- Email: [email protected]
2–42 Radiation-Induced Malignancies Following Radiotherapy for Breast Cancer
stage breast cancer: Updated results of a prospective randomized trial (abstract 4). Int J Radiat Oncol Biol Phys 51(Suppl. 1):2-3, 2001.
of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst 96:115-121, 2004.
9. Hartsell WF, Recine DC, Griem KL, et al: Delaying the initiation of intact breast irradiation for patients with lymph node positive breast cancer increases the risk of local recurrence. Cancer 76:2497-2503, 1995.
11. Rouëssé J, Cvitkovic F, De Lalande B, et al: Concomitant or sequential chemo-radiotherapy (CRT) in operable breast cancer. Final results of a French multicentric phase III study (abstract 649). Breast Cancer Res Treat 76:S160, 2002.
10. Vinh-Hung V, Verschraegen C: Breastconserving surgery with or without radiotherapy: Pooled-analysis for risks
12. Calais G, Serin D, Fourquet A, et al: Randomized study comparing adjuvant radiotherapy (RT) with concomi-
2–42
thyroid gland; malignant melanoma; myeloid leukemia; or second primary breast cancer. Findings.—Compared with the nonRT group, patients who had undergone RT for their primary breast cancer were at significantly elevated risk for lung cancer at 10-14 years after the initial breast cancer diagnosis (relative risk [RR], 1.62; 95% confidence interval [CI], 1.05-2.54) and at 15+ years after the initial breast cancer diagnosis (RR, 1.49; 95% CI, 1.05-2.14). Patients who had undergone RT were also at elevated risk of myeloid leukemia at 1-5 years after the initial breast cancer diagnosis (RR, 2.99; 95% CI, 1.13-9.33) and of esophageal cancer at 15+ years after the initial breast cancer diagnosis (RR, 2.19; 95% CI, 1.10-4.62). They were also at higher risk of developing a second breast cancer at 5-10 years (RR, 1.34; 95% CI, 1.10-1.63) and at 15+ years after the initial breast cancer diagnosis (RR, 1.26; 95% CI, 1.00-1.59). Conclusions.—Although many genetic and environmental factors influence the development of cancer, the excess of second cancers among women given RT in this study suggests a causal role for RT in these long-term survivors of breast cancer. The risks of developing certain second cancers (lung, esophageal, or second breast cancer) were elevated at 15+ years after diagnosis of the initial
Radiation-Induced Malignancies Following Radiotherapy for Breast Cancer Roychoudhuri R, Evans H, Robinson D, et al (Guy’s King’s and St. Thomas School of Medicine, London) Br J Cancer 91:868-872, 2004
Background.—The benefits of radiation therapy (RT) for patients with breast cancer are thought to outweigh the risks of developing radiation-induced cancer. Still, the risks of a second malignancy in breast cancer survivors who underwent RT cannot be ignored, particularly as the likelihood of long-term survival after such treatment increases. The purpose of this retrospective review was to identify the incidence of certain second cancers in breast cancer survivors who underwent RT in comparison with that among breast-cancer survivors who did not undergo RT. Methods.—The Thames Cancer Registry was used to collect data on 64,782 women diagnosed with breast cancer between January 1961 and December 2000. All subjects had undergone surgery for their first breast cancer; 33,763 women had received RT and 31,019 had not (nonRT group). The Registry was searched to identify second cancers of the lung, colon, esophagus, or
tant chemotherapy (CT) versus sequential treatment after conservative surgery for patients with stages I and II breast carcinoma (abstract 95). Int J Radiat Oncol Biol Phys 54(Suppl. 2):57-58, 2002.
breast cancer. Still, the incidence of second cancer was fairly low overall, and the excess risk of second cancer associated with RT, in absolute terms, was only about 160 cases. Thus, the benefits of RT for patients with breast cancer still outweigh the risks of developing subsequent second cancers. This study of the incidence of second malignancies was based on tumor registry data from a large number of patients, thus inspiring confidence in the results and conclusions. However, population-based tumor registries may not include many details about initial treatment and subsequent tumors. For example, in this report, no data were presented on the type of RT given (such as beam energy), the volumes and sites irradiated, or the doses delivered. Nor do we know the doses received by the sites at which second malignancies subsequently developed. Similarly, for second primary lung cancer and esophageal cancer, no data regarding the exact locations of the new tumors were presented. It would have been interesting to know whether the esophageal and lung malignancies developed mainly in patients who received irradiation to the internal mammary and supraclavicular regions and whether the esophageal cancers were in the thoracic or cervical esophagus. ®
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
191 191
Even considering an excess risk of second malignancies related to RT for breast cancer, that risk, reported in absolute numbers, was about 160 cancers per 34,000 patients who underwent RT. Thus, the additional risk of developing
a new cancer from the RT given after surgery for breast cancer was less than 1%. I agree with the authors that this small risk is greatly offset by the benefits of adjuvant RT for breast cancer. Also, improvements in the techniques
for delivering RT should mean that much smaller volumes of lung and esophagus are exposed to high doses of radiation than was the case in the past. M. Deutsch, MD
ANNOTATED BIBLIOGRAPHY Acute Toxicity of High-Dose-Rate Intracavitary Brachytherapy With the MammoSite Applicator in Patients With Early-Stage Breast Cancer
site dry, and possibly the addition of prophylactic antibiotics, can significantly improve infection rates. M. Keisch, MD
Richards GM, Berson AM, Rescigno J, et al
References
Ann Surg Oncol 11:739-746, 2004 This paper reports another valuable early experience with the MammoSite device. Other small studies with short follow-up have been published showing similar results.1,2 Overall, the early experiences have been positive, with modest acute reactions (mostly skin erythema) and good early cosmesis. Notably, all results published to date have shown wound infection rates higher than the 3.7% reported in the initial Food and Drug Administration trial3 and have ranged from 6% to 16%. Unpublished findings from the American Society of Breast Surgeons MammoSite Registry trial of this device also indicate slightly higher infection rates and suggest that meticulous wound care, including careful dressing changes, care in keeping the
1. Dowlatshahi K, Snider H, Gittleman M, et al: Early experience with balloon brachytherapy for breast cancer Arch Surg 139:603-607, 2004. 2. Harper JL, Jenrette JM, Vanek KN, et al: Acute complications of mammosite brachytherapy: a single institution’s initial clinical experience. Int J Radiat Oncol Biol Phys 61:169-174, 2005. 3. Keisch M, Vicini F, Kuske R, et al: Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast conserving therapy. Int J Radiat Oncol Biol Phys 55:289-293, 2003.
COSMETIC AND RECONSTRUCTIVE SURGERY 2–43
Botulinum Toxin Infiltration for Pain Control After Mastectomy and Expander Reconstruction Layeeque R, Hochberg J, Siegel E, et al (Univ of Arkansas, Little Rock; Central Arkansas Veterans Hosp System, Little Rock) Ann Surg 240:608-614, 2004
Background.—Immediate reconstruction of the breast with subpectoral tissue expansion is a well-established
192 192
®
technique that provides satisfactory cosmetic results after mastectomy. However, tissue expansion is associated with significant pain and discomfort immediately after surgery and during the subsequent saline expansion phase. Long-term arm and shoulder pain has been reported in up to 50% of patients so treated at 1 year after surgery. Severe pain during subpectoral expansion can result in inadequate expansion or surgical removal of expanders and thus abandonment of reconstruction. The purpose of the present study was to investigate the hypothesis
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
that infiltration of the chest wall musculature after mastectomy with botulinum toxin (BT) would result in prolonged inhibition of muscle spasm and postoperative pain, thereby facilitating breast reconstruction with tissue expanders. Methods.—This prospective study was conducted with all patients undergoing mastectomy with tissue expander placement over a 2-year period between 2001 and 2003. Patients were nonrandomly assigned to the treatment group (infiltration with 100 units of diluted BT into the pectoralis major, serratus anterior,
of ipsilateral breast tumor recurrence and mortality. J Natl Cancer Inst 96:115-121, 2004.
9. Hartsell WF, Recine DC, Griem KL, et al: Delaying the initiation of intact breast irradiation for patients with lymph node positive breast cancer increases the risk of local recurrence. Cancer 76:2497-2503, 1995.
11. Rouëssé J, Cvitkovic F, De Lalande B, et al: Concomitant or sequential chemo-radiotherapy (CRT) in operable breast cancer. Final results of a French multicentric phase III study (abstract 649). Breast Cancer Res Treat 76:S160, 2002.
10. Vinh-Hung V, Verschraegen C: Breastconserving surgery with or without radiotherapy: Pooled-analysis for risks
12. Calais G, Serin D, Fourquet A, et al: Randomized study comparing adjuvant radiotherapy (RT) with concomi-
2–42
thyroid gland; malignant melanoma; myeloid leukemia; or second primary breast cancer. Findings.—Compared with the nonRT group, patients who had undergone RT for their primary breast cancer were at significantly elevated risk for lung cancer at 10-14 years after the initial breast cancer diagnosis (relative risk [RR], 1.62; 95% confidence interval [CI], 1.05-2.54) and at 15+ years after the initial breast cancer diagnosis (RR, 1.49; 95% CI, 1.05-2.14). Patients who had undergone RT were also at elevated risk of myeloid leukemia at 1-5 years after the initial breast cancer diagnosis (RR, 2.99; 95% CI, 1.13-9.33) and of esophageal cancer at 15+ years after the initial breast cancer diagnosis (RR, 2.19; 95% CI, 1.10-4.62). They were also at higher risk of developing a second breast cancer at 5-10 years (RR, 1.34; 95% CI, 1.10-1.63) and at 15+ years after the initial breast cancer diagnosis (RR, 1.26; 95% CI, 1.00-1.59). Conclusions.—Although many genetic and environmental factors influence the development of cancer, the excess of second cancers among women given RT in this study suggests a causal role for RT in these long-term survivors of breast cancer. The risks of developing certain second cancers (lung, esophageal, or second breast cancer) were elevated at 15+ years after diagnosis of the initial
Radiation-Induced Malignancies Following Radiotherapy for Breast Cancer Roychoudhuri R, Evans H, Robinson D, et al (Guy’s King’s and St. Thomas School of Medicine, London) Br J Cancer 91:868-872, 2004
Background.—The benefits of radiation therapy (RT) for patients with breast cancer are thought to outweigh the risks of developing radiation-induced cancer. Still, the risks of a second malignancy in breast cancer survivors who underwent RT cannot be ignored, particularly as the likelihood of long-term survival after such treatment increases. The purpose of this retrospective review was to identify the incidence of certain second cancers in breast cancer survivors who underwent RT in comparison with that among breast-cancer survivors who did not undergo RT. Methods.—The Thames Cancer Registry was used to collect data on 64,782 women diagnosed with breast cancer between January 1961 and December 2000. All subjects had undergone surgery for their first breast cancer; 33,763 women had received RT and 31,019 had not (nonRT group). The Registry was searched to identify second cancers of the lung, colon, esophagus, or
tant chemotherapy (CT) versus sequential treatment after conservative surgery for patients with stages I and II breast carcinoma (abstract 95). Int J Radiat Oncol Biol Phys 54(Suppl. 2):57-58, 2002.
breast cancer. Still, the incidence of second cancer was fairly low overall, and the excess risk of second cancer associated with RT, in absolute terms, was only about 160 cases. Thus, the benefits of RT for patients with breast cancer still outweigh the risks of developing subsequent second cancers. This study of the incidence of second malignancies was based on tumor registry data from a large number of patients, thus inspiring confidence in the results and conclusions. However, population-based tumor registries may not include many details about initial treatment and subsequent tumors. For example, in this report, no data were presented on the type of RT given (such as beam energy), the volumes and sites irradiated, or the doses delivered. Nor do we know the doses received by the sites at which second malignancies subsequently developed. Similarly, for second primary lung cancer and esophageal cancer, no data regarding the exact locations of the new tumors were presented. It would have been interesting to know whether the esophageal and lung malignancies developed mainly in patients who received irradiation to the internal mammary and supraclavicular regions and whether the esophageal cancers were in the thoracic or cervical esophagus. ®
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
191 191
Even considering an excess risk of second malignancies related to RT for breast cancer, that risk, reported in absolute numbers, was about 160 cancers per 34,000 patients who underwent RT. Thus, the additional risk of developing
a new cancer from the RT given after surgery for breast cancer was less than 1%. I agree with the authors that this small risk is greatly offset by the benefits of adjuvant RT for breast cancer. Also, improvements in the techniques
for delivering RT should mean that much smaller volumes of lung and esophagus are exposed to high doses of radiation than was the case in the past. M. Deutsch, MD
ANNOTATED BIBLIOGRAPHY Acute Toxicity of High-Dose-Rate Intracavitary Brachytherapy With the MammoSite Applicator in Patients With Early-Stage Breast Cancer
site dry, and possibly the addition of prophylactic antibiotics, can significantly improve infection rates. M. Keisch, MD
Richards GM, Berson AM, Rescigno J, et al
References
Ann Surg Oncol 11:739-746, 2004 This paper reports another valuable early experience with the MammoSite device. Other small studies with short follow-up have been published showing similar results.1,2 Overall, the early experiences have been positive, with modest acute reactions (mostly skin erythema) and good early cosmesis. Notably, all results published to date have shown wound infection rates higher than the 3.7% reported in the initial Food and Drug Administration trial3 and have ranged from 6% to 16%. Unpublished findings from the American Society of Breast Surgeons MammoSite Registry trial of this device also indicate slightly higher infection rates and suggest that meticulous wound care, including careful dressing changes, care in keeping the
1. Dowlatshahi K, Snider H, Gittleman M, et al: Early experience with balloon brachytherapy for breast cancer Arch Surg 139:603-607, 2004. 2. Harper JL, Jenrette JM, Vanek KN, et al: Acute complications of mammosite brachytherapy: a single institution’s initial clinical experience. Int J Radiat Oncol Biol Phys 61:169-174, 2005. 3. Keisch M, Vicini F, Kuske R, et al: Initial clinical experience with the MammoSite breast brachytherapy applicator in women with early-stage breast cancer treated with breast conserving therapy. Int J Radiat Oncol Biol Phys 55:289-293, 2003.
COSMETIC AND RECONSTRUCTIVE SURGERY 2–43
Botulinum Toxin Infiltration for Pain Control After Mastectomy and Expander Reconstruction Layeeque R, Hochberg J, Siegel E, et al (Univ of Arkansas, Little Rock; Central Arkansas Veterans Hosp System, Little Rock) Ann Surg 240:608-614, 2004
Background.—Immediate reconstruction of the breast with subpectoral tissue expansion is a well-established
192 192
®
technique that provides satisfactory cosmetic results after mastectomy. However, tissue expansion is associated with significant pain and discomfort immediately after surgery and during the subsequent saline expansion phase. Long-term arm and shoulder pain has been reported in up to 50% of patients so treated at 1 year after surgery. Severe pain during subpectoral expansion can result in inadequate expansion or surgical removal of expanders and thus abandonment of reconstruction. The purpose of the present study was to investigate the hypothesis
Breast Diseases: A Year Book Quarterly Vol 16 No 2 2005
that infiltration of the chest wall musculature after mastectomy with botulinum toxin (BT) would result in prolonged inhibition of muscle spasm and postoperative pain, thereby facilitating breast reconstruction with tissue expanders. Methods.—This prospective study was conducted with all patients undergoing mastectomy with tissue expander placement over a 2-year period between 2001 and 2003. Patients were nonrandomly assigned to the treatment group (infiltration with 100 units of diluted BT into the pectoralis major, serratus anterior,