Results of treatment of primary breast carcinoma by radical radiotherapy with artificial pneumothorax

ClinicalRadiology (1986) 37, 313-315 © 1986RoyalCollegeof Radiologists

0009-9260/86/686313502.00

Results of Treatment of Primary Breast Carcinoma by Radical Radiotherapy with Artificial Pneumothorax A. BENGHIAT, C. J. TYRRELL, H. E. DAVIDSON, G. SHEERS* and M. L. FENNER'p

Department of Radiotherapy and Oncology and *Department of Thoracic Medicine, Plymouth General Hospital, Plymouth, Devon One hundred and forty-three w o m e n with primary breast carcinoma were treated by radical radiotherapy associated with artificial pneumothorax to include the breast and lymphatics e n b l o c with large opposed fields. Surgery was restricted to local excision or drill biopsy. Most patients received a tumour dose of 5200-5600 cGy in 19-22 fractions over 4 weeks and were followed up for at least 5 years. Local control was achieved in 87% ofT1, 52% of T 2, 27% of T a and 23% of T 4 tumours. For T 2 tumours local control was greater following excision biopsy (75%) than when surgery was more limited (21%). Acute morbidity was mostly minor and self-limiting. The commonest permanent late complication was restriction of shoulder movement in 20 patients. This method although safe and feasible does not offer significant advantages over conventional techniques.

The variety of techniques used for irradiating the breast and its lymphatics indicates that no single method is entirely satisfactory. The need to avoid the lung has led to the use of multiple fields with the attendant risks of over-dosage or under-dosage at junctions. Bands of fibrosis may develop in areas of overlap to the detriment of the cosmetic result. By inducing an artificial pneumothorax to collapse the lung away from the radiation fields, Fenner (1974) designed a method of en bloc irradiation eliminating the hazards of overlapping fields and also enabling the irradiation of the full thickness of the chest wall to include the intercostal lymphatics, which may be important in the genesis of carcinomatous pleural effusions. This article is dedicated in memory of Dr Matthew Fenner (Fig. 1), as a tribute to his originality and enthusiasm in developing this technique at a time when modern ideas on breast conservation were in their infancy.

Some operable patients who were considered by the referring surgeons to have a poor prognosis were also accepted. All patients were initially assessed by a chest physician (G.S.). Not everyone referred was considered suitable for this technique. In particular, those with preexisting lung disease or pleural adhesions were excluded from entry to this study. Excision biopsy was performed in 27 of 31 T1, and in 32 of 56 T 2 tumours. For large T 2 and inoperable (T 3 and T4) carcinomas, surgery was confined to either drill biopsy or axillary node biopsy. The radiation technique has previously been described in detail ( F e n n e l 1974). Pneumothorax was induced in stages over 2-7 days. The breast, axilla, supraclavicular fossa and internal mammary chain were treated en bloc by large parallel opposed fields and the treatment set-up aided by an individually constructed perspex shell. Tissue compensation was achieved with individually made wax blocks, except for those patients treated at Bristol where wedge filters were used. The adequacy of the pneumothorax was radiographically verified twice weekly and air added when required. After completion of radiotherapy, the lung was allowed to re-expand naturally over several weeks. All the patients were treated on a cobalt-60 unit at extended source-skin distance (100-110 cm) to achieve the necessary field sizes, typically 25 cm × 11 cm. Most women (128) received a minimum tumour dose of between 5200 cGy and 5600 cGy in 19-22 fractions of 260-280 cGy given daily over 4 weeks. The remaining 15 patients received various doses ranging from 3500 cGy in 10 fractions to 6000 cGy in 24 fractions. Eleven of the Bristol patients received a local boost of between 10002000 cGy to the primary site either by photon or electron therapy or with an iridium-wire implant. • Follow-up was for between 5 and 12 years and only three living patients, all with T4 tumours, were lost to follow up before 5 years.

PATIENTS AND M E T H O D S

One hundred and forty-three women aged between 29 and 94 years (median 56 years) were treated in the period 1972-79. One hundred and eight were treated at Plymouth General Hospital until 1976, and 35 at the Bristol Radiotherapy Centre from 1976 to 1979. Fiftyone patients were premenopausal, and 85 postmenopausal. The menopausal status of seven was unrecorded. The distribution of patients by stage is shown in Table 1. The patients were selected for this treatment, especially in the early years, either because they had refused mastectomy or because they were inoperable. tDr Fenner died in 1980.

RESULTS

The local control rate is shown in Table 2. For those patients with T 2tumours, control was markedly better if an excision had been performed (see below). The crude 5-year survival for the whole group was 50%, with 84% for Stage T 1 and 50% for Stage T 2. The projected 10-year survival is shown in Fig. 2. Forty-four patients had a salvage mastectomy for suspected persistent or recurrent disease; of these, 32 remained locally controlled. Recurrent carcinoma was histologically confirmed in 40 of the 44 mastectomy specimens. The cosmetic result was not recorded in 108 patients mainly because of death or recurrent disease. Where this was

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CLINICAL RADIOLOGY

100

80

, %

-

-T1 (n=31) (16}

60

Survival 40

~

20

,,---~T 2

(171

113) ~

,

•

(n=56)

.Y3(n:29) (81

. . . . .

(;IT4 (n=21)

Years Fig. 2 - Survival according to T stage.

seen. Twenty patients developed chronic restriction of the shoulder joint. This was not related to acute shoulder stiffness but was more frequent in those treated at Bristol (10 out of 35) than in the Plymouth patients (10 out of 108). Only five patients developed significant lung contraction. Radionecrosis of bone occurred in three cases: two had fractured ribs (both of whom had received an iridium-wire implant to the primary site) and one patient fractured her clavicle.

Fig. 1 - D r M a t t h e w L. F e n n e r 1929-1980.

assessable, it was judged excellent in 17, good in 15 and poor in three cases. Twenty-six patients developed a malignant pleural effusion. This was ipsilateral in 13 cases, contralateral in six, and bilateral in seven. Acute morbidity was mostly minor. Some patients had transient cough, dyspnoea and pleuritic pain with the pneumothorax and 11 patients developed a brief reactive pleural effusion. After completing radiotherapy three women had a persistent pneumothorax requiring aspiration. Twenty-four patients developed a stiff shoulder which subsided spontaneously within 6 months. Some troublesome permanent late reactions were

Table 1 - TNM stage at presentation

T1 T2 T3 2"4 Tx Total

No

Nla

Nlb

N2

N3

Total

21 32 14 6 1 74

7 10 1 4 22

3 12 12 7 4 38

1 2 4 1 8

1 1

31 56 29 21 6 143

Table 2 - Local control by radiotherapy with artificial pneumothorax

T Stage

No. of pattents

Control (%)

T1 Tz T3 T4 Tx

27/31 29/56 8/29 5/21 4/6

87 52 27 23 66

DISCUSSION

These results show that this technique is feasible and safe. The local control achieved for T 1 tumours (87%) is comparable to that recorded in other series of breast conservation therapy. The control of T 2 tumours overall is disappointing (52%) but it is higher (75%, 24 out of 32 patients) when excision biopsy was performed; after drill or node biopsy local control was achieved in five out of 24 cases (21%). This is in keeping with the results of Calle et al. (1978) who achieved 87% local control in early tumours (those less than 3 cm, Nla) treated by local excision and radiotherapy. They emphasised the importance both of tumour size and excision, as the control for those who did not have a lumpectomy (those greater than 3 cm, o r Nlb) was only 41%. Pierquin etal. (1980) reported local control in 95% of T 1 and in 92% of T 2 tumours at 5 years. Only 20% of the T 2 tumours had been excised and they attribute their results to the use of a high dose of 3700 cGy from an iridium-wire implant following external irradiation of 45 Gy, if an excision had not been performed (Pierquin et al., 1983). Recently, Fisher et al. (1985) showed excellent 5-year results with 92% local control for patients with tumours less than 4 cm treated by segmental mastectomy and radiotherapy. The control of locally advanced tumours (27% for T 3 and 23% for T4) is unsatisfactory. Better results may have been achieved by routinely boosting the dose to the primary site. By adding an interstitial implant, Bruckman et al. (1979) found 76% local control at 5 years in patients with Stage III disease compared with only 41% in those receiving external irradiation alone.

RADICAL RADIOTHERAPY WITH PNEUMOTHORAX FOR BREAST CARCINOMA

Generally the pneumothorax and radiotherapy were well tolerated with self-limiting reactions. The major permanent disability was restriction of the shoulder joint, and though this was more common in those treated at Bristol, it was not related to tumour dose. It seems likely that the use of wedge filters instead of wax compensators led to inhomogeneities in the dose distribution. This series offers an opportunity to investigate the role of the intercostal lymphatics in the causation of carcinomatous pleural effusion. If they provide a channel for the spread of malignant cells to the pleura, then irradiation of the full thickness of the chest wall might be expected to reduce the incidence of ipsilateral effusions. Stoll and Ellis (1953), reporting on 86 patients with breast carcinoma and pleural effusion, recorded ipsilateral effusion in 80%, contralateral in 14% and bilateral in 6%. Porter (1965) also found ipsilateral effusions in 49 of 76 patients (64%). The present series therefore supports the possible role of the intercostal lymphatics in the spread of breast cancer, as the incidence of ipsilateral effusions was reduced to 50% (13 out of 26). However, the numbers are too small to allow any definite conclusion and it is also conceivable that pleural adhesions occurring after re-expansion of the lung may have prevented the accumulation of fluid. In conclusion, this technique provides acceptable therapeutic results for small tumours that are excised, and confirms the poorer local control of larger tumours where a complete excision is not performed. However, it is traumatic and time-consuming with appreciable morbidity and, although conceptually attractive, it does

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not offer any significant advantages over conventional methods of radiotherapy with breast conservation. Acknowledgements.We are grateful to the staff at the Bristol Radiotherapy Centre for permitting access to their records, Mr J. Pearn for statistical assistance and Mrs Pauline Glover for typing the manuscript. We also wish to thank Messrs D Dobson and G. Hodges for constructing the treatment shells and compensators. REFERENCES Bruckman, J. E., Harris, J. R., Levene, M. B., Chaffey, J. T. & Hellman, S. (1979). Results of treating stage III carcinoma of the breast by primary radiation therapy. Cancer, 43, 985-993. Calle, R., Pilleron, J. P., Schlienger, P. & Vilcoq, J. R. (1978) Conservative management of operable breast cancer. Cancer, 42, 2045-2053. Fenner, M. L. (1974). The treatment of primary breast cancer by radical radiotherapy with artificial pneumothorax. Chnical Radiology, 25, 203-210. Fisher, B., Bauer, M., Margolese, R , Polsson, R., Pilch, Y., Redmond, C. et al. (1985). Five-year results of a randomlsed chnlcal trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. New England Journal of Medicine, 312, 665-673. Pierquin, B., Otmezguine, Y. & Lobo, P. A. (1983). Conservative management of breast carcinoma, the Creteil experience. Acta Radiologica Oncology, 22, 101-107. Pierquin, B., Owen, R , Maylin, C., Otmezgulne, Y , Raynal, M., Mueller, W. et al. (1980). Radical radiation therapy of breast cancer. International Journal of Radiation Oncology, Biology, Physics, 6, 17-24. Porter, E H. (1965). Pleural effusion and breast cancer. Brmsh Medical Journal, i, 251-252. Stoll, B. A. & Ellis, F. (1953). Treatment by oestrogens of pulmonary metastases from breast cancer. British Medical Journal, ii, 796800.