Leela Krishnan

Ten-year results in 1070 patients with stages I and II breast cancer treated by conservative surgery and radiation therapy

Background. One thousand seventy patients treated conservatively for Stages I and II breast cancer between the years 1982 and 1994 were reviewed. The median follow‐up was 40 months with a maximum follow‐up of 152 months.

Breast Conservation Therapy with Tumor Bed Irradiation Alone in a Selected Group of Patients with Stage I Breast Cancer

Abstract: Radiotherapy after breast‐conserving surgery increases local control. We tested the feasibility of limited surgery with tumor bed irradiation only with 192Ir in a selected group of patients with stage I breast cancer. Twenty‐five breasts in 24 women more than 60 years old with low‐ or intermediate‐grade stage I tumors were treated with placement of interstitial catheters at the time of lumpectomy and axillary node dissection. This procedure was followed by after‐loading with low‐dose 192Ir to deliver 20–25 Gy to the tumor bed over 24–48 hours. There were neither local recurrences in the breast nor distant recurrences at a median follow‐up of 47 months (range 25–90 months). Cosmetic appearance ranged from very good to excellent. There were no long‐term complications. It is feasible to treat a select group of patients with tumor bed irradiation, using relatively low doses of interstitial irradiation, with excellent local control and no significant morbidity.

Form or function? Part 1. Subjective cosmetic and functional correlates of quality of life in women treated with breast-conserving surgical procedures and radiotherapy.

Quality of life (QOL) after a diagnosis of cancer varies considerably across individuals. Treatment‐related factors that predict QOL for women who are diagnosed with breast carcinoma require further specification. This study was designed to develop a measure of perceived aesthetic (e.g., breast shape) and functional status (e.g., pain, mobility) after breast‐conserving surgical treatment (BCT) and radiotherapy, to examine the relations of these indicators with patient QOL, and to determine whether these relations varied as a function of diagnosis duration.

Management of advanced squamous cell carcinomas of the maxillary sinus

From 1970 to 1988, 41 cases of advanced maxillary sinus cancers were treated at the University of Kansas Medical Center. Local control for the 37 evaluable patients was achieved in 21 (57%). Local control by radiation therapy alone was achieved in ten of 19 (53%) patients compared with eight of 14 (57%) treated with a combination of surgery and radiation therapy. A dose greater than 6500 cGy correlated with better local control in patients treated with radiation therapy alone. Neck node failure occurred in three of 35 (8%) patients when not electively treated. Neck metastasis either at presentation or at a later stage reduced survival. The overall absolute survival for the entire group at 5 years was 35%. A combination of preoperative radiation therapy and surgery is recommended for patients with advanced‐stage maxillary sinus cancer. Radiation therapy is an equally good alternative for those who are not surgical candidates or refuse surgery.

Local recurrence following breast conservation therapy in African-American women with invasive breast cancer.

BACKGROUND African-American women have a lower survival rate than white women following a diagnosis of invasive breast cancer. Limited information is available regarding the impact of race on results of breast conservation therapy (BCT). METHODS Local recurrence rates were compared in 71 African-American patients (73 breasts) and 204 white patients (208 breasts) with stage I and II breast cancer treated with BCT. RESULTS Overall 5-year actuarial recurrence rates were 13% in African-Americans and 4% in whites (P = 0.075). These rates were 9% and 4%, respectively, if patients with local skin/soft tissue recurrences were excluded (P = 0.587). Exclusion of these skin/soft tissue failures eliminated any significant difference seen in recurrence between stage II African-American and white patients (P = 0.163). African-American women had less favorable recurrences, including tumor in more than one quadrant or local skin/ soft tissue involvement (P = 0.001). CONCLUSIONS Overall actuarial recurrence rates were slightly higher, but not significantly different, in African-American and white women following BCT. A much less favorable pattern of local recurrence was seen in the African-American patients (P = 0.001), which may represent the presence of more biologically aggressive tumors in these women.

Cosmetic results in early breast cancer treated with lumpectomy, peri-operative interstitial irradiation, and external beam radiation

Patients with operable breast cancer were treated at the University of Kansas Medical Center with lumpectomy, peri-operative interstitial Iridium, and external beam radiotherapy, and concomitant adjuvant chemotherapy in a majority of node positive cases. Examination of the cosmetic results in 85 breasts followed for at least 2 years, at a median of 41 months revealed 20% to be excellent, 44% to be very good, 24% good, 9% fair, and 4% to have poor results. In this paper cosmesis is analyzed with reference to the size of the primary, its location, age of the patient, whether the patient received adjuvant chemotherapy, and whether the regional nodes were treated. In this group of patients, the size and the site of the primary, patients age, and whether adjuvant chemotherapy was administered or not, did not adversely affect the aesthetic outcome. Treatment of the regional nodes gave a worse mean cosmetic score compared to the group in whom only the breast was treated (37.51 vs. 58.98 respectively, p less than 0.001). Among the 11 patients with fair/poor cosmesis, all had regional nodal treatment, 7/11 had inner quadrant lesions, and 7/11 had lesions greater than T1. Further follow-up and accrual would be needed to confirm our results and affirm if other factors would change.

Leiomyosarcoma of the inferior vena cava: a case report and review of the literature

A 68-year-old white female presented with two years of progressively worsening dyspnea. Echocardiography revealed a large right atrial mass and partial obstruction of the inferior vena cava. Further imaging revealed a cystic dense mass in the inferior vena cava and right atrium. Immunohistochemical stains were consistent with leiomyosarcoma. Intraoperatively, the tumor was noted to originate from the posterior aspect of the inferior vena cava. The patient underwent successful resection of the mass. Adjuvant radiation therapy was completed. The patients dyspnea gradually improved and she continues to remain disease free five years post-resection.

Electron beam irradiation after reconstruction with silicone gel implant in breast cancer

Irradiation for breast cancer in the presence of a silicone gel breast prosthesis is sometimes necessary. There is a concern among radiation and other oncologists as to whether the presence of the prosthetic implant would interfere with delivery of the needed irradiation doses. Electron beams, with their finite penetration and rapid fall-off, offer a mode of adequately treating the recurrence and minimizing the radiation to the underlying normal structures, such as the lung and the heart. The dose distribution using 9–20 MeV electrons in the presence of a breast prosthesis is compared to the dose distribution without the implant in a tissue equivalent water phantom. The results reveal no significant difference in the dose delivered due to the presence of the prosthesis. Clinical verification of the dosimetry in the presence of the prosthesis confirmed that the presence of the silicone gel implant does not compromise treatment by irradiation in the management of breast cancer.

Effect of silicone gel breast prosthesis on electron and photon dose distributions

The effect of a silicone gel breast prosthesis on the absorbed dose distribution of 9-20 MeV electron beams and 1.25-15 MV photon beams was studied. Compared to water measurements, at depths smaller than the practical range of the electron beams, the central axis depth dose values below the prosthesis were lower for all energies by as much as 3.5%. However, at depths near the practical range, the central axis depth dose values for the prosthesis were greater than that of water by as much as 33%. Since this occurs near the end of the electron range, the resultant difference may not be clinically significant. Results of the effect of breast prosthesis on photon depth dose distributions reveal that no clinically significant perturbation is produced by the breast prosthesis using Co-60, 6- and 15-MV radiations.

Radiobiological advantages of an immediate interstitial boost dose in conservative treatment of breast cancer

Minimum surgery with irradiation is emerging as one of the main modalities of therapy for operable early breast cancer. Between June 1982 and June 1986, 110 breasts with Tis, T1 to T3 lesions have been treated at our institution with lumpectomy and interstitial irradiation to the tumor bed with Iridium-192 perioperatively followed by external beam irradiation. There have been two local recurrences at or near the vicinity of the primary, at a median follow-up of 60 months. To analyze the parameters that might have contributed to the local control, we have examined the treatment volumes, prescribed dose to the tumor bed, dose at the core of the tumor bed, and dose to the surrounding normal tissue. Immediate interstitial implant has the radiobiological advantage of delivering continuous low dose irradiation, immediately upon removal of gross tumor to residual foci. Implantation of the afterloading catheters intraoperatively facilitates accurate dose delivery and avoidance of geographical misses. By precise treatment of any residual foci, immediately upon removal of the gross mass, perioperative interstitial irradiation improves local control and by facilitating less radical surgical excision, leads to better cosmetic results.