官肺、心脏和脊髓等的剂量基本相似,差异均无统计学意义。两组计划的验证通过率差异无统计学意义,且均能应用于临床治疗。8FIMRT-ED计划比8FIMRT-NC计划的单次总机器跳数更少,分别为（1 282.35±184.84） MU和（1 302.05±195.37） MU,具有统计学意义（t=2.590, P<0.05）。结论:在乳腺癌根治术后的调强放疗临床计划中,采用NC和ED两种外扩方法均可以将皮肤通量有效外扩,且靶区剂量和危及器官受量均能满足临床治疗要求,两者剂量学无显著差异,但采用ED方法进行外扩,单次总机器跳数更少。     

Radiation-induced changes in the breast

Thirty-six postirradiation breast tissue specimens from 30 patients with breast cancer treated by primary radiation therapy were evaluated to define the effects of therapeutic doses of ionizing radiation on the residual non-neoplastic breast tissue. Breast tissue was sampled an average of 30.4 months after completion of therapy because of the development of new clinically or mammographically detectable abnormalities within the treated breasts. The average radiation dose was 6,399 rad to the primary tumor area and 4,778 rad to the remainder of the breast. Breast tissue sections from 35 nonirradiated patients served as control specimens. The most characteristic radiation effects consisted of atypical epithelial cells in the terminal duct lobular unit ( TDLU ) associated with lobular sclerosis and atrophy. These changes were present in all of the irradiated patients but varied in severity and extent among patients and within individual patients. This variation was not related to the presence or absence of carcinoma elsewhere in the specimen, radiation dose, patient age, time to postirradiation tissue sampling, or use of adjuvant chemotherapy. Epithelial atypia in larger ducts, stromal changes, and vascular changes were less frequent but were always accompanied by prominent TDLU changes. Radiation effects could usually be clearly distinguished from carcinoma involving the TDLU by the absence of both cellular proliferation and distention of the involved TDLU and by the preservation of cellular polarity and cohesion in areas of presumed radiation-induced injury. Familiarity with these changes is of considerable practical importance in that they must be distinguished from new or recurrent neoplasms.     

基于3D打印的胸部个体化剂量验证体模设计

目的:为更精确地对治疗计划进行验证,利用3D打印设计出反映患者真实情况的个体化体模。方法:依据病人定位时的CT图像重建并进行3D打印得到患者的三维立体结构空壳,然后以CT值为依据选择各组织的辐射等效材料完成填充,即得到体现病人特征的个体化剂量验证体模。结果:将合成的等效材料行CT扫描,骨组织、肺组织、软组织、肿瘤CT值分别为1 100、-747.6、-22、-471 HU,误差均小于22%。结论:最终设计的胸部体模能够较准确地体现个体之间的差异,等效材料辐射等效性较好,可用于实际剂量验证。     

Radiotherapy of stage IEA primary breast lymphoma: case report

A 47-year-old woman was referred for the treatment to our Hospital because of a palpable nodule in the upper medial quadrant of her right breast. After tumor excision, pathohistological examination showed a follicular center cell lymphoma grade 2, B-cell type (CD20+, bc16+, CD10+, bcl2+). The final diagnosis was stage IEA primary extranodal non-Hodgkin s breast lymphoma. The involved breast was irradiated isocentrically with two opposite 6-megavolt (MeV) photon beams delivered from the linear accelerator (tangential fields) using asymmetric collimator opening. Radiation volume, inclinations of the medial and lateral field, and the part of the underlying chest wall and lung parenchyma were determined during the radiotherapy simulation process. The total irradiation dose was 44 Gy delivered in single daily doses of 2 Grays (Gy). After breast photon irradiation, a boost to the tumor bed was performed by a direct 12 MeV electron beam, with a total dose of 6 Gy delivered over three days. Since primary non-Hodgkin lymphoma of the breast is rather rare, there has been no uniform approach to its treatment. The advantage of applying the asymmetric collimator jaw opening in breast radiotherapy is the instant reduction of the dose at margin fields, resulting in both the protection of neighboring lung parenchyma and the good coverage of planned target volume.     

Three-dimensional heart dose reconstruction to estimate normal tissue complication probability after breast irradiation using portal dosimetry

Irradiation of the heart is one of the major concerns during radiotherapy of breast cancer. Three-dimensional (3D) treatment planning would therefore be useful but cannot always be performed for left-sided breast treatments, because CT data may not be available. However, even if 3D dose calculations are available and an estimate of the normal tissue damage can be made, uncertainties in patient positioning may significantly influence the heart dose during treatment. Therefore, 3D reconstruction of the actual heart dose during breast cancer treatment using electronic imaging portal device (EPID) dosimetry has been investigated. A previously described method to reconstruct the dose in the patient from treatment portal images at the radiological midsurface was used in combination with a simple geometrical model of the irradiated heart volume to enable calculation of dose-volume histograms (DVHs), to independently verify this aspect of the treatment without using 3D data from a planning CT scan. To investigate the accuracy of our method, the DVHs obtained with full 3D treatment planning system (TPS) calculations and those obtained after resampling the TPS dose in the radiological midsurface were compared for fifteen breast cancer patients for whom CT data were available. In addition, EPID dosimetry as well as 3D dose calculations using our TPS, film dosimetry, and ionization chamber measurements were performed in an anthropomorphic phantom. It was found that the dose reconstructed using EPID dosimetry and the dose calculated with the TPS agreed within 1.5% in the lung/heart region. The dose-volume histograms obtained with EPID dosimetry were used to estimate the normal tissue complication probability (NTCP) for late excess cardiac mortality. Although the accuracy of these NTCP calculations might be limited due to the uncertainty in the NTCP model, in combination with our portal dosimetry approach it allows incorporation of the actual heart dose. For the anthropomorphic phantom, and for fifteen patients for whom CT data were available to test our method, the average difference between the NTCP values obtained with our method and those resulting from the dose distributions calculated with the TPS was 0.1% +/- 0.3% (1 SD). Most NTCP values were 1%-2% lower than those obtained using the method described by Hurkmans et al. [Radiother. Oncol. 62, 163-171 (2002)], using the maximum heart distance determined from a simulator image as a single pre-treatment parameter. A similar difference between the two methods was found for twelve patients using in vivo EPID dosimetry; the average NTCP value obtained with EPID dosimetry was 0.9%, whereas an average NTCP value of 2.2% was derived using the method of Hurkmans et al. The results obtained in this study show that EPID dosimetry is well suited for in vivo verification of the heart dose during breast cancer treatment, and can be used to estimate the NTCP for late excess cardiac mortality. To the best of our knowledge, this is the first study using portal dosimetry to calculate a DVH and NTCP of an organ at risk.     

Intercostal nerves block for mastectomy in two patients with advanced breast malignancy

Regional anesthesia is recognized as an alternative to general anesthesia for modern breast cancer surgery. Various techniques of block have been described. Each has its unique problems. Regional anesthesia was chosen for simple mastectomy in two patients with advanced breast malignancy, due to compromised pulmonary status resulting from widespread malignant infiltration of both lungs. We used intercostal nerves block. The block was supplemented with an infraclavicular infiltration to interrupt the branches of the superficial cervical plexus that provide sensation to the upper chest wall and subcutaneous infiltration in the midline to block the nerve supply from the contralateral side. Anesthesia was generally effective and the operations were uneventful. Both patients and surgeons expressed satisfaction. We conclude that where patients have significant comorbidities that make general anesthesia undesirable, the use of intercostal nerves block remains a safe and reliable anesthetic option that allows the patient access to surgery for simple mastectomy.     

Myofibroblastic sarcoma of the breast. Report of a case induced by radiotherapys

Myofibroblastic sarcoma (MFS) is an uncommon tumor rarely located in the breast. Ionizing radiation is a carcinogen capable of inducing sarcomas through DNA damage. A 42-year-old woman was diagnosed with synchronous bilateral breast infiltrating ductal carcinoma with axillary lymph node metastases on the left side. After modified left radical mastectomy and simple right mastectomy, she underwent postoperative radiation with a total volume dose of 50 Gy that included the thoracic wall and the left axillary-supraclavicular region. After a latency period of 6 years and 4 months, the patient developed an MFS in the area of radiation (mammary upper outer quadrant). To our knowledge, only 11 cases of MFS have been previously published in the breast. The study of the 12 cases including the present one revealed that the ages of the patients ranged from 42 to 86 years (mean 60.3 years). There was a clear difference concerning sex (M:F, 1:5). The average duration of the lesion varied from 1 week to 8 months (mean 3.3 months). The size ranged from 2.2 to 22 cm (average 5.1 cm). The tumors showed frequent mitosis and areas of necrosis. The percentage of recurrences, metastasis, and death due to the tumor was 27.3%, 36.4%, and 27.3% respectively. MFS cases differ from those affecting extramammary regions. They are more common in females and show a greater degree of aggressiveness. Correct diagnosis of mammary MFS requires morphological and immunohistochemical study. We present for the first time a case of MFS of the breast induced by radiotherapy.     

Possibilities of the cytological method in the determination of therapeutic pathomorphosis of breast cancer]

Combined treatment was used in 380 patients with breast cancer stage IIB, IIIA and IIIB. Preoperative therapy included large-fraction radiation (213 patients) or CMP chemotherapy course (176 patients). It was followed by radical mastectomy and postoperative chemotherapy, radiation. Cytograms of the specimens from the removed tumors were compared to pretreatment findings. This served the basis for recognition of 4 degrees of breast cancer pathomorphosis. The scheme can be used as additional morphological information on the degree of the breast cancer destruction and should be taken into consideration together with other data.     

Dose correlation for thoracic motion in radiation therapy of breast cancer

This work investigates the dose correlation for deformed objects due to thoracic motion for radiotherapy treatment of breast cancer. An analytical model has been developed to reconstruct patient anatomy based on the assumption that the body will expand or compress proportionally during respiration. The patient geometry at any phase during a breathing pattern is reconstructed using the CT data taken at the inspiration and expiration phases and the breathing level which can be related to the measured chest wall motion. A correlation between the voxels in the inspiration (or expiration) geometry and the voxels in the reconstructed geometry at any phase of the breathing pattern is established so that the dose can be accumulated during a treatment. The method has been implemented for treatment planning dose calculation by interfacing with a Monte Carlo code. The patient geometry files for different phases of the breathing pattern are generated and the three-dimensional dose data are obtained from the Monte Carlo simulations. The final dose distribution is reconstructed from the dose data at different breathing phases based on patient's breathing pattern associated with chest wall movements.     

Psychological effects of breast-conserving cancer treatment and mastectomy

Patients in the early stages of breast cancer were studied one year after treatment to ascertain the psychological effects of mastectomy and a breast-conserving alternative, lumpectomy plus radiation therapy. Patients who had had a mastectomy felt less attractive, less sexually desirable, and more ashamed of their breasts. They also experienced less enjoyment in their sexual relationships than they had before treatment. Patients who had radiation therapy experienced no changes in these areas. For these reasons, half of the mastectomy patients regretted not having chosen the breast-conserving alternative.