Kanta R. Desai

Arm lymphedema in patients treated conservatively for breast cancer: Relationship to patient age and axillary node dissection technique

Arm lymphedema (ALE) was evaluated in 74 patients treated conservatively for breast cancer. ALE was defined based upon measurements performed upon 35 volunteer subjects who did not have and were never treated for breast cancer. Multiple variable statistical analysis of 74 breast cancer patients revealed that age at diagnosis was the most important factor related to the subsequent development of ALE. ALE appeared in 7 of 28 patients (25%) 60 years of age or older but in only 3 of 46 (7%) younger patients (p less than 0.02). Axillary node dissection (AND) was the only other statistically significant factor. For the younger patients, obesity and post-operative wound complications appeared to be contributing factors. For the older patients, AND technique was the only significant factor. ALE developed in only 1 of 10 (10%) of the older patients who underwent AND without splitting the pectoralis minor muscle (PMM), but in 6 of 11 (55%) who underwent AND with PMM split (p less than 0.03). Splitting the PMM during AND did not yield more lymph nodes for pathological analysis nor did it yield a higher incidence of patients with nodal metastases. Neither the use of lymph node radiation therapy fields, radiation to the full axilla, nor systemic chemotherapy was associated with ALE. We conclude that older patients are at higher risk of ALE and that this complication can possibly be reduced by not splitting the PMM during axillary node dissection.

Breast retraction assessment: an objective evaluation of cosmetic results of patients treated conservatively for breast cancer☆

Breast Retraction Assessment (BRA) is an objective evaluation of the amount of cosmetic retraction of the treated breast in comparison to the untreated breast in patients who receive conservative treatment for breast cancer. A clear acrylic sheet supported vertically and marked as a grid at 1 cm intervals is employed to perform the measurements. Average BRA value (+/- standard deviation) in 29 control patients without breast cancer was 1.2 cm (+/- 0.7 cm). Average BRA value in 27 patients treated conservatively for clinical Stage I or II unilateral breast cancer was 3.7 cm (+/- 2.1 cm). BRA values in breast cancer patients ranged from 0.0 to 8.5 cm. Statistical analysis revealed that tumor size, employment of adjuvant chemotherapy and use of separate radiation lymph node fields were not factors in breast retraction. Patients who received a local radiation boost to the primary tumor bed site had statistically significantly less retraction than those who did not receive a boost. Patients who had an extensive primary tumor resection had statistically significantly more retraction than those who underwent a more limited resection. In comparison to qualitative forms of cosmetic analysis, BRA is an objective test that can quantitatively evaluate factors which may be related to cosmetic retraction in patients treated conservatively for breast cancer.

Patient self-evaluation of cosmetic outcome of breast-preserving cancer treatment

Thirty-two patients with Stage I or II breast cancer who had completed conservative breast-preserving treatment were asked to rate their cosmetic outcomes. Within this group, extent of the surgical excision of the breast tumor varied, with biopsy scars ranging from 2 to 19.5 cm. All patients had received external beam radiotherapy, with local boost doses in 17 cases. The average interval between self-evaluation and the completion of radiotherapy was 19 months. Patients completed a questionnaire rating the appearance of the treated breast, the degree of difference between breasts and overall satisfaction with cosmesis. They were asked to describe differences between breasts and to make any additional comments. Appearance of the treated breast was rated good to excellent by 94%, although 88% noted a difference of slight to moderate degree between treated and untreated breasts. Overall, 78% of patients were very to extremely satisfied, while moderate satisfaction was reported by 19%. Reports of breast differences included reduced size of the treated breast (44%), increased firmness (31%), elevation (25%), and skin color changes (22%). Reasons for dissatisfaction included chronic breast pain in 3 patients, breast edema in one and arm edema in one. Two patients wanted the untreated breast reduced in size. Statistically significant inverse relationships were found between the length of the biopsy scar and patient ratings of both appearance of the treated breast and overall satisfaction. These results indicated that although most patients were satisfied with cosmetic results of breast-preserving treatments, they are quite discriminating in their evaluations of differences between breasts. Functional factors such as pain and edema had a negative impact on satisfaction with cosmesis.

Total skin electron irradiation for mycosis fungoides: relationship between acute toxicities and measured dose at different anatomic sites

From June 1978 to June 1986, 50 patients with primary and recurrent mycosis fungoides were treated with total skin electron irradiation (TSEI), using the Stanford technique, to a total dose of 3600 cGy. TSEI was used alone, or in combination with low dose total body photon irradiation, or MOPP. Thermoluminescent dosimeter (TLD) measurements of the prescribed skin dose were obtained on twenty patients. The dorsum of the foot was 24% higher. The axillae, the bottom, and the arch of the foot were significantly underdosed. Frequencies of acute toxicities noted at 2000 cGy were: Skin, Grade I-II (RTOG) 80%. Partial epilation: scalp, 100%; eyebrows and at eyelashes, 20%. Nail dystrophy, 48%. Edema: hands and feet, 44%. Bullae: dorsum of feet, 8%; hands, 4%; and 3600 cGy: Skin, grade III 22%. Total epilation: scalp, 66%; eyebrows and eyelashes, 56%. Nail loss, 38%. Edema: hands and feet, 76%. Bullae: dorsum of feet, 34%; hands, 12%. Conjunctivitis, 4%. Large bullae, were more significant on the dorsum of the feet. Severe moist desquamation occurred in eight patients who had ulcerated lesions on initial presentation. Three patients were hospitalized due to ulceration and skin infection. All patients completed treatment after a short to moderate break. No patient developed skin necrosis, or corneal ulceration. No correlation exists between dose level, degree and onset of toxicity with previous chemotherapy or TBI. We conclude that the overall toxicity of TSEI is well tolerated.

BREAST EDEMA IN PATIENTS TREATED CONSERVATIVELY FOR STAGE I AND II BREAST CANCER

Breast edema was evaluated in 45 patients with Stage I or II breast cancer (including two with simultaneous, bilateral disease), who were treated by breast-preserving treatment approaches. Multiple variable statistical analysis revealed that bra cup size was the only factor significantly related to the appearance of breast edema. Breast edema occurred in 3 of 20 breasts (15%) with bra cup size A or B, as compared to 13 of 27 breasts (48%) with bra cup size C, D or DD(p less than 0.03). Breast edema was more likely to occur in patients who underwent full axillary dissection as compared to those who underwent axillary sampling or no axillary surgery. This observation, however, was not statistically significant. Neither the radiation therapy parameters nor the use of adjuvant chemotherapy were found to be related to the development of breast edema. Breast edema appears to be a transient phenomenon observed most frequently in the first year after the end of irradiation. It was observed much less frequently in those patients evaluated over 1 year following the end of radiation therapy.

Multiple variable analysis of factors responsible for cosmetic retraction in patients treated conservatively for stage I or II breast carcinoma

A method for objective evaluation of cosmetic outcome of patients treated conservatively for breast carcinoma allowed the location of the nipples on two coordinates. The method was applied in 41 patients, 5 to 41 months following the completion of radiation therapy. Multiple variable analysis revealed that extensiveness of resection of the primary breast tumor was the major factor associated with breast retraction. The only other factor of significance was patient age at diagnosis. Neither the radiation therapy parameters, the use of adjuvant chemotherapy, nor any other analyzed factor was found to be associated with cosmetic breast retraction.

Acute normal tissue tolerance to 7 day per week accelerated fractionation.

Fifty-six sites in 49 patients were irradiated by a 7 day/week accelerated fractionation schedule to conventional tumor doses. Daily doses were 180 to 200 rad in 85% of sites. Patients were analyzed for normal tissue tolerance. A 7 day/week accelerated fractionation appears clinically tolerable at 180 rad per fraction.