Deborah A. Markiewicz

The effects of sequence and type of chemotherapy and radiation therapy on cosmesis and complications after breast conservation therapy

PURPOSE Chemotherapy plays an increasingly important role in the treatment of both node-negative and node-positive breast cancer patients, but the optimal sequencing of chemotherapy and radiation therapy is not well established. The purpose of this study is to evaluate the interaction of sequence and type of chemotherapy and hormonal therapy given with radiation therapy on the cosmetic outcome and the incidence of complications of Stage I and II breast cancer patients treated with breast-conserving therapy. METHODS AND MATERIALS The records of 1053 Stage I and II breast cancer patients treated with curative intent with breast-conserving surgery, axillary dissection, and radiation therapy between 1977-1991 were reviewed. Median follow-up after treatment was 6.7 years. Two hundred fourteen patients received chemotherapy alone, 141 patients received hormonal therapy alone, 86 patients received both, and 612 patients received no adjuvant therapy. Patients who received chemotherapy +/- hormonal therapy were grouped according to sequence of chemotherapy: (a) concurrent = concurrent chemotherapy with radiation therapy followed by chemotherapy; (b) sequential = radiation followed by chemotherapy or chemotherapy followed by radiation; and (c) sandwich = chemotherapy followed by concurrent chemotherapy and radiation followed by chemotherapy. Compared to node negative patients, node-positive patients more commonly received chemotherapy (77 vs. 9%, p < 0.0001) and/or hormonal therapy (40 vs. 14%, p < 0.0001). Among patients who received chemotherapy, the majority (243 patients) received concurrent chemotherapy and radiation therapy with two cycles of cytoxan and 5-fluorouracil (5-FU) administered during radiation followed by six cycles of chemotherapy with cytoxan, 5-fluorouracil and either methotrexate (CMF) or doxorubicin(CAF). For analysis of cosmesis, patients included were relapse free with 3 years minimum follow-up. RESULTS The use of chemotherapy had an adverse effect on cosmetic outcome compared to no chemotherapy, which was of borderline significance at 3 years (92% excellent or good cosmetic outcome vs. 96% respectively, p = 0.057); however, cosmesis was not different at 5 years (91 vs. 93% respectively, p = 0.67). Cosmesis was not significantly different between patients treated sequentially and those treated concurrently (3 year: 87 vs. 93% respectively, p = 0.33), nor was it different between patients who received CMF vs. CAF (3 year: 92 vs. 93% respectively, p = 0.89). Hormonal therapy did not influence cosmetic outcome (p = 0.78). The incidence of Grade 4 or 5 arm edema (> or = 2 cm difference in arm circumference) was 2% without chemotherapy vs. 8% with chemotherapy (p = 0.00002). However, the incidence of arm edema was not affected by sequencing or type of chemotherapy (all p > or = 0.52). Patients treated sequentially had a 10% incidence of Grade 4 or 5 arm edema vs. 7% in the patients treated concurrently (p = 0.52). The incidence was 7 vs. 9% in patients treated with CMF vs. CAF (p = 0.73). The incidence of clinical pneumonitis and rib fracture was not influenced by use of chemotherapy, sequence of chemotherapy or use of hormonal therapy (all p > or = 0.06). CONCLUSIONS Chemotherapy can be given concurrently with radiation therapy in the treatment of Stage I and II breast cancer with breast-conserving therapy without seriously compromising cosmetic outcome or incidence of complications compared to patients receiving other sequences of chemotherapy. Hormonal therapy did not affect cosmesis or complications. The chemotherapeutic regimen of cytoxan and 5-FU concurrent with radiation therapy followed by more chemotherapy is one reasonable option for breast conservation therapy in patients requiring chemotherapy.

MRI of carotid angiopathy after therapeutic radiation.

Objective Our goal was to assess whether significant secondary atherosclerotic changes from radiation can be detected on SE MR of the neck. Materials and Methods Pre- and postradiation MR scans of 16 patients with head and neck malignancies were studied randomly, independently, and blindly by two readers to determine the frequency of narrowing of the carotid arterial lumen and obliteration of the carotid space within the carotid sheath. Results Interval narrowing of either the common, internal, or external carotid artery lumen was seen in 108 of 192 (56%) of vessels evaluated on postradiation MR scans compared with preradiation studies. The differences in the grades of vessel luminal diameter were statistically significant (p < 0.05 for one reader and p < 0.0001 for the other reader). Among the 16 patients, 3 patients had vessels with a critical degree of stenosis, newly appearing on postradiation scans. Seven of 16 patients had diffuse obliteration of the planes within the carotid space. Conclusion The incidence of accelerated atherosclerosis from therapeutic radiation may be greater than expected in nonirradiated patients. Magnetic resonance scans are an effective, noninvasive method for this type of follow-up.

Breast Conservation Therapy in Patients with Early‐Stage Breast Cancer Who Have Undergone a Second Re‐Excision of the Primary Tumor Bed: A Report of Four Cases

Abstract: For the women with early‐stage breast cancer who are candidates for breast conservation therapy, re‐excision of the primary tumor bed has commonly been used in patients for several indications. These indications include positive margin or uncertain margin status of the primary excision or residual microcalcifications on postbiopsy mammogram. If the pathology from the re‐excision does not confirm negative margin status, mastectomy is generally recommended. This article examines patients who have undergone a second re‐excision (i.e., a lumpectomy followed by two re‐excisions) who have been treated with breast conservation therapy rather than a mastectomy.