Re-irradiation of the chest wall for local breast cancer recurrence

Results of salvage brachytherapy with hyperthermia

Re-Bestrahlung der Brustwand bei lokalen Brustkrebsrezidiven

Ergebnisse der Salvage-Brachytherapie mit Hyperthermie

Abstract

Aim

Following mastectomy and adjuvant external beam radiation therapy in patients with breast cancer, the incidence of local or locoregional recurrence is approximately 9 % (2–20 %). Alongside the often limited possibilities of surgical treatment, radiation therapy combined with superficial hyperthermia is the most effective local therapy. In the present work, a retrospective analysis of salvage brachytherapy combined with superficial hyperthermia for chest wall recurrences is presented.

Patients and methods

Between 2004 and 2011, 18 patients with a total of 23 target volumes resulting from chest wall recurrences after previously mastectomy and external beam radiation therapy (median 56 Gy, range 50–68 Gy) were treated with superficial brachytherapy as salvage treatment: 8 patients (44 %) had macroscopic tumor, 3 (17 %) had microscopic tumor (R1), and 7 (39 %) had undergone R0 resection and were treated due to risk factors. A dose of 50 Gy was given (high-dose rate [HDR] and pulsed-dose rate [PDR] procedures). In all, 5 of 23 patients (22 %) received additional concurrent chemotherapy, and in 20 of 23 (87 %) target volumes additional superficial hyperthermia was carried out twice weekly.

Results

The 5‑year local recurrence-free survival was 56 %, the disease-free survival was 28 %, and a 5-year overall survival was 22 %. Late side effects Common Toxicity Criteria (CTC) grade 3 were reported in 17 % of the patients: 2 of 18 (11 %) had CTC grade 3 fibrosis, and 1 of 18 (6 %) had a chronic wound healing disorder.

Conclusion

Re-irradiation as salvage brachytherapy with superficial hyperthermia for chest wall recurrences is a feasible and safe treatment with good local control results and acceptable late side effects.

Zusammenfassung

Ziel

Nach einer Mastektomie und adjuvanter Strahlentherapie bei Patientinnen mit Mammakarzinom kommt es bei 9 % (2–20 %) zum lokalen bzw. lokoregionären Rezidiv. Neben den oft limitierten operativen Behandlungsmöglichkeiten ist die Strahlentherapie mit Oberflächenhyperthermie die effektivste Lokaltherapie. Im Folgenden wird eine retrospektive Analyse der Ergebnisse der Re-Bestrahlung als Salvage-Brachytherapie beim Brustwandrezidiv vorgestellt.

Patienten und Methode

In den Jahren 2004 bis 2011 wurden 18 Patientinnen mit insgesamt 23 Zielvolumina aufgrund eines Thoraxwandrezidivs nach bereits früher erfolgter Mastektomie und perkutaner Strahlentherapie. (Median 56 Gy, Spanne 50–68 Gy) mit einer Salvage-Oberflächen-Brachytherapie behandelt – 44 % Patientinnen mit makroskopischem Tumor, 17 % in einer R1-Situation und 39 % nach einer R0-Resektion aufgrund von Risikofaktoren. Die applizierte Dosis betrug 50 Gy („high-dose rate“ [HDR] und „pulsed-dose rate“ [PDR]). In 5/23 (22 %) Fällen wurde eine simultane Chemotherapie durchgeführt, bei 20/23 (87 %) Zielvolumina außerdem 2‑mal wöchentlich eine Oberflächenhyperthermie.

Ergebnisse

Das lokalrezidivfreie 5‑Jahres-Überleben betrug 56 %, das krankheitsfreie 5‑Jahres-Überleben 28 % und das 5‑Jahres-Gesamtüberleben 22 %. Bei 17 % der Patientinnen wurden chronische Nebenwirkungen nach den Common Toxicity Criteria (CTC) vom Grad 3 beobachtet, darunter 2/18 Patientinnen (11 %) mit einer Fibrose CTC Grad 3 und eine Patientin (1/18, 6 %) mit einer chronischen Wundheilungsstörung.

Schlussfolgerung

Die Salvage-Brachytherapie beim Thoraxwandrezidiv als Re-Bestrahlung in Verbindung mit Oberflächenhyperthermie stellt eine durchführbare und sichere Behandlung mit guter lokaler Kontrolle und akzeptablem Nebenwirkungsprofil dar.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. 1.

    Buchanan CL, Dorn PL, Fey J, Giron G, Naik A, Mendez J, Murphy C, Sclafani LM (2006) Locoregional recurrence after mastectomy: incidence and outcomes. J Am Coll Surg 203:469–474

    Article  PubMed  Google Scholar 

  2. 2.

    Bedwinek J (1994) Natural history and management of isolated local-regional recurrence following mastectomy. Semin Radiat Oncol 4:260–269

    Article  PubMed  Google Scholar 

  3. 3.

    Karabali-Dalamaga S, Souhami RL, O’Higgins NJ, Soumilas A, Clark CG (1978) Natural history and prognosis of recurrent breast cancer. British Med J 2:730–733

    CAS  Article  Google Scholar 

  4. 4.

    van Tienhoven G, Voogd AC, Peterse JL, Nielsen M, Andersen KW, Mignolet F, Sylvester R, Fentiman IS, van der Schueren E, van Zijl K, Blichert-Toft M, Bartelink H, van Dongen JA (1999) Prognosis after treatment for loco-regional recurrence after mastectomy or breast conserving therapy in two randomised trials (EORTC 10801 and DBCG-82TM). EORTC Breast Cancer Cooperative Group and the Danish Breast Cancer Cooperative Group. Eur J Cancer 35:32–38

    Article  PubMed  Google Scholar 

  5. 5.

    Willner J, Kiricuta IC, Kolbl O (1997) Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Results of univariate and multivariate analysis. Int J Radiat Oncol Biol Phys 37:853–863

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Budach W, Matuschek C, Bolke E, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Piroth MD, Sautter-Bihl ML, Sedlmayer F, Souchon R, Wenz F, Sauer R, Breast Cancer Expert Panel of German Society of Radiation O (2015) DEGRO practical guidelines for radiotherapy of breast cancer V: Therapy for locally advanced and inflammatory breast cancer, as well as local therapy in cases with synchronous distant metastases. Strahlenther Onkol 191:623–633

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Strnad V, Lotter M, Kreppner S, Fietkau R (2015) Reirradiation for recurrent head and neck cancer with salvage interstitial pulsed-dose-rate brachytherapy: Long-term results. Strahlenther Onkol 191:495–500

    Article  PubMed  Google Scholar 

  8. 8.

    Lahmer G, Lotter M, Kreppner S, Fietkau R, Strnad V (2013) Protocol-based image-guided salvage brachytherapy. Early results in patients with local failure of prostate cancer after radiation therapy. Strahlenther Onkol 189:668–674

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Mason KA, Thames HD, Ochran TG, Ruifrok AC, Janjan N (1994) Comparison of continuous and pulsed low dose rate brachytherapy: biological equivalence in vivo. Int J Radiat Oncol Biol Phys 28:667–671

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Lettmaier S, Lotter M, Kreppner S, Strnad A, Fietkau R, Strnad V (2012) Long term results of a prospective dose escalation phase-II trial: interstitial pulsed-dose-rate brachytherapy as boost for intermediate- and high-risk prostate cancer. Radiother Oncol 104:181–186

    Article  PubMed  Google Scholar 

  11. 11.

    Common Terminology Criteria for Adverse Events, Version 3.0. http://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/ctcaev3.pdf. Accessed 5 Dec 2014

  12. 12.

    Kim K, Chie EK, Han W, Noh DY, Oh DY, Im SA, Kim TY, Bang YJ, Ha SW (2010) Prognostic factors affecting the outcome of salvage radiotherapy for isolated locoregional recurrence after mastectomy. Am J Clin Oncol 33:23–27

    Article  PubMed  Google Scholar 

  13. 13.

    Harms W, Krempien R, Hensley FW, Berns C, Wannenmacher M, Fritz P (2001) Results of chest wall reirradiation using pulsed-dose-rate (PDR) brachytherapy molds for breast cancer local recurrences. Int J Radiat Oncol Biol Phys 49:205–210

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Jones EL, Oleson JR, Prosnitz LR, Samulski TV, Vujaskovic Z, Yu D, Sanders LL, Dewhirst MW (2005) Randomized trial of hyperthermia and radiation for superficial tumors. J Clin Oncol 23:3079–3085

    Article  PubMed  Google Scholar 

  15. 15.

    Phromratanapongse P, Steeves RA, Severson SB, Paliwal BR (1991) Hyperthermia and irradiation for locally recurrent previously irradiated breast cancer. Strahlenther Onkol 167:93–97

    CAS  PubMed  Google Scholar 

  16. 16.

    van der Zee J, van der Holt B, Rietveld PJ, Helle PA, Wijnmaalen AJ, van Putten WL, van Rhoon GC (1999) Reirradiation combined with hyperthermia in recurrent breast cancer results in a worthwhile local palliation. Br J Cancer 79:483–490

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Harms W, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Krug D, Piroth MD, Sautter-Bihl ML, Sedlmayer F, Souchon R, Wenz F, Sauer R, Breast Cancer Expert Panel of the German Society of Radiation O (2016) DEGRO practical guidelines for radiotherapy of breast cancer VI: therapy of locoregional breast cancer recurrences. Strahlenther Onkol 192:199–208

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Datta NR, Puric E, Klingbiel D, Gomez S, Bodis S (2016) Hyperthermia and radiation therapy in locoregional recurrent breast cancers: a systematic review and meta-analysis. Int J Radiat Oncol Biol Phys 94:1073–1087

    Article  PubMed  Google Scholar 

  19. 19.

    Linthorst M, van Geel AN, Baaijens M, Ameziane A, Ghidey W, van Rhoon GC, van der Zee J (2013) Re-irradiation and hyperthermia after surgery for recurrent breast cancer. Radiother Oncol 109:188–193

    Article  PubMed  Google Scholar 

  20. 20.

    Linthorst M, Baaijens M, Wiggenraad R, Creutzberg C, Ghidey W, van Rhoon GC, van der Zee J (2015) Local control rate after the combination of re-irradiation and hyperthermia for irresectable recurrent breast cancer: Results in 248 patients. Radiother Oncol 117:217–222

    Article  PubMed  Google Scholar 

  21. 21.

    Vernon CC, Hand JW, Field SB, Machin D, Whaley JB, van der Zee J, van Putten WL, van Rhoon GC, van Dijk JD, Gonzalez Gonzalez D, Liu FF, Goodman P, Sherar M (1996) Radiotherapy with or without hyperthermia in the treatment of superficial localized breast cancer: results from five randomized controlled trials. International Collaborative Hyperthermia Group. Int J Radiat Oncol Biol Phys 35:731–744

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Friedel G, Kuipers T, Dippon J, Al-Kammash F, Walles T, Kyriss T, Veit S, Greulich M, Steger V (2008) Full-thickness resection with myocutaneous flap reconstruction for locally recurrent breast cancer. Ann Thorac Surg 85:1894–1900

    Article  PubMed  Google Scholar 

  23. 23.

    Pameijer CR, Smith D, McCahill LE, Bimston DN, Wagman LD, Ellenhorn JD (2005) Full-thickness chest wall resection for recurrent breast carcinoma: an institutional review and meta-analysis. Am Surg 71:711–715

    PubMed  Google Scholar 

  24. 24.

    Lindford AJ, Jahkola TA, Tukiainen E (2013) Late results following flap reconstruction for chest wall recurrent breast cancer. JPRAS 66:165–173

    CAS  PubMed  Google Scholar 

  25. 25.

    Henderson MA, Burt JD, Jenner D, Crookes P, Bennett RC (2001) Radical surgery with omental flap for uncontrolled locally recurrent breast cancer. ANZ J Surg 71:675–679

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Levy Faber D, Fadel E, Kolb F, Delaloge S, Mercier O, Mussot S, Fabre D, Dartevelle P (2013) Outcome of full-thickness chest wall resection for isolated breast cancer recurrence. Eur J Cardio Thorac Surg 44:637–642

    Article  Google Scholar 

  27. 27.

    van der Pol CC, van Geel AN, Menke-Pluymers MB, Schmitz PI, Lans TE (2009) Prognostic factors in 77 curative chest wall resections for isolated breast cancer recurrence. Ann Surg Oncol 16:3414–3421

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Warzelhan J, Stoelben E, Imdahl A, Hasse J (2001) Results in surgery for primary and metastatic chest wall tumors. Eur J Cardio Thorac Surg 19:584–588

    CAS  Article  Google Scholar 

  29. 29.

    Downey RJ, Rusch V, Hsu FI, Leon L, Venkatraman E, Linehan D, Bains M, van Zee K, Korst R, Ginsberg R (2000) Chest wall resection for locally recurrent breast cancer: is it worthwhile? J Thorac Cardiovasc Surg 119:420–428

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Hanagiri T, Nozoe T, Yoshimatsu T, Mizukami M, Ichiki Y, Sugaya M, Yasuda M, Takenoyama M, Sugio K, Yasuda H, Yasumoto K (2008) Surgical treatment for chest wall invasion due to the local recurrence of breast cancer. Breast Cancer 15:298–302

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Prof. V. Strnad MD.

Ethics declarations

Conflict of interest

A. Auoragh, V. Strnad, O.J. Ott, M.W. Beckmann, and R. Fietkau declare that they have no competing interests.

Ethical standards

This article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Auoragh, A., Strnad, V., Ott, O.J. et al. Re-irradiation of the chest wall for local breast cancer recurrence. Strahlenther Onkol 192, 617–623 (2016). https://doi.org/10.1007/s00066-016-1010-z

Download citation

Keywords

  • Radiotherapy
  • Quality of life
  • Hyperthermia, induced
  • Neoplasm recurrence, local
  • Mastectomy

Schlüsselwörter

  • Strahlentherapie
  • Lebensqualität
  • Induzierte Hyperthermie
  • Lokaler Neoplasierückfall
  • Mastektomie