En Bloc Excision of Phyllodes Tumor of the Breast: Radical Approach Heralds Better Outcome

IntroductionSurgery is the primary treatment of phyllodes tumor of the breast, and margins are the most important risk factor associated with local recurrence. We conducted a retrospective audit of 433 patients treated at our center.Patients and MethodsWomen who presented with phyllodes tumors between 1999 and 2017 were included in the analysis. Data was collected from the hospital medical records, telephonic interviews, and electronic mail.ResultsOf the 433 women included in this study, 177 (40.9%) had benign phyllodes tumors, 84 (19.4%) were borderline, 131 (30.3%) were malignant, and 41 (9.5%) had sarcoma. A history of previous excision was noted in 154 (35.6%) patients, of which 104 presented with local recurrence. Of the total patients, 209 (48.3%) underwent breast conservation surgery; the median pT was 6 cm. At a median follow-up of 37.9 months, the 5-year disease-free survival (DFS) was 82.9%. On multivariate analysis, the factors that impacted DFS were histology (hazard ratio, 4.1; 95% confidence interval [CI], 1.5-10.9; P = .005) and history of previous excision biopsy (hazard ratio, 3.39; 95% CI, 1.76-6.52; P < .001). We analyzed 231 women who presented without any prior excision separately, wherein at a median follow-up of 44.1 months, the DFS was 92.1% (95% CI, 92.05%-92.15%). In addition, less recurrences were noted in this cohort (5.6% [13/231] in no-excision biopsy vs. 12.5% with surgery done prior to presentation to our institute).ConclusionA previous history of excision and the histologic subtype of phyllodes tumor are factors that have an impact on DFS, thus emphasizing the need for appropriate surgical planning and en bloc excision of the phyllodes at presentation.     

Validation of Recursive Partitioning Analysis Classification in Patients with Brain Metastases from Non-small Cell Lung Cancer Treated with Short-course Accelerated Radiotherapy

AimsTo study various prognostic factors affecting outcome and to validate Radiation Therapy Oncology Group recursive partitioning analysis (RPA) class in non-small cell lung cancer (NSCLC) with brain metastases treated with short-course accelerated radiotherapy (SCAR).Materials and methodsThe case records of 100 patients with NSCLC consecutively treated at Tata Memorial Hospital from August 2006 to August 2009 were studied for various patient, tumour and treatment-related prognostic factors. Patients received whole-brain radiotherapy to a dose of 20 Gy/five fractions over 1 week (n = 90) or 30 Gy/10 fractions over 2 weeks (n = 10). The Kaplan–Meier estimate was used for survival analysis in SPSS v15.ResultsThe median overall survival was 4.0 months (range 0.5–30.0 months). The 6-, 12-, 18- and 24-month survival rates were 35.8, 18.0, 9.3 and 6.2%, respectively. Of the various prognostic factors, RPA class (II versus III, P value = 0.023), Karnofsky performance score (<70 versus ≥70, P value = 0.039) and the use of systemic therapy (yes versus no, P value = 0.00) emerged as significant on univariate analysis. RPA classification effectively separated the patient population into prognostically distinct subgroups. The median overall survival for RPA class II and RPA class III was 6 and 4 months, respectively. The use of systemic therapy prolonged overall survival by 6 months (3 months versus 9 months).ConclusionThe SCAR regimen is an effective and resource-sparing palliative strategy for brain metastases in NSCLC. The results validate the usefulness of RPA classification in this specific subset of patients treated with SCAR.     

Radiation therapy planning of a breast cancer patient with in situ pacemaker--challenges and lessons

A postmenopausal lady with an in situ pacemaker developed a lump in the left breast and was diagnosed to have breast cancer. The patient underwent breast conservative surgery and was planned for post operative radiotherapy. The location of the tumor relative to the pacemaker provided a unique challenge in planning radiotherapy and the patient had an uneventful post radiotherapy course. A literature review revealed that modern generation pacemakers are very sensitive to radiation compared to their older counterparts. The present article makes suggestions towards reducing dose in radiotherapy planning in pacemaker patients.     

Use of tomotherapy in treatment of synchronous bilateral breast cancer: dosimetric comparison study

Objective:

Synchronous malignancy in both breasts is a rare incidence. The present study aims at dosimetric comparison of conventional bitangential radiotherapy (RT) technique with conventional [field-in-field (FIF)] and rotational [Helical TomoTherapy® and TomoDirect™ (TD); Accuray Inc., Sunnyvale, CA] intensity-modulated RT for patients with synchronous bilateral breast cancer (SBBC).

Methods:

CT data sets of 10 patients with SBBC were selected for the present study. RT was planned for all patients on both sides to whole breast and/or chest wall using the above-mentioned techniques. Six females with breast conservation on at least one side also had a composite plan along with tumour bed (TB) boost using sequential electrons for bitangential and FIF techniques or sequential helical tomotherapy (HT) boost (for TD) or simultaneous integrated boost (SIB) for HT.

Results:

All techniques produced acceptable target coverage. The hotspot was significantly lower with FIF technique and HT but higher with TD. For the organs at risk doses, HT resulted in significant reduction of the higher dose volumes. Similarly, TD resulted in significant reduction of the mean dose to the heart and total lung by reducing the lower dose volumes. All techniques of delivering boost to the TB were comparable in terms of target coverage. HT-SIB markedly reduced mean doses to the total lung and heart by specifically lowering the higher dose volumes.

Conclusion:

This study demonstrates the cardiac and pulmonary sparing ability of tomotherapy in the setting of SBBC.

Advances in knowledge:

This is the first study demonstrating feasibility of treatment of SBBC using tomotherapy.Breast cancer is the most common malignancy amongst females in the world, including Indian females.¹ Cancer in both breasts is an uncommon presentation. Incidence of bilateral breast cancer (BBC) has been reported in the range of 1.4–11.8% with the majority being metachronous cancer.^2,3 Depending upon various definitions adopted by authors, synchronous BBC (SBBC) accounts for approximately 0.4–2.8% of all breast cancers.^4,5 Whether bilaterality confers worse prognosis or similar prognosis is yet to be conclusively determined. Some studies have indicated that there is no difference in survival between the unilateral vs BBC patient groups, while other studies claim that bilateral carcinoma significantly reduces survival.^6,7 Treatment in patients with BBC is similar to that in patients with unilateral breast cancer wherein adjuvant radiotherapy (RT) forms an integral part of the breast conservation algorithm. The safety of breast conservation surgery (BCS) for SBBC has been documented in literature.^8,9 Adjuvant RT for breast cancer typically includes whole breast irradiation after lumpectomy or chest wall irradiation after mastectomy with or without regional nodal irradiation. This is accomplished using conventional bitangential portals that include part of the anterior chest wall adjacent to the RT target.^10–12 RT delivery in cases of SBBC is even more complex owing to multiple field junctions, which results in heterogeneous dose distributions as well as significantly higher irradiation volume of organs at risk (OARs) such as the lungs and heart.The reported incidence of radiation pneumonitis (RP) varies from 0% to 80% depending upon the radiation technique, length of follow-up, imaging modality used and the end point chosen.^13–16 Although symptomatic RP is a rare clinical complication for unilateral breast cancer, it has a potential detrimental effect of reducing the normal functional reserve and should be taken into consideration given the long life expectancy of patients and higher volume of irradiation owing to bilaterality in patients with SBBC. The risk and severity of RP is influenced by various therapy-related (volume of incidentally irradiated lung, region of irradiated lung, radiation dose, fractionation and concomitant use of systemic agents, particularly paclitaxel) and patient-related factors (age, pre-existing lung disease, poor pulmonary function, smoking habits, genetic predisposition). The most significant amongst these include patient age, locoregional RT, reduced pre-RT pulmonary reserve and concomitant tamoxifen use with adjuvant RT.^17–19 These factors correlate with various dosimetric indices [V₂₀, D₂₅, mean lung dose (MLD)] that predict the risk of RP.²⁰Similarly, the toxic effect of radiation on the heart has been well documented. The long-term risk of ischaemic heart disease following breast RT has been correlated with the mean heart dose, maximum heart distance and various dosimetric parameters (V₂₀, V₃₀ and V₄₀). Moreover, several patient-related risk factors (body mass index, diabetes mellitus, dyslipidaemia, tobacco/alcohol consumption, prior heart disease) and systemic agents (anthracyclines, trastuzumab, tamoxifen) modify the risk of radiation-induced cardiac toxicity.^21,22 Patients with BBC receive a higher radiation dose to the heart (owing to scatter radiation from the right side) and would be at increased risk of radiation-induced cardiac toxicity.²³Although techniques of delivering RT have improved considerably for various sites in past two decades, the technique of delivering RT to the breast or chest wall, unilateral or bilateral, has not changed much. Various other methods have been used to deliver RT to the breast and/or the chest wall for SBBC across the world, such as electron arc therapy, or static or rotational intensity-modulated RT (IMRT), but none has been compared with conventional bitangential RT.^24,25Helical TomoTherapy® (HT) (Accuray Inc., Sunnyvale CA) is a radiation delivery modality that delivers an intensity-modulated fan beam using a 6-MV linear accelerator mounted on a ring gantry that rotates around the patient as he/she advances slowly through the gantry bore.²⁶ Dosimetric data regarding the use of HT in breast cancer treatment have resulted in equivocal results, not only in the context of target coverage and homogeneity but in the sparing of the heart and lungs as well. Although HT has been studied in the context of partial breast irradiation, whole breast irradiation and locoregional nodal irradiation,^27–30 fewer data are available on the dosimetry and feasibility of HT in the context of SBBC requiring bilateral adjuvant radiation with or without simultaneous integrated boost (SIB) of the tumour bed (TB).TomoDirect™ (TD) (Accuray Inc.) is a static or non-rotational extension of HT, which is also referred to as TomoTherapy®. In this application of TomoTherapy, the patient is translated craniocaudally through fixed gantry positions with simultaneous beam modulation. Up to 12 coplanar fixed beams can be used for dose optimization and target coverage. Similar to HT, dosimetric and clinical data are also available with TD in both, three-dimensional conformal RT (3DCRT) and/or IMRT mode for treatment of unilateral breast cancer treatment.^28,31–33 However, no data are available on the dosimetry and feasibility of TD in the context of SBBC.In our study, we aimed to compare conventional bitangential RT with conventional IMRT and two techniques of tomotherapy, namely HT and TD dosimetrically in the context of SBBC.     

Brain metastases from breast cancer: management approach

Brain metastases are a significant cause of morbidity and mortality in patients with breast cancer. HER-2 positivity is an increasingly recognized risk factor for the development of brain metastases. Although considerable progress has been made in the treatment of this complication, supportive measures like steroids, anti-seizure medication and whole-brain radiation remain the cornerstones of management in the majority of patients. The current review discusses the above and other issues like surgical excision, stereotactic radiotherapy, adjuvant radiation, radiosensitization and chemotherapy. A brief discussion of the recent evidence for the use of 'HER-1/ HER-2'-targeted therapy is also present.     

The diagnostic dilemma of primary central nervous system melanoma

Melanomas are malignant neoplasms of melanocytes developing predominantly in the skin, but occasionally arising from eyes, mucous membranes, and the central nervous system (CNS). The CNS can be affected by a spectrum of melanocytic lesions ranging from diffuse neurocutaneous melanosis, to a focal and benign neoplasm (melanocytoma), and to an overtly malignant tumor (melanoma). Primary melanocytic lesions involving the CNS are typically concentrated in the perimedullary and high cervical region. Primary CNS melanoma cannot be reliably distinguished from metastatic melanoma on neuroimaging and histopathological characteristics alone: its diagnosis is established only after exclusion of secondary metastatic disease from a cutaneous, mucosal or retinal primary. We present two patients with primary CNS melanoma and discuss relevant issues, available treatment options, and expected outcomes. Awareness of disease spectrum and clinico-biological differences may be used to guide therapeutic decision-making for a patient with a proven or suspected primary CNS melanoma.