|Year : 2016 | Volume
| Issue : 6 | Page : 3-13
|Date of Web Publication||30-Nov-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Breast. J Can Res Ther 2016;12, Suppl S2:3-13
Patterns of care in neuroendocrine cancer of the breast: An individual patient data analysis
Wineeta Melgandi , Rony Benson, Supriya Mallick, Goura Kishor Rath
Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, India, E-mail: [email protected]
Objectives: Neuroendocrine cancer of the breast constitutes (NCB) less than 0.1% of all breast cancers. We did an individual patient data analysis to identify the patterns of care and prognostic factors for this rare tumor of the breast. Materials and Methods: We performed PubMed search with the following MesH terms: "Neuroendocrine cancer breast, Neuroendocrine cancer breast and treatment, and Neuroendocrine cancer breast and survival" to find all possible publications pertaining to NCB. Individual patient data was tabulated. SPSS version 16 was used for statistical analysis and Kaplan-Meier test was used for survival analysis. Results: Patient characteristics of 38 patients were evaluable. Median age was 52 years (range: 34-88). At presentation 4 (10.5%) patients had metastatic disease while 34 (89.5%) were non metastatic. 35.3% of the patients who underwent surgery underwent breast conservation surgery while 64.7% underwent mastectomy. 59.3% of the patients who had nodal surgery were found to be node positive. 68.2% of the patient's received some form of chemotherapy. Adjuvant radiation was used in 41.2% of the patients. Adjuvant hormone therapy was used in 20.5% of the patients treated radically. The median follow up was 15 months. The median overall survival (OS) was 5.25 years. Univariate analysis revealed nodal status to be associated with better OS (median OS 5.25 years for node negative versus 2.83 years for node positive disease, P = 0.041). Conclusion: NCB is associated with a good outcome with a median OS of 5.25 years and nodal status was found to an important prognostic factor for this rare tumor.
Role of molecular classification of node negative breast cancer: A changing paradigm in breast cancer prognosis
Vibhay Pareek , Rajendra Bhalavat, Manish Chandra
Department of Radiotherapy, Jupiter Hospital, Thane, Maharashtra, India, E-mail: [email protected]
Introduction: With the increase in the number of node negative Breast Cancer cases on the rise with better diagnostic modalities and early detection, it is challenge to decide for adjuvant therapy as majority cases are treated by surgery alone. Materials and Methods: Retrospective analysis of 220 node negative breast cancer patients who underwent surgery and excluding those who received Neo-adjuvant chemotherapy was done as a single institute experience. Assessment of role of age, size, lymphovascular emboli, estrogen receptor, progesterone receptor, HER2neu Ki-67, grade and molecular classification were analyzed in their role as prognostic factors in respect to the events associated on follow up (recurrence, metastases, second malignancy or death) using-Pearson Chi-square method and logistic regression method for statistical analysis. Results: On applying univariate and multivariate analysis, size more than 5 cm of the tumor associated with ER Negativity and LVE Positivity were associated with higher rates of early failures (P < 0.05). PR Negativity showed borderline significance in the role of early failures (P = 0.06). The stage of the tumor and molecular classification also showed significance in the rate of early failures and distant metastasis (P < 0.05). Age showed no major significant relation with failure rates. Conclusions: ER negativity, PR negativity, LVE positivity and size >5 cm are associated with poor prognosis in node-negative breast cancers.
Breast conservation in early and locally advanced breast cancer: Regional cancer centre, JIPMER experience
R. Chandramouli , K. Gunaseelan, K. S. Reddy, S. Vivekanandam, N. Vijayaprabhu, V. Parthasarathy
RCC, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]
Introduction and Objectives: Breast preservation is the standard care for early breast cancer. The therapeutic challenges of locally advanced stage are well recognized, especially increased risk of local recurrence. However, with introduction of neoadjuvant chemotherapy (NACT), significant tumour regression is achieved, thereby permitting breast conservation, hence a non-randomized single arm study was conducted. Materials and Methods: From 2007 to 2014 one hundred & ten patients were recruited. 59 out of 110 underwent NACT. All underwent lumpectomy and axillary dissection & intraoperatively template guided rigid/flexible needle with 2 or 3 plane. After 2D/3D based CT - planning, HDR dose of 15-16 Gy/2 - 2.5 Gy/# BD given for 3-5 days. Whole breast irradiation (46-50 Gy) was delivered after a 2-3 weeks' gap. CTV & DHI parameters were studied. Acute skin toxicity assessed at end of treatment. Cosmetic assessment done at 3 months according to Harvard scale. Unpaired t and Chi-square tests were used for analysis of parameters. Results: The ipsilateral breast tumour recurrence rate was (5) 4.5% with median follow up 5.4 years. Mean D90 (91.5%) and V90 (90.7%). Mean V100 was 84.20%. DHI range 0.7-0.8. The ipsilateral breast except the CTV (Breast-CTV) received a mean dose of 33.2%. Mean dose received by heart was 7.2%. Mean dose received by contralateral breast was (V5%) 1.6% & (V10%) 0.08%. Mean dose received by ipsilateral lung was (V5%) 46% & 18% (V10%). Mean dose to skin is significantly 24.9% brachytherapy. Excellent/good overall cosmesis is observed in 69 patients and fair/poor cosmesis observed in 32 patients. Poor cosmesis was observed in 9 patients. Conclusions: Breast conservation treatment options show comparable local control with acceptable dosimetric parameters & cosmetic outcomes even in LABC. With careful patient selection, optimal treatment planning, and careful attention to excision margins & radiation doses, breast conservation can be performed in these patients without sacrificing local control of disease.
Early clinical experience with adjuvant hypofractionated external beam radiotherapy in breast cancer patients: A prospective study to evaluate locoregional control, acute and late toxicity
S. Jayashanker , Litan Naha Biswas, Tanweer Shahid, Mukti Mukherjee
Department of Radiotherapy, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India, E-mail: [email protected]
Introduction: Radiotherapy had revolutionized the treatment for breast cancer. The purpose of the study was to understand the safety and efficacy of hypofractionated radiotherapy in breast cancer. Materials and Methods: A prospective observational case series study was conducted during 2014-15. Female breast cancer patients aged ≥18 years of good performance status requiring adjuvant radiotherapy were included in the study. Patients were followed up weekly during the course of radiotherapy and 3 monthly thereafter for 1.5 years. Parameters analysed included Locoregional Recurrence Free Survival (LRRFS), Disease Free Survival (DFS), acute and late skin toxicity using RTOG toxicity guidelines and Cosmesis using Harvard scale in upfront Breast Conservation Surgery (BCS) patients (compared with historical controls of conventional fractionation). Results: The present study reports 50 cases of non-metastatic breast carcinoma. The median age of the study population was 53 years. Hypofractionation was well tolerated in our patients as 90% of patients had Grade 1 acute skin toxicity while Grade 2 was noted in 10% of the study population and that too in BCS patients. Cumulative locoregional recurrence free survival and disease free survival was 98% and 94% respectively at 18 months. No significant difference was found in cosmesis between upfront BCS patients in the study and historical control with conventional fractionation (P value - 0.435). Conclusions: Hypofractionated radiotherapy is a feasible option for breast cancer patients. Early oncologic outcomes in terms of LRRFS and DFS are encouraging. Early cosmetic outcomes were excellent to good and were seen to be at par with conventional fractionation.
Sequencing of chemotherapy and radiotherapy postbreast conservative surgery
K. S. Sandeep , M. G. Janaki
Department of Radiotherapy, MS Ramaiah Medical College, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Current practices of sequencing chemotherapy and radiotherapy in patients undergoing breast conservative surgery include radiotherapy followed by chemotherapy, chemotherapy followed by radiotherapy, sandwiching chemotherapy with radiotherapy. A delay in starting radiotherapy results in loco regional relapse. The objective of this retrospective study is to assess the time of starting of adjuvant radiation in our department. Materials and Methods: Patients of carcinoma breast who underwent breast conservative treatment between Jan 2014 to July 2016 were retrospectively reviewed to know the sequencing of the radiotherapy and chemotherapy. Descriptive statistics was used to analyse the results. Results: Patients underwent breast conservative treatment between Jan 2014 to July 2016. The mean duration of follow up was 17 months. All are margin negative status. 18 patients were stage II and 7 were stage I disease. 13 out of 25 were less than 50 years age, ER and PR positive were 17 patients, one was HER2neu positive. The pattern of treatment surgery followed by radiation and chemotherapy were 11, surgery followed by chemotherapy and radiotherapy were 15, neoadjuvant chemotherapy followed by chemotherapy and radiotherapy were 4 and neoadjuvant chemo followed by radiation were 1, the duration between surgery to radiation less than 4 months were 7, 4 to 7 months 15, more than 7 months were 3. In 4 to 7-month group 9 patient received adjuvant 6 cycles FAC chemotherapy before radiation, 4 patient received adjuvant 4 cycles docetaxel and 4 cycles FAC before radiation, 2 received hormonal therapy after radiation. Conclusion: Most patients received adjuvant radiation within seven months of surgery and majority received chemotherapy before and after radiation.
Pattern of breast cancer presentation and treatment outcome in a tertiary government setup
Surabhi Gupta , Laxman Pandey, Ankur Mudgal, Pragya Singh,
K. N. Pradeep
Department of Radiotherapy, S.N. Medical College and Hospital, Agra, Uttar Pradesh, India, E-mail: [email protected]
Introduction: Carcinoma breast incidence has dramatically increased over the past few decades. In spite of much advancement in diagnostic and therapeutic arena prognosis of disease has not changed in proportionate rate. Materials and Methods: A retrospective analysis of total 389 pts was done, who completed their treatment from yr 2009 to 2014 in the dept. Aims : to analyse the clinical profile of enrolled breast cancer pts and to review the treatment outcome in terms of DFS, OS, pattern of failure. Results: Maximum number of pts. (39.95%). were of 41 to 50 yrs age group. Maximum number of presentation was of stage II (41.1%). 4.11% pts. were nullipara. Premenopausal verses postmenopausal ratio was 0.51%. 58.6% pts presented as a post op cases out of which, 7.6% pts presented with post op recurrence while. 4.78% pts with post op residual ds and 25.4% pts as fresh cases. 64% pts. presented with painless lump, While 20% associated with pain. Triple negative cases were 16.49%. The mean period of time lapse between surgery and radiotherapy was 6-7 months. Maximum recurrence were observed within 1 year of completion of treatment followed by 3 rd year recurrence. Two year DFS was 25%. 63.29% pts received conventional RT, while 18.98% hypofractionated RT.17.7% pts. received palliative RT. Conclusions: Now a days a different trend is being seen in risk factors and clinical profile. We have to give more emphasis on resource development in government set up, as due to overburden machine pts usually get defaulted from the treatment and this ultimately contribute to increased mortality.
Assessment of level of breast cancer awareness among women registered at a regional cancer centre
Akanksha Solanki , Acharya Tulsi, RCTRI, Bikaner
Department of Radiotherapy, Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner, E-mail: [email protected]
Objective: Aim of study was to assess level of awareness of breast cancer (BC) among recently diagnosed patients registered at our regional centre. Methodology: Among 112 registered cases of BC in July-August 2016, 58 patients were included in study. These patients were interviewed and data regarding cancer awareness was obtained. The questionnaire was framed by modification of "The Breast Module of the Cancer Research UK Cancer Awareness Measure" & included patient's demographic, physiologic, & reproductive factors, knowledge about symptoms of BC and age related risk, frequency and confidence of breast self examination (BSE), barriers to seek medical help. Results: Average age of included patients was 46.5 ± 12.8 years. 70.68% patients were rural and 29.32% were urban. Awareness of BC was decreasing with increasing age. "Breast lump" and "pain in breast" were mentioned by 93.10% patients as symptom of BC. From listed 11 symptoms, average 3 and 7 symptoms were identified by rural and urban patients respectively. 86.20% patients were having no knowledge about BSE while 6.89% patients were well known and confident. 3.5 months was average time between appearance of first symptom and approaching to doctor. Emotional and social barriers (79.31%) and lack of awareness (74.13%) were major causes of delayed presentation. Other factors were difficulty to arrange transport and make out time to go to doctor (41.37%). Knowledge about age related risk was poor (20.68%). Conclusion: Designing educational programmes and screening camps could result in spreading awareness among community making BC amenable to early detection and better treatment.
A prospective randomised study to compare hypofractionated radiotherapy with conventional radiotherapy in postmastectomy breast cancer patients
L. Pandey , S. Gupta, P. Singh, Durgesh Sharma
Department of Radiotherapy, Sarojini Naidu Medical College, Agra, Uttar Pradesh, India, E-mail: [email protected]
Aim: To compare different radiation treatment schedule in post op carcinoma breast patients in terms of toxicities (Pulmonary and cardiac), OS, DFS and recurrence rates. Materials and Methods: In this prospective study total 40 pts. were included. In Study group (24) pts. were given EBRT to loco-regional area with a dose schedule of 40 Gy/15# at of 5# per week and Control group (16) pts. received a dose of 50 Gy/25#/5 weeks, at of 2 Gy/#. Radiotherapy was delivered with telecobalt machine in both the groups. Results: In study group, 1 pt. showed local recurrence and 3 pts. developed distant metastasis. Acute Grade I, II and III skin toxicities were seen in 20 (84%), 3 (12%) and 1 (4%) pt. respectively. No case with late skin toxicity was reported. Acute or late haematological toxicities were not seen in any case. Late pulmonary toxicity seen in only 1 pt. 2 pt (8%) reported late cardiac toxicity in form of 10% ejection fraction reduction. Grade I, II, III lymphedema were seen in 3, 1, 1 pt. respectively. In control arm, 3 pts. developed distant metastasis. Acute skin toxicities Grade I, II were seen in 14 pts. (88%), 2 pts. (11%) respectively, no case with late skin toxicity was reported. Acute or late radiation pneumonitis were not seen in any case. 1 pt. (6%) reported late cardiac toxicity. Grade I, II, lymphedema were seen in 1 (6%), 1 (6%), pt. respectively. 1 year DFS in study group was 84% and control group it was 82%. Conclusion: In this study both of the group showed the equivocal results hence in a government set up where radiation waiting list is very long, hypo fractionated radiotherapy may be a better option.
Dose to left anterior descending artery in patients treated with conventional and hypofractionation schedules in breast cancer: A simulation based dosimetric comparison
Sneha Susanna George , Pamela Jeyaraj, Rajesh Chandran, Jaineet Sachdeva, Shubhra Rathore, Preety Negi
Department of Radiotherapy, Christian Medical College, Ludhiana, Punjab, India, E-mail: [email protected]
Objective: To perform dosimetric comparison of radiation doses to LAD delivered by conventional and hypofractionation schedules. Materials and Methods: 50 patients who received adjuvant radiotherapy for breast cancer in the Department of Radiotherapy in Christian Medical College and Hospital, Ludhiana between 01.09.2014 and 29.02.2016 were included. Patients were assigned to receive adjuvant external beam radiation dose of 50 Gy in 25 fractions over 35 days (Group 1 - conventional fractionation) and 42.5 Gy in 16 fractions over 22 days (Group 2 - hypofractionation). All the patients had been simulated with non contrast spiral CT. Delineation of the LAD was done in the treatment planning CT image sequences. Dosimetric data pertaining to the radiation dose received by the LAD was analyzed and compared. Results: The mean and maximum dose to the LAD were observed to be more in patients with left sided breast carcinoma and who received adjuvant radiation therapy by standard fractionation. The dosimetric parameters of V5, V10, V20 and V30 of LAD were observed to be higher in the hypo fractionation arm. Statistical analysis shall be performed and the observations shall be presented with significanct values. Conclusions: We observed that the maximum dose to LAD is more in the conventional fractionation arm and the DVH parameters were found to be more in the hypo fractionation arm. A prospective randomized study is needed to arrive at any conclusion regarding the dosimetric distribution. To comment on the benefit of fractionation on the cardiac effect, a longer follow up with cardiac investigations is needed.
Single institutional plan evaluation of interstitial HDR brachytherapy and 3D conformal radiation therapy in breast cancer after breast conserving surgery
Pareek Vibhay , Bhalavat Rajendra, Chandra Manish
Department of Radiotherapy, Jupiter Hospital, Thane West, Maharashtra, India, E-mail: [email protected]
Introduction: Breast Conserving Surgery has formed a major treatment aspect in early Breast Cancer. Radiation therapy has formed an integral part in treatment of early breast Cancer. 3D-CRT has formed the technique of choice in the treatment and Interstitial Brachytherapy has been employed in select cases. We report the single-institutional dosimetric comparison of patients treated with two forms of accelerated partial breast irradiation: interstitial HDR brachytherapy and 3D conformal external beam quadrant irradiation (3D-CRT). Materials and Methods: A retrospective dosimetric comparison of interstitial HDR brachytherapy and 3D-CRT was performed. Five patients were included for a dosimetric comparison of the dose received by the ipsilateral breast, PTV, heart, and ipsilateral lung. Interstitial patients were treated with 3.5 Gy in 10 fractions to 35 Gy. 3D-CRT patients were treated with 3.85 Gy in 10 fractions to 38.5 Gy using multiple iso-centric beams. The CT images from simulation or implant evaluation were transferred into our 3D treatment planning software. The lumpectomy cavities were outlined for every patient. The PTV was constructed as a uniform expansion of 1.5 cm for all interstitial HDR patients and a 1.0 cm expansion in addition to the CTV expansion of 1.0 cm and 1.5 cm for the 3D-CRT patients. The CTV expansion for 3D-CRT and the PTV expansion for the brachytherapy patients were limited to the chest wall and skin. Normal structures including both ipsilateral lung and breast and heart for left-sided lesions were outlined. The lumpectomy cavity was subtracted from the PTV and normal breast tissue for evaluation. To evaluate dose to the ipsilateral breast and lung, PTV, and heart, a dose-volume histogram (DVH) analysis was performed. All histograms were normalized to the volume of the structure (i.e., expressed as percent volume). Results: The average percentage of the breast receiving 100% and 50% of the prescribed dose (PD) was higher in the 3D-CRT group (24% and 48%, respectively) compared with interstitial patients (10% and 26%, respectively). Improved coverage of the PTV was noted in the 3D-CRT plans compared with interstitial HDR plans. With the interstitial HDR technique, 58% of the PTV received 100% of the PD compared with 100% with 3D-CRT techniques. The percentage of the PTV receiving 90% of the PD was 68% and 100% for the interstitial HDR and 3D-CRT patients, respectively. The ipsilateral lung V20 was slightly higher for 3D-CRT at 5% compared with 0% for brachytherapy technique. The heart doses were found to be least with Interstitial Brachytherapy compared to 3D-CRT. Conclusions: In those treated with 3D-CRT, coverage of the PTV was better with 3D-CRT but varied with the definition used. The coverage at 90% of the PD, statistical difference was observed between 3D-CRT and Interstitial Brachytherapy (3D-CRT better than interstitial). 3D-CRT resulted in better coverage of the PTV compared with interstitial brachytherapy technique. Better PTV coverage with 3D-CRT came at the cost of a higher integral dose to the remaining normal breast. The lung dose, Cardiac Dose and Contralateral Breast Dose were minimal with Interstitial Brachytherapy compared to 3D-CRT. Dosimetrically, the best partial breast irradiation technique appears to depend on the clinical situation.
Effect of conventional fractionation versus hypofractionation on pulmonary function test in carcinoma of breast
A. Sathish , H. B. Govardhan, T. Naveen, Siddanna R. Palled, Ibrahim Khaleel, P. Sridhar, L. Nabiza Begum, Nivedita Sarkar
Department of Radiotherapy, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Many studies show conventional fractionation schedule cause significant pulmonary toxicity in patients with carcinoma breast. This study is taken up to compare the effect of conventional and hypofractionation on PFT in such patients. Materials and Methods: A total of 60 patients, who are all candidates for radiation therapy from August 2015 to July 2016 were taken up for this prospective study. Spirometry based PFT were done before radiation therapy as base line, at 1 month after RT and once in every 3 months. 40 patients were treated with 50 Gy in 25 fractions and 20 in 40 Gy in 16 Fractions to chest wall +/-SCF by 3DCRT. The change in lung functions were compared with the base line values and correlated with lung doses taken from DVH. Results: Before radiation therapy, 12 (20%) patients had normal PFT, 18 (30%) mild PFT, 25 (41.66%) moderate and 5 (8.3%) severe PFT. The mean FVC, FEV1 and FEF maximum at base line were 2.09, 1.87 and 3.61 respectively. At one month after radiation therapy, the mean FVC, FEV1 and FEF were 2.08, 1.65 and 3.30 respectively. 10 (16.6%) patients had normal, 8 (13.3%) mild, 35 (58.3%) moderate and 7 (11.6%) severe PFT. At three months after radiation therapy, the mean FVC, FEV1 and FEF were 1.81, 1.36 and 2.6 respectively. 7 (11.66%) patients had normal, 8 (13.3%) mild, 33 (55%) moderate and 12 (20%) severe PFT. Conclusions: Post radiation PFT values were found to decrease due to underlying radiation induced pneumonitis and fibrosis which was more in hypofractionation schedule.
Obesity and breast cancer: A single institution experience
T. C. Vinitha , S. Patricia, Rajesh Balakrishnan, Subhashini John
Department of Radiotherapy, Christian Medical College and Hospital, Vellore, Tamil Nadu, India, E-mail: [email protected]
Introduction: To study the profile of premenopausal and postmenopausal breast cancer patients who were treated in our institution from July 2010 to July 2015 and explore the relationship of obesity with stage at diagnosis, estorogen receptor (ER) positive status, recurrence of disease and comorbidities. Materials and Methods: A series of 344 patients who were diagnosed and treated for invasive carcinoma breast in our institution during the period of July 2010 to July 2015 were analyzed. Data was collected from medical records. The variables analyzed were menopausal status, stage at presentation, estrogen receptor (ER) status, progesterone receptor (PR) status, HER2 Neu status, recurrence at follow up and BMI according to WHO grading of BMI for Asian population. Analysis was done using SPSS. Results: Majority (46.2%) of patients were between 36 to 50 years of age. Majority of women (53.5%) were postmenopausal and 72.7% presented with locally advanced breast cancer. ER positivity was 52.3%. Obesity was 54.7%, overweight 19.2%, normal 21.5% and underweight 4.7%. Mean duration of follow up was 34.06 months. 17.2% had developed metastasis or progression at last follow-up. There was no association noted between obesity versus menopausal status, ER status or disease recurrence. Conclusions: There was no statistically significant association between obesity versus menopausal status, stage at diagnosis, ER status or disease recurrence. Randomized prospective controlled studies in Indian population are needed to further validate this finding.
Squmous cell carcinoma of breast: A case series
Paramjeet Kaur , Anil Khurana, Nupur Bansal, Ashok K. Chauhan
Department of Radiotherapy, Pt BD Sharma, PGIMS, Rohtak, Haryana, India, E-mail: [email protected]
Introduction: Squamous cell carcinoma of breast is rare, aggressive, tumours with poor prognosis. Reported Incidence is 0.1% of all invasive breast carcinomas. Aim: A series of 3 patients with pure squamous cell carcinoma of breast presented analyzing clinical presentation, treatment and outcome. Materials and Methods: Total 3 patients having primary squamous cell carcinoma of breast were evaluated from January 2009 to June 2016. Two had primary in left breast while one in right breast. Age of presentation was 49, 59 and 62 years. Two patients were postmenopausal. Mammography was done in all patients and no skin nipple areola complex was found involved in any patients. The diagnosis was confirmed by trucut biopsy. On immunohistochemistry all were positive for cytokeratin. All patients were hormone receptor negative. Results: All patients were treated with neoadjuvant chemotherapy with Paclitaxel and carboplatin 3-4 cycles followed by surgery in two patients. One patient had aggressive and metastatic disease and did not undergo surgery. Two patients received radiotherapy followed by hormonal therapy. Conclusion: Primary squamous cell carcinoma (SqCC) of the breast is a very rare. The treatment of primary SqCC of the breast is same as other histological types of breast cancer that include involve surgery, chemotherapy, hormonal therapy and radiation therapy.
Comparison of conventional and single isocentric three-dimensional conformal radiotherapy of carcinoma breast
Suman Kumar Putha , Sourjya Banerjee, Aastha Garg, Challapalli Srinivas, P. U. Saxena, K. Dinesh Pai
Department of Radiotherapy, Kasturba Medical College Hospital, Manipal University, Mangalore, Karnataka, India, E-mail: [email protected]
Introduction: To compare classical and mono isocentric three dimensional conformal radiotherapy (3D CRT) plans of carcinoma of breast treated with three dimensional conformal radiotherapy (3DCRT) and to study the volumetric doses to lung and heart. Materials and Methods: Two sets of treatment plans, one with conventional tangential beams to breast/chest wall and AP ± PA beams to supraclavicular region using separate isocentres for each, and another plan using a single isocentre, covering both, the chest wall and supraclavicular region. The plan was evaluated in terms of dose volume histograms (DVHs) pertaining to planned dose coverage, maximum & mean doses for both PTVs and volumetric doses of organs at risk (OAR). Results: In the study, using conventional 3D CRT technique- the mean value of lung dose V 20 was 24.22%, and the mean value of lung dose V 30 was 21.62%. The mean percentage of heart dose V 30 was 11.13% (±13.01%). The conformity index (CI) was 0.96. Using the single isocentric technique, the mean value of lung dose V 20 was 27.15% and lung dose V 30 was 22.32%. The mean percentage of heart doses V30 was 10.35%. These values were less than the standard 46%. The CI was 0.97. Conclusions: The results of our study demonstrated that the dose distribution to target volumes was superior with the mono isocentric 3DCRT which reduces on-table time and positional errors. The lung and heart volumes irradiated were well within tolerance dose limits.
Dosimetric analysis of intensity modulated radiotherapy and volumetric modulated arc therapy in postmastectomy in patients with left-sided carcinoma breast
M. Phaneendra , S. Shyama Prem, R. Seenisamy
Department of Radiotherapy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]
Objective: To compare the dosimetric parameters between IMRT and VMAT in PMRT patients with left-sided carcinoma breast. Materials and Methods: 25 patients were recruited and 2 plans were generated for CT data of each patient-VMAT with 2 partial arcs each for the chest wall and supraclavicular fossa and IMRT with 7 fields each for the chest wall and the supraclavicular fossa. Results: The mean volume of PTV receiving 47.5 Gy was not different in VMAT and in IMRT. The homogeneity index was VMAT and 0.15 (±0.09) in IMRT with significant difference. The conformity index in VMAT had no significant difference to that of IMRT. The mean heart dose, V 5Gy , V 10Gy , V 20Gy , and V 30Gy for heart were significantly lesser for VMAT than IMRT. For the ipsilateral lung, V 10Gy and V 20Gy were significantly lesser for VMAT plans. The lung V 40Gy for the lung was higher for the VMAT than IMRT. The mean lung dose and V 30Gy was not significantly different. Contralateral breast received significantly lesser doses in IMRT. The monitor units were significantly lesser in VMAT. Conclusions: VMAT is dosimetrically superior to IMRT for left-sided breast cancer patients owing to its equivalent PTV coverage and better sparing of heart and left lung. The advantages of the VMAT include lesser Monitor Units and reduced treatment time which can improve the patient's compliance to the treatment and intra-fractional motion errors.
Target volume coverage in conventional planning of postmastectomy adjuvant radiotherapy of breast cancer patients when comparing RTOG based contoured plan: A dosimetric study
Mohammad Azam , Animesh Agrawal, S. Farzana, Kamal Sahni, Madhup Rastogi, Rohini Khurana, Rahat Hadi, Shantanu Sapru, Anoop Srivastava
Department of Radiation Oncology, Dr RMLIMS, Lucknow, Uttar Pradesh, India, E-mail: [email protected]
Objective: Conventional field radiotherapy based on anatomical landmarks has been the traditional treatment for breast cancer. Having proven efficacy it is still the current standard of treatment. The Radiation Therapy Oncology Group (RTOG) has published guidelines for contouring target volumes in postmastectomy patients. The impact of this guideline in current clinical practice is less known hence we have analyzed dose-volume histograms (DVHs) for these plans and compared them with the proposed treatment plans to treat RTOG-defined targets. Materials and Methods: RTOG consensus definitions were used to contour the target volumes in 20 previously treated post-mastectomy patients. The prescription was 42.4 Gy in 16 fractions. DVHs were generated from clinically designed plans that had actually been delivered to each patient. For comparing dose to target volumes, new plans were generated with the goal of covering 95% of volume to 90% of prescribed dose. Results: In RTOG contoured Group, coverage improved for the SCV (V90 = 83 versus 94.9%, P < 0.05) and CW (V90 = 89.8 versus 95.2%, P < 0.05). Axillary nodal coverage improved for Level-1 (V90 = 80.35 versus 96.40%, P < 0.05), Level-II (V90 = 85.93 versus 97.09%, P < 0.05) and Level III (V90 = 86.67 versus 98.6%, P < 0.05). The dose to the ipsilateral lung is increased (V20 = 23.87 versus 28.73%, P < 0.05). Low dose to heart is increased in left sided cases (V5 = 14.52 versus 16.72%, P < 0.05) while same in right sided cases. Conclusions: The study shows that radiotherapy using the RTOG consensus guidelines improves coverage to target volumes with a nonsignificant increase in normal organ dose compared to that based on anatomical landmarks.
Dosimetric comparison for active breathing coordinator reduces radiation dose to the heart and lungs in patients with left breast cancer using VMAT techniques
C. Prabagaran , S. S. Mokha, Piyush Jain, N. Bharath Kumar, Gaurav Kumar, Chhamta Dutt, D. Manigandan 1
Department of Radiotherapy, City Hospital and Research Centre, Jabalpur, Madhya Pradesh, 1 Department of Radiotherapy, Fortis Hospital, Mohali, Punjab, India, E-mail: [email protected]
Introduction: For women with left-sided breast cancer, there is risk of potential cardiotoxicity from the radiation therapy. Different breath-hold methods have been utilized. The two dominant methods are the spirometry-based active breathing coordinator (ABC R3.0) system (Elekta Ltd., Crawley, UK) and the video-based real-time position management (RPM) system (Varian Medical Systems, Palo Alto, USA). The device is essentially a mouth piece attached to a spirometer and the patient's nose is pegged to ensure they are breathing only through the device. As the spirometer is connected to a computer, the Radiation Teams are able to visualize the patient's level of inspiration. Once the patient has reached the required threshold, pinch valves in the spirometer remotely close, preventing the patient from exhaling or inhaling outside the required threshold. A wide array of planning techniques has been reported in the DIBH literature, but one planning study compared VMAT-Deep Inspiration Breath-Hold (DIBH) Technique and VMAT-Free-Breathing (FB) Technique. DIBH allows this potentially superior planning technique to be used while minimizing cardiac dose. Materials and Methods: The Pinnacle treatment planning system, v.9.8 (Philips Radiation Oncology Systems, Fitchburg, WI) employs a collapsed cone convolution (CCC) algorithm method is currently regarded as one of the better practical options for dose calculation. Philips Pinnacle v9.8 TPS is used to generate VMAT plans, for a Elekta Infinity machine with a Agility 160 MLC (Elekta Ltd., Crawley, UK). Our VMAT planning protocol uses a single isocenter with two partial composite arcs, each consisting of two complementary arcs of identical gantry rotations. Again Plan is used to generate Free-Breathing (FB) plans, for Infinity with a Pinnacle TPS. The plan quality was evaluated by dose conformity, homogeneity, dose fall-off and leakages. Efficiency is measured in treatment planning and delivery time. In order to investigate the dosimetric impact of the ABC, two sets of CT images were acquired. Results and Discussion: Ten left-sided breast cancer cases are studied. The PTV volumes plan range from 534 to 620 cc. Plans were evaluated by target coverage, minimum and maximum dose to target, Quality of Coverage (QI), Homogeneity Index (HI) and conformity index (CI). Dosimetric parameters for analysis included RTOG protocol in Heart, Left Lung, Right Lung, Greater Vessels, Opposite Breast, Liver, Spine max dose including Monitor Units (MU). Patient selection is long breath-hold 20-30 sec is desirable. All plans were optimized using six megavolts (6 MV) X-ray, and the objective dose-volume parameters were identical at the beginning of optimization for the different plans, Planning study compared VMAT-Deep Inspiration Breath-Hold (DIBH) Technique and VMAT-Free-Breathing (FB) Technique. DIBH allows this potentially superior planning technique to be used while minimizing cardiac dose [Table 1], Lungs dose etc. ABC is viable options to reducing margin for respiratory motion and main advantage was automated beam on and off during treatment of the patients without man interrupts the machine beam.
|Table 1: 6 MV photon average dose for both volumetric modulated arc therapy (deep inspiration breath - hold) and volumetric modulated arc therapy (free - breathing) plans for all 10 patients|
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Marchand V. Dosimetric comparison of free-breathing and deep inspiration breath-hold radiotherapy for lung cancer. Strahlenther Onkol 2012;188:582-9.
Clinical use of Helical tomotherapy with simultaneous integrated boost in treatment of primary synchronous bilateral breast cancer: First report of its kind
Shanu Jain , T. Wadasadawala 1 , A. Budrukkar 1 , S. Chakraborty 1 , R. R. Upreti 1 , S. Paul 1 , R. Phurailatpam 1 , K. Joshi 1 , R. Sarin 1
Department of Radiotherapy, Tata Memorial Hospital, Mumbai, Maharashtra, India, 1 Research Fellow, E-mail: [email protected]
Objective: To report the clinical use of HT with SIB technique in PSBBC patients. Materials and Methods: 21 patients of PSBBC treated from Jan 2013 to June 2016 were retrospectively studied for evaluation of dosimetric, clinical and treatment details. Long term lung toxicities were assessed using baseline and 1 yr post RT PFT and HRCT scan. Disease related outcomes were analyzed using Kaplan Meier curves in SPSS 18.0. Results: The cohort included 13 patients with bilateral BCT, 2 with bilateral MRM and rest 6 with BCT on one side and MRM on other. SIB was given in 14 patients. 9 received bilateral SCF RT, 10 unilateral SCF, 1 both SCF and IMN whereas no nodal RT was given in 2 patients. Mean V95 was 94.2% and 94.6% on right and left side respectively and V90 was 98% on both sides. Mean dose to the right lung, left lung and heart was 10.8 Gy, 9.8 Gy and 5.7 Gy respectively. Planning objectives of V20 Gy <20%, V30 <10% and V5 <50% were met for both lungs and heart. 13 patients developed grade I, 7 grade II and 1 grade III acute dermatitis. 11 patients developed grade I, 3 grade II and 1 grade III acute dysphagia. 8 patients developed grade II post RT pulmonary parenchymal changes and only 1 developed grade III change in HRCT according to Nishioka scoring. PFT parameters did not show any significant drop except FEV1. None developed symptomatic radiation induced pneumonitis. At a median follow up of 25 months, 3 year DFS, OS and LRC were 65.6%, 83.3% and 85.7% respectively. Conclusions: Thus, Helical Tomotherapy is a safe and well tolerated treatment technique in treating patients with PSBBC.
Localization of tumor bed for boost radiation following breast conservation surgery
M. Mrutyunjayarao , K. Gunaseelan, N. Vijayaprabhu, D. Kadambari
Department of Radiotherapy, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, E-mail: [email protected]
Introduction: Breast conservation therapy is the standard treatment for operable early stage breast cancer which includes removal of the primary tumor with adequate margins followed by radiotherapy. 50-60% of all local recurrences occur at or near the initial site of the tumor mandating the need for tumor bed boost. The benefit of tumor bed boost was evaluated by different trials but the optimal method for delineation of tumor bed volume in still debatable. Materials and Methods: Twenty one patients undergoing breast conservation surgery were recruited in the study. Different boost volumes were contoured for each patient based on surgical clips, preoperative CT, patient guided localisation, operating surgeon's clinical examination and postoperative scar. Taking surgical clips as the standard, we have compared the other methods with respect to volume overlap and volume of unnecessary irradiation of breast tissue. Dosimetric evaluation and organ at risk doses were studied in individual methods. Results: Self-localization of tumor volume by patient is next best method after surgical clip volume for boost radiotherapy planning compared to other method. Percentage of matching of Self-localization of tumor volume by patient, Surgeon's localization of tumor volume, Preoperative CT-based tumor volume and Scar-based boost volume with the surgical clip volume are 34%, 28%, 29% and 23% respectively. The volume of unnecessary irradiated breast tissue in Self-localization of tumor volume by patient, Surgeon's localization of tumor volume, Preoperative CT-based tumor volume and Scar-based boost volume with the surgical clip volume are 64cc, 56cc, 42cc and 57cc respectively. The difference between the methods was statistically significant by one way ANOVA with Duncan's test. With respect to OAR doses no significant difference observed among the methods except mean lung dose are higher in surgical clip method and skin doses are less in surgical clip and preoperative CT based target volume delineation methods. Conclusions: Patient based localization method matches maximally with surgical clip volume compared to other methods, hence this way of localizing tumor bed could be an viable option if surgical clips are not placed. However we require larger groups and multi-institution study for making it valid. Looking at breast cancer outcomes through different time windows.
Looking at breast cancer outcomes through different time windows
th Shikha Goyal , Tejinder Kataria, Shyam Singh Bisht, Deepak Gupta, Trinanjan Basu, Ashu Abhishek, Susovan Banerjee
Division of Radiation Oncology, Medanta - The Medicity, Gurgaon, Haryana, India, E-mail: [email protected]
Objective: To determine if evolution in non-metastatic breast cancer (NMBC) treatment have helped improve outcomes. Materials and Methods: We compared the demographic profile, treatment practices and outcomes in non-metastatic breast cancer from two tertiary centres over two time periods (1982-85, 2009-2013). Results: From 1982-85, 449/495 treated patients were evaluable (322 [71.7%] ͳ50 years; 301 [67%] pre-/perimenopausal). Stage distribution - T1-2: 173 (38.5%), T3-4: 237 (52.8%), Tx: 39 (8.7%); N0-1: 361 (80.4%), N2-3: 88 (19.6%). All patients underwent mastectomy and adjuvant CMF. 342 (76%) patients received radiotherapy (RT): 45 Gy/15 Fr to chestwall (CW) and 40 Gy/15 Fr to regional nodes. Hormone manipulation consisted of surgical/radiation castration in 67 (14.9%). There were 118 (26.2%) distant, 67 (14.9%) chest wall and 15 (3.3%) nodal recurrences. From 2009-13, 364 patients were evaluable (322 [88.4%] ͳ50 years; 301 [82.7%] pre-/perimenopausal). Stage - T1-2: 302 (83%), T3-4: 55 (15.1%), Tx: 7 (1.9%); N0-1: 256 (70.3%), N2-3: 104 (28.6%), Nx: 4 (1.1%). 179 (49.2%) underwent mastectomy; 185 (50.8%) had breast conservation (BCS). 51 (14%) received taxane/anthacycline-based neoadjuvant chemotherapy (NACT). ER, PR and Her-2/neu were positive in 68.3%, 61% and 26%. Adjuvant RT was given for T3+/N+/BCS; supraclavicular (SCF) RT if 34 nodes positive or extracapsular extension. Axilla was not irradiated routinely. RT consisted of 50-54 Gy/25-27 Fr to CW/breast (+boost 12-15 Gy after BCS) and 50 Gy/25 Fr to SCF. IMRT/VMAT were used in 350 (96.2%) patients. Hormone therapy (aromatase inhibitors or tamoxifen) and trastuzumab were given as indicated. Recurrence was seen in 36 patients overall: 32 (8.8%) distant, 7 (1.9%) chest wall and 6 (1.6%) nodal recurrences. In both periods, recurrences were significantly associated with higher T-stage (T3-4) and N+ disease. Conclusion: The latter treatment cohort was younger, had smaller T-size but more N+ disease with higher utilization of NACT. BCS was introduced with consequent more RT use. Modulated RT techniques, newer chemotherapy and hormone therapy options have improved local/distant control. Nodal recurrences are consistently low and omission of axillary RT has not negatively impacted outcomes.
Acute toxicity in hypofractionated versus conventional radiotherapy in breast cancer patients after breast conservation surgery
Renu Madan 1,2 , Subhash Chander 1 , Suman Bhasker 1
1 Department of Radiotherapy, All India Institute of Medical Sciences, New Delhi, 2 Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India, E-mail: [email protected]
Introduction: Hypofractionated radiotherapy is routinely used for breast cancer treatment in western countries. However, it is not commonly used in India. We conducted this study to determine the effect of radiation fractionation on acute toxicity in breast cancer patients after breast conservation surgery (BCS) in Indian patients. Materials and Methods: This was a prospective phase II randomized control trial, conducted at Department of Radiotherapy, AIIMS, New Delhi. One hundred twelve breast cancer patients who underwent BCS were enrolled wef September 2014 to October 2015. Randomization was done into control arm (50 Gy in 25 fractions to whole breast followed by boost of 16 Gy in 8 fractions) and study arm (40 Gy in 15 fractions to whole breast followed by boost of 10 Gy in 4 fractions). Results: Twelve patients were excluded from the study and a total of 100 patients were available for analysis (58 and 42 in control and study arm respectively). Patients were assessed weekly during radiotherapy and 1, 3 and 6 months afterwards. All patients had at least one month of follow up. Hypofractionated radiotherapy was well tolerated as compared to conventional radiotherapy. Incidence of acute grade I, II and III skin toxicity was 72%, 32% and 15% in arm I and 60%, 25% and 9% in arm II respectively (p-NS). No patient developed grade IV toxicity. Conclusions: Hypofractionated radiotherapy is feasible, convenient and has a better safety profile. Use of hypofractionated RT should be encouraged to increase machine output and to improve quality of life by reducing hospital visits.
Profile of breast cancer patients with treatment outcome
Ritusha Mishra , Himanshu Mishra, A. Mandal, A. K. Asthana
Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India, E-mail: [email protected]
Aim: To analyse the profile and treatment outcome of breast cancer at our centre. Materials and Methods: A retrospective study done on breast cancer patients who were registered in the department of Radiotherapy at our institute during a period of January 2009 to July 2011. A total of 235 registered patients were included and were followed up. The data was analysed with SPSS version 16. Observations: The maximum number of patients (35.3%) belonged to the age group of 41-50 years. The age range was 24-80 years with mean of 47.3 ± 11.3 years; majority being premenopausal. The predominant clinical feature was painless lump in the breast (98.7%). Upper outer quadrant involvement was seen in 60%. The most common stage at presentation was IIIB followed by stage IV. Neoadjuvant chemotherapy was given in 32% cases, Modified radical mastectomy was done more frequently than breast conservation surgery in early disease also. Radiotherapy was given in 44%. Hormonal receptor status was known in 30% cases. 122 patients completed the planned treatment; Kaplan Meier survival analysis showed that at 5 months disease free survival was 93.3%, at 9 months it was reduced to 81.7%, thereafter at 18 months it was reduced to 63%. Conclusion: Majority presented after the age of forty years with painless lump as the most common manifestation. The late presentation was one of the important issues as about 40% cases were stage III or higher which adversely affected the outcome. Therefore early detection and complete treatment are of paramount importance to improve the outcome.
Triple negative breast cancers: An audit of treatment pattern
Paramjeet Kaur , Nupur Bansal, Anil Khurana, Ashok K. Chauhan
Department of Radiotherapy, Pt BD Sharma, PGIMS, Rohtak, Haryana, India, E-mail: [email protected]
Introduction: Triple negative breast cancers have more aggressive behavior than other subtype breast cancer. These cancer accounts for approximately 20 percent of breast cancers diagnosed worldwide, which amounts to almost 200,000 cases each year. In general the basic principles of diagnosis and management are similar to those of breast cancer in many aspects however risk factors, molecular and pathologic characteristics, natural history, and chemotherapy sensitivity are unique of these cancers. Aim: To assess age, and tumor factor, treatment strategies, and to evaluate outcome of treatment. Materials and Methods: The present retrospective study conducted at department of radiotherapy - II Pt BD Sharma PGIMS, Rohtak from January 2015 to June 2016. Total 17 patients of triple negative breast cancer registered and followed up during this period were analyzed for demographic and clinicopathological data and treatment variables. Results: Median age at presentation was 44 years. Nine patients (52%) had left side breast cancer. Most common tumor T3 11/17 (65%) N 1 - 10/17 (59%), N2 4/17. Two (12%) had metastatic disease at the time of presentation, bone metastases in one patient liver and lung in other patient. Ten patients were treated with Neoadjuvant chemotherapy with Inj Paclitaxel 80 mg/m 2 and Inj Carboplatin AUC 2 for 3-4 cycles followed radical modified mastectomy. Then each patient was given adjuvant Chemotherapy with same regime of TP to complete total of six courses of chemotherapy. Thereafter, External beam radiotherapy to Chest wall and drainage area was given in a dose of 50 Gy in 25 fractions over 5 weeks. Two patients with metastatic disease received six courses of chemotherapy. Five patients underwent MRM followed by 6 cycles of chemotherapy. Each patient was further treated with radiotherapy. The patients were followed for 8 months range 6-11 months. Five patient developed recurrence during follow up. Conclusion: Triple negative breast cancer behave aggressively, common in younger females. Majority of patients presented with advanced disease and associated with poor outcome.
Internal mammary node contouring guidelines in breast cancer: An original article
Geeta S. Narayanan, th Rishabh Kumar , S. Rashmi
Department of Radiotherapy, Vydehi Institute of Medical Sciences, Bengaluru, Karnataka, India, E-mail: [email protected]
Introduction: Regional nodal irradiation as a component of both postmastectomy and postlumpectomy radiation has been shown in numerous randomized trials and meta-analyses to have a significant impact on locoregional control, breast cancer mortality, and, in some cases, overall survival. A recent meta-analysis showed an improvement in overall survival on addition of internal mammary nodes as a target in nodal radiation. There is paucity on data on IMN contouring, though ESTRO recommends a margin of 5 mm around the internal mammary vessels, there is no objective proof of what percentage of nodes get covered when we use a 5 mm margin. We intend to investigate the same. Materials and Methods: 10 clinically node positive non metastatic breast cancer patients will be subjected to a Contrast enhanced CT reconstructed to 1.25 mm slice thickness. Internal mammary vessels will be contoured on the treatment planning system and an isotropic margin of 2.5, 5, 7.5 and 10 mm will be given. With each margin percentage of the covered or missed nodes will be recorded. Total number of nodes and its location with respect to the tumor location will also be recorded. Results: an objective proof of the margin required to cover the maximum percentage of IMN nodes will be provided at the conference. This data will fill the knowledge gap that exists regarding the adequacy of the 5 mm margin provided by ESTRO consensus guidelines. Conclusions: To best of our knowledge there is no study that provides objective proof for the adequacy of the 5 mm margin to IM vessels in treating IMN.
Medullary breast carcinoma: Its behaviour, management and prognosis: An experience from a tertiary care institute
Tapan Kumar Sahoo , Saroj Kumar Das, Saroj Kumar Das Majumdar, Asaranti Kar, Dillip Kumar Parida
Department of Radiation Oncology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India, E-mail: [email protected]
Objectives: To report the incidence, stage at presentation, receptor status, management and prognosis of the medullary breast carcinoma. Materials and Methods: Nine cases of medullary breast carcinomas were included in the study from August 2013 till date. Results: All the cases were presented at early stage. Seven cases were with triple negative receptor status, one case with estrogen receptor (ER) positive, progesterone receptor (PR) negative and HER2 receptor positive status and another case was ER and PR negative but HER2 positive. All the patients were treated with surgery followed by adjuvant chemotherapy, radiotherapy and/or hormone therapy as per oncology team discussion. All the nine cases tolerated treatment well and under regular follow up with an average period of 24 months without any recurrence or distant metastasis. Conclusion: Most cases were with triple negative receptor status, early stage at presentation, less lymph node involvement and without any disease recurrence or distant metastasis on follow up after treatment supporting the literature. But large studies with longer duration of follow up are necessary to know about the prognosis of the disease.
Key words: Atypical, breast carcinoma, medullary variant, prognosis
Dosimetric comparison of intensity modulated radiotherapy versus three dimensional conformal radiotherapy of chest wall in post mastectomy breast cancer patients: A prospective observational study
Department of Radiotherapy, Sree Venkateswara, Institute of Medical Sciences, India, E-mail: [email protected]
Context: Evidence shows that IMRT leads to better dose distribution than 3DCRT for whole breast radiotherapy and for post mastectomy chest wall irradiation with internal mammary nodes. Data on the effect of IMRT of chest wall in post mastectomy breast cancer patients without IMN are scarce in literature. Aim: To compare dosimetric parameters of IMRT with 3D-CRT in postmastectomy chest wall irradiation. Settings and Design: Prospective observational study. Materials and Methods: For 30 postmastectomy breast cancer patients, 7 field IMRT plan and tangential beam 3D-CRT plan were generated. The dose prescribed to PTV was 50 Gy in 25 fractions. Statistical Analysis: Dose parameters are compared by using paired t-test, P value <0.05 is considered significant. Results: On comparison, D 95(%) of PTV (3D-CRT 47.26 Gy); IMRT 48.37 Gy (P < 0.01), HI and CI were significantly improved with IMRT. In Left chest wall irradiation, with IMRT V 30 of heart was decreased from 23.31% to 18.99% (P = 0.075) and D mean (14.05 Gy 3D-CRT, 19.06 Gy IMRT) was increased (P < 0.01). V 5 of heart was increased from 6.55% (3D-CRT) to 92.35% (IMRT) (P < 0.001). Ipsilateral lung D mean (21.13 Gy 3D-CRT, 18.08 Gy IMRT, P = 0.07) and V20 (38.22% 3D-CRT, 35.14% IMRT P = 0.006) decreased with IMRT. Low dose volumes of lung was increased with IMRT. Conclusions: The benefit is marginal in sparing OAR in post mastectomy chest wall without IMN radiation, which is achieved at the cost of increase in low dose volumes of lungs and heart. IMRT can be used in situations where strict constraints to the heart and lungs are not satisfied.
Key words: 3D-CRT, IMRT, post mastectomy chest wall
A comparative dosimetric study of two different techniques (IMRT vs. 3D-CRT) in left sided breast cancer
Vipul Nautiyal , Ravi Kant, Meenu Gupta, Saurabh Bansal, Jyoti Bisth, P. Henit Raj, Mushtaq Ahmad, Sunil Saini
Department of Radiotherapy, Cancer Research Institute, SRHU, Dehradun, Uttarakhand, India, E-mail: [email protected]
Background: This study evaluates the dose distribution of reversed planned tangential beam intensity modulated radiotherapy (IMRT) compared to standard wedged tangential beam three-dimensionally planned conformal radiotherapy (3D-CRT) of the left sided breast cancer patients. Methods: For 20 unselected subsequent left sided breast cancer patients tangential beam IMRT and tangential beam 3D-CRT plans were generated for the radiotherapy. The prescribed dose was 45 Gy in 20 fractions as our institutional protocol. Dose-volume histograms were evaluated for the PTV and organs at risk. Parameters of the dose distribution were compared using the pair-t-test. Results: Although there is no significant difference in the ipsilateral mean lung dose in both technique but 5 Gy volume of left lung is 7% higher in IMRT group. In all patients treated on the left side, 30 Gy volume of heart is 22% higher in 3DCRT group (18.3% vs 14.1%) and the mean heart dose is also 27% higher in 3DCRT compare to IMRT (19.8 Gy versus 14.3 Gy). The PTV showed a significantly better conformity index with IMRT; the homogeneity index was not significantly different. Conclusions: Tangential beam IMRT demonstrated a significantly better conformity and homogeneity index for the PTV of the left breast cancer patients with a significant reduction in the mean doses of the heart for the left-sided breast cancer patients.
Dosimetric comparison of heart and left lung dose in conventional versus hypofractionated RT in carcinoma left breast receiving radiotherapy to chest wall: A preliminary institutional data
A. Tripathy , N. Panda, S. Padhi, L. Pattanayak, I. Priyadarsini, M. K. Behera, B. R. Routray
Department of Radiotherapy, AHRCC, Cuttack, Odisha, India,
E-mail: [email protected]
Introduction: Over the past decade, incidence of carcinoma breast has been on the rise and adjuvant radiotherapy plays an important part in its management. Besides conventional fractionation regimes, hypofractionation is now standardized in many centres. Here, we give an institutional data of dosimetry comparing conventional and hypofractionated regimes in left sided carcinoma breast patients receiving radiotherapy to chest wall. Aim: To compare heart and left (ipsilateral) lung doses in conventional and hypofractionated radiotherapy in carcinoma left breast patients receiving radiotherapy to chest wall. Methodology: 20 patients with carcinoma left breast who underwent modified radical mastectomy were included in the study. They were randomized into two arms (10 each)-conventional RT (50 Gy/25#) and hypofractionated RT (40 Gy/15#). All the patients were planned in LINAC using 6 MV photons by 3DCRT. The goal of planning was to ensure that the 95% isodose covered 100% of the planning target volume (PTV). The heart and left (ipsilateral) lung doses were compared between the two regimes. Results: In conventional arm, the mean mean dose to heart was found to be 5.67 Gy while it was 5.52 Gy in hypofractionated arm. In conventional arm, the mean V15 of heart was 10.86%, mean V20 was 10.31% and mean V30 was 8.96% while in hypofractionated arm, the mean V15 of heart was 13.2%, mean V20 was 12.07% and mean V30 was 9.55%. The mean central lung distance (CLD) in conventional arm was 2.83 cm while it was 3.2 cm in hypofractionated arm. The mean left lung dose was 10.48 Gy in conventional arm as compared to 9.63 Gy in hypofractionated arm. In conventional arm, the mean V15 of left lung was 22.55% and mean V20 was 21.19% while in hypofractionated arm, the mean V15 of left lung was 25.31% and mean V20 was 23.29%. Conclusion: The mean dose to heart and left lung in both conventional and hypofractionated RT are comparable. The V30 of heart and V20 of ipsilateral lung in both arms are well within limits according to the Quantec guidelines. Hence, hypofractionated RT has an advantage of patient compliance and cost effectiveness over conventional RT.
Key words:Heart dose, hypofractionation, left lung dose
Trend of metastatic breast carcinoma and correlation various prognostic factors: AHRCC experience
Mohanty Sulagna , Padhi Sanjukta, B. R. Routray, L. Pattanayak, N. Panda
Department of Radiotherapy, A. H. Regional Cancer Centre, Cuttack, Odisha, India, E-mail: [email protected]
Background: World over carcinoma breast is the most frequent cancer among female (As per International Agency for Research on cancer data - 22.2% in 2008 to 27% in 2012). In India, the incidence is in rising trend in a tune of 0.5-2% per annum (Murthy et al.). Most of the women are young with aggressive tumour characteristics and high propensity for metastasis. Hence the current management of primary breast cancer warrants prognostication, stratification and optimal selection of therapy. A current data by Steven Halls revealed 20-30% of all women first diagnosed with localised breast cancer usually develop distant metastasis & 10% upfront present with metastasis. Aims and Objective: The current study was undertaken to correlate various prognostic factors and the pattern of metastasis in carcinoma breast patients. Materials and Methods: 178 Patients with carcinoma breast were analysed retrospectively from institutional records from May 2015 to May 2016. Data are analyzed using SPSS version 21. Observation: Though 40 to 50 years is the most common age group (37.1%), prevalence in the 30 to 40 years age group is comparable (33.1%). Maximum numbers of patients are in stage IIA (27.5%) followed by stage IIIA (23%), IIIC (21.9%), and IIB (19.7%) respectively. 64.6% of the patients had grade II malignancy followed by grade III (30.89%). NPI ≥5.4 which is a poor outcome indicator accounted for 48.3% of the total cases followed by NPI 3.4 to 5.39 (39.3%). Majority of patients (45.5%) had triple negative receptor status and 23.5% of total patients had both triple negative receptor status and poor NPI. ER, PR negative HER2-neu expression is seen in 16.8% of total patients. In moderate NPI group, triple negative receptor status is frequently observed followed by ER, PR negative HER2-neu expression.18.1% patients had both ER, PR receptor positive HER2-neu negative and had good NPI. Distant metastasis was seen in 26.4% of total patients and bone was found to be the most common metastatic site (38.98%). Amongst the metastatic breast cancer patients, 44.6% were found to have triple negative receptor status and 74.4% had poor NPI. Conclusion: From this retrospective study it is concluded that there is a rising trend in incidence of breast cancer in younger age group (<40 years). Most of them present with advanced stages of disease. Moderate and poor NPI subgroups have triple negative receptor status followed by ER, PR negative and HER-2-neu expression. Bone is the commonest metastastic site and most of the metastatic breast cancer patients had poor NPI.
A prospective randomized study comparing conventionally fractionated versus hypofractionated post mastectomy radiotherapy in locally advanced breast cancer in female
Debanti Banerjee , Abhishek Basu, Krishnangshu Bhanja Choudhury, Kazi Sazzad Manir, Kousik Ghosh, Subir Gangopadhyay
Department of Radiotherapy, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]
Introduction: Hypofractionated radiotherapy (HypoRT) has become acceptable in early breast cancer, but it has seldom been compared with conventionally fractionated radiotherapy (ConRT) in post mastectomy female patients of Locally Advanced Breast Cancer (LABC). Materials and Methods: Between November 2014 and September 2015, biopsy proven LABC patients with normal baseline haematological, Cardiological, pulmonary status and ECOG PS 0-1 were included in this prospective, randomized single institutional study. After receiving NACT with 5-Fluorouracil, Epirubicin, Cyclophosphamide followed by MRM and adjuvant Docetaxel, patients were randomized as-Arm A: HypoRT 40 Gy/15#/3 weeks and Arm B: ConRT 50 Gy/25#/5 weeks. The endpoints were locoregional control, toxicities and Progression Free survival (PFS). Results: Forty nine patients (24 Arm A & 25 Arm B) were analyzed at a median follow up of 7 months. Baseline characteristics were comparable. The median age was 45 years. Majority of patients were postmenopausal and ER negative. Compliance to chemotherapy was similar and acceptable. Mean PTV coverage was 95.14% (Arm A) and 95.81% (Arm B) (P=0.225). Lung V20 and median cardiac doses were acceptable. There was no locoregional recurrence but distant metastasis occurred in 4/24 patients in Arm A Including 1 death vs. 3/25 in Arm B (P value 0.641). Acute and late toxicities in both arms were comparable except more acute Grade 3 skin toxicity in Arm B (48%, P value 0.046). PFS was 16.42 months vs. 15.99 months in Arms A and B respectively (P=0.651). Conclusion: Although there are drawbacks of this study, it demonstrates that hypofractionated PMRT can be a viable option in LABC.
Surface dosimetry of contralateral breast during postmastectomy radiation in breast cancer patients treated by cobalt 60 teletherapy using breastcone
R. Sandhya , Iqbal Ahmed, M. Ravikumar, Amrut Kadam, Rajesh Javarappa, V. Chendil
Department of Radiotherapy, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India,
E-mail: [email protected]
Introduction: Women with a history of breast cancer have a 10% to 15% risk of developing a new primary in the contralateral breast. Second cancer induction in the contralateral breast (CB) is an issue of some concern in breast radiotherapy. In order to reduce the dose to the contralateral breast during breast irradiation, the dose to the contralateral breast needs to be documented and quantified. Objective: To determine the surface dose to contralateral breast by using thermoluminiscence dosimeter chips. Materials and Methods: Proven cases of carcinoma breast receiving adjuvant radiotherapy to chest wall with conventional fractionation with supraclavicular field irradiation were considered for the study. All patients received adjuvant radiotherapy on Telecobalt using breastcone, to a total dose of 50 Gy in 25 fractions over 5 weeks. Patients were considered for assessment of surface dose received by contralateral breast on first 3 days of external beam radiotherapy. Thermoluminiscence dosimeter (TLD) chips were placed on opposite breast just before radiotherapy to the ipsilateral chest wall and read on TLD reader after 3 consecutive readings. Results: It was observed that the doses closer to the treatment field ranged from 505 cGy to 1247 cGy and doses at the farthest points away from treatment field ranged from 82.79 cGy to 142.5 cGy. Conclusions: Thermoluminescence dosimetry is a reasonably accurate method to measure the dose in CB. The surface dose of CB ranges from 73.48607 cGy to 1687.825 cGy. Patients who are younger and live longer may have an increased risk of developing CB cancer. Hence, stratergies needs to be applied to reduce the dose to the CB.
Molecular subtyping of invasive breast cancer and its relation to common risk factors: A hospital based study
Department of Radiotherapy, Mahavir Cancer Sanstan, Patna, Bihar , India, E-mail: [email protected]
Objectives: Breast cancer is the most common cancer among Indian women and can be stratified in molecular subtypes by using a panel of immunohistochemical markers for estrogen, progesterone and HER 2neu receptor, which is more closely related to the behavior of the disease. Majority of our patients do not have the traditional risk factors, and often present with an advanced stage of the disease which progresses despite treatment. So, this study was done to determine the prevalence of various molecular subtypes in our patients and its relation to their menopausal status and body mass index (BMI). Materials and Methods: 446 invasive breast cancer patients treated at Mahavir Cancer Sansthan, Patna from January 2015 to December 2015 were retrospectively analysed for their age, parity, history of breast feeding, menopausal status, height, weight, ER, PR & HER2neu receptor status. They were then classified in four molecular subgroups, Luminal A, Luminal B, Triple negative and HER2neu positive cancers . Results: 68.38% patients were premenopausal with a mean age of 47.12 years. 24.38% patients were obese or overweight, with an average BMI of 22.38. Luminal A subtype followed by Triple Negative subtype was found in 37% and 29% of the patients respectively. Patients with Triple Negative subtype increased from 27.76% to 32.55% (P = 0.31) as the BMI increased to more than 25 and from 25.53% to 30.81% (P = 0.25) in postmenopausal versus premenopausal patients. Conclusion: Overall prevalence of triple negative subtype in our patients is high. Premenopausal age group and obesity may be related to triple negative subtype.
Prospective study to compare hypofractionated radiotherapy versus conventional radiotherapy in carcinoma breast
Sunny Kumar , S. N. Prasad, S. Singh, P. Shukla, J. K. J. Verma, P. K. Singh, M. Korde
Department of Radiotherapy, J.K. Cancer Institute, Kanpur, Uttar Pradesh, India, E-mail: [email protected]
Introduction: The standard radiotherapy schedule for chest wall irradiation post mastectomy is 50 Gy in 25#. However hypo-fractionated radiotherapy in breast is hypothesised to be effective in carcinoma breast radiobiologicaly. We tested the two dose schedule of 15# and 25#. Materials and Methods: Patients with histopathologically proven breast cancer were selected from OPD of j k cancer institute and randomised in two arms. Arm A - 40 Gy in 15# over 3 weeks and Arm B - 50 Gy in 25# 0 ver 5 weeks. Results: we observed that in terms of local control, distant metastasis and late toxicity both the arms are equally effective but significantly reduced acute toxicity and treatment breaks in Arm A. Conclusions: by attaining similar efficacy and late reactions we can reduce acute reactions and treatment breaks if we follow hypo-fractionated schedule in ca breast.
A prospective study comparing hypofractionated versus conventional adjuvant radiotherapy following mastectomy in female breast cancer patients of Northeast India
Partha Pratim Medhi , M. Bhattacharyya, V. Jagtap, A. K. Kalita, T. R. Borbora, R. Sunku
Department of Radiotherapy, Dr. B. Borooah Cancer Institute, Guwahati, Assam, India, E-mail: [email protected]
Introduction: To compare hypofractionation to conventional dose fractionation for postmastectomy irradiation in locally advanced breast cancer patients, as prospective data in this aspect is scarce. If found equivalent to conventional radiotherapy, a short hypofractionated regimen when implemented in our resource-constrained set-up, will result in economic benefits for patients and increased turnover in radiotherapy departments. Materials and Methods: 50 female breast cancer patients receiving adjuvant radiotherapy post-mastectomy, were randomized to hypofractionated (40 Gy/15 fractions) or conventional (50 Gy/25 fractions) doses. Radiotherapy was delivered to include the chest wall and ipsilateral axilla, supraclavicular nodes were irradiated if indicated. Treatment was delivered using conventional fields planned meticulously in a 2D X-ray Simulator. The time for treatment completion between the two groups was calculated. Patients were evaluated for acute and late toxicities and breast cancer related events upto a minimum of 1 year. Appropriate statistical tests were applied for analysis of data. Results: Each arm had 25 patients. The mean time of treatment completion (P < 0.0001) and treatment delay (P = 0.0009) was significantly less in the hypofractionated arm. Hypofractionated arm had less acute skin toxicity and also less late toxicities like skin pigmentation, erythema, fibrosis and lymphedema, though it was not statistically significant (P value > 0.05). Loco-regional relapse, distant relapse and survival at 1 year were similar in both the arms. Conclusions: Hypofractionated radiotherapy has lesser toxicity, significantly shorter treatment duration and appears to be more acceptable than conventional radiotherapy, especially in our set-up. However, longer follow-up will be required to comment on disease control.
Results of chest wall reirradiation using HDR surface mould brachytherapy by 3D image-based volume optimization for postmastectomy local recurrence
Nibedita Biswas, Bodhisattwa Dutta, Rajanigandha Tudu,
Arkoprovo Halder, Rumeli Roy, Asit Ranjan Deb
Department of Radiotherapy, Medical College Kolkata, West Bengal, India, E-mail: [email protected]
Objective: To assess the effectiveness of HDR surface mould brachytherapy and associated toxicity in case of post mastectomy, post radiotherapy chest wall recurrence. Materials and Methods: A single institutional prospective study was carried out between July 2015 and April 2016 comprising of 9 patients. All of them presented with post mastectomy post radiotherapy (50 Gy or equivalent) chest wall recurrence. Indication of irradiation was a progressive macroscopic skin recurrence in 6 cases and incomplete surgical resection in 3 cases. Standard treatment consist of 10 Gy in 4 fractions using Ir 192. The reference dose to skin surface was prescribed at 5 mm distance from the source by 3D image-based volume optimization. The outcome was assessed in terms of control of skin nodules and associated skin and pulmonary toxicities. Results: Local control was obtained in 7 out of 9 patients at 6 weeks of follow up. 2 patients developed grade III acute skin toxicity and 3 patients had grade II skin toxicity at 3 weeks of follow up. 1 patient died of brain metastasis after 3 months. Conclusion: Reirradiation of the chest wall using HDR surface mould brachytherapy is effective and provides good local control with acceptable toxicity.
Trastuzumab in HER-2-neu positive breast cancer in female: A single institutional audit
Debanti Banerjee , Kazi Sazzad Manir, Krishnangshu Bhanja Choudhury, Abhishek Basu, Chhaya Roy, Subir Gangopadhyay
Department of Radiotherapy, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India, E-mail: [email protected]
Introduction: Human epidermal growth factor receptor-2 (HER-2-neu) overexpression occurring in about 30% of human breast cancer, is a poor prognostic factor. Trastuzumab (a humanized monoclonal antibody against HER-2-neu) can cause improvement in HER-2-neu over expressive breast cancer. Trastuzumab can cause cardiomyopathy usually detected by decrease of Left Ventricular Ejection Fraction (LVEF). Materials and Methods: We performed a retrospective single institutional audit among 26 Her-2-neu positive female patients of breast cancer who received Trastuzumab between November 2014 to June 2016. All patients had normal baseline Cardiological status (LVEF >50%). HER- 2-neu overexpression was detected by either Immunohistochemistry (IHC) or Fluorescent in situ hybridisation (FISH) from core cut biopsy specimen. They all received Inj. Trastuzumab with loading dose of 8 mg/kg followed by 3 weekly maintenance doses with 6 mg/kg either in adjuvant (22/26) or in metastatic (4/26) setting. 2D Echocardiography was repeated after every three cycles. Results: Median age of the study group was 45 years. Most of the patients were postmenopausal (65.4%) and ER negative (65.4%). Left sided tumour was predominant (61.5%). Mean baseline LVEF was 64.54% (SE 0.920). 1 year of Trastuzumab therapy was completed in 7 patients. Trastuzumab had to be discontinued in 3 patients (due to pyrexia of unknown origin in 1 & disease progression in 2). One patient defaulted during treatment. Median number of cycles was 9 (range 2 to 17). Mean LVEF of last performed 2D Echocardiography was 64.08% (S.E. 0.972). Conclusions: Trastuzumab can be safely used in HER-2-neu over expressive breast cancer with regular Echocardiography monitoring.
Dosimetric comparison of intensity modulated radiotherapy versus three-dimensional conformal radiotherapy of chest wall in postmastectomy breast cancer patients: A prospective observational study
Department of Radiotherapy, SVIMS, Tirupati, Andhra Pradesh, India, E-mail: [email protected]
Objective: Evidence shows that IMRT leads to better dose distribution than 3DCRT for whole breast radiotherapy and for post mastectomy chest wall irradiation with internal mammary nodes. Data on the effect of IMRT of chest wall in post mastectomy breast cancer patients without IMN are scarce in literature. Aim: To compared osimetric parameters of IMRT with 3D-CRT in postmastectomy chest wall irradiation. Settings and Design: Prospective observational study. Materials and Methods: For 30 postmastectomy breast cancer patients, 7 field IMRT plan and tangential beam 3D-CRT plan were generated. The dose prescribed to PTV was 50 Gy in 25 fractions. Statistical Analysis: Dose parameters are compared by using paired t-test, P value < 0.05 is considered significant. Results: On comparison, D 95(%) of PTV (3D-CRT 47.26 Gy); IMRT 48.37 Gy (P < 0.01), HI and CI were significantly improved with IMRT. In Left chest wall irradiation, with IMRT V 30 of heart was decreased from 23.31% to 18.99% (P = 0.075) and D mean (14.05 Gy 3D-CRT, 19.06 Gy IMRT) was increased (P < 0.01). V 5 of heart was increased from 6.55% (3D-CRT) to 92.35% (IMRT) (P < 0.001). Ipsilateral lung D mean (21.13 Gy 3D-CRT, 18.08 Gy IMRT, P = 0.07) and V20 (38.22% 3D-CRT, 35.14% IMRT P = 0.006) decreased with IMRT. Low dose volumes of lung was increased with IMRT. Conclusions: The benefit is marginal in sparing OAR in post mastectomy chest wall without IMN radiation, which is achieved at the cost of increase in low dose volumes of lungs and heart. IMRT can be used in situations where strict constraints to the heart and lungs are not satisfied.
Key words: 3D-CRT, IMRT, postmastectomy chest wall
The impact of axillary lymph node dissection and conventional or hypofractionated adjuvant nodal irradiation on the risk of lymphedema in postmastectomy breast cancer patients: A prospective study
Kartick Rastogi , Sandeep Jain, Aseem Rai Bhatnagar 1 , Shivani Gupta, R. K. Spartacus, Nikesh Agarwal, Sandeep Bhaskar, Kampra Gupta, Neeraj Sharma, Ajay Singh Chaudhary
Department of Radiation Oncology, Sawai Man Singh Medical College and Attached Hospitals, 1 Linear Accelerator Center, Sawai Man Singh Hospital, Jaipur, Rajasthan, India, E-mail: [email protected]
Introduction: To study the effect of axillary dissection and adjuvant nodal irradiation on the risk of lymphedema in breast cancer patients who underwent mastectomy. Materials and Methods: From April 2015 to March 2016, we selected 100 consecutive breast cancer patients prospectively who underwent mastectomy and axillary lymph node dissection and were candidates for adjuvant radiotherapy. All patients received radiotherapy on linear accelerator with 3-dimensional conformal radiotherapy technique. 50 patients received the standard conventional dose of 50 Gy in 25 fractions with 2 Gy per fraction and 50 patients received hypofractionated radiotherapy with dose of 42.72 Gy in 16 fractions with 2.67 Gy per fraction. We measured the arm circumference at a distance of 10 cm proximal and 10 cm distal to the lateral epicondyle of both arms at presentation and at 6 months of completion of radiotherapy. Lymphedema was defined as a difference of ≥2 cm from the baseline in the arm circumference on the side of axillary lymph node dissection on these measurements. Results: At a followup of 6 months, the cumulative incidence of lymphedema was 13%. Cumulative incidence by radiotherapy type was: 12% (conventional fractionated radiotherapy (CF)) and 14% (hypo fractionated radiotherapy (HF)). The relative risk for HF was 1.1667 (p = 0.7665) compared to CF. Cumulative incidence by the region irradiated was: 2.5% (chest wall alone (CW)) and 19.6% (chest wall and regional lymph nodal radiation (CW+RLNR)). The relative risk for CW + RLNR was 7.6721 (p = 0.0458) compared to CW radiotherapy. Cumulative incidence by combination of radiotherapy type and the region irradiated was: 5% (CF, CW), 0% (HF, CW), 16.6% (CF, CW + RLNR) and 22.5% (HF, CW + RLNR). The incidence of lymphedema with the number of lymph node dissected was 6.6% for 110 LN (7.1% with CF, 6.2% with HF), 10% for 1120 LN (11.1% with CF, 13% with HF) and 30% for >20 LN (22.2% with CF, 27.2% with HF). The relative risk for LN >20 was 4.5 (p = 0.0489). Conclusions: Adjuvant RLNR significantly increases the risk of development of lymphedema compared to CW RT alone. There was no significant difference in the lymphedema between CF and HF. Greater number of the lymph nodes dissected remains another independent significant risk factor for the development of lymphedema.
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