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X-ray treatment of inoperable cancer of the breast
INOPERABLE
CANCER
OF
THE
BREAST
347
X - R A Y T R E A T M E N T OF I N O P E R A B L E C A N C E R OF THE B R E A S T B-z WLADYSLAW JASINISKI, ANDRZEJ HLINIAK, JEREMI ~WII~CKI, AN, ZOFIA WII~CKOWSKA X-RAY THERAPY DEPARTMENT, INSTITUTE OF ONCOLOGY, GLIW1CE, POLAND
X-RAY treatment of inoperable cancer of the breast is a difficult task owing to the necessity of uniform irradiation with large doses of an extensive and irregular mass of tissue represented by the breast, together with the thoracic wall and the axillary and supraclavicular regions. In addition, th e difficulties are increased by the fact that the size of this block of tissues varies considerably with particular patients ; further complications arise from the necessity of protecting the lungs against the deleterious effects of X-rays. Attempts to find the best possible solution of the difficulties encountered are worth while, because inoperable cancer of the breast is fairly frequent and, in many cases, efficient treatment may secure to the patient many years of survival in reasonable health. Roentgentherapy in conjunction with hormonal treatment extends the useful scope of radiotherapeutic methods; positive results are obtained even in a number Of patients with disseminated cancer.
MATERIAL Between i947 and I95O , 233 patients were treated for cancer of the breast at the Institute of Oncology at Gliwice ; these included I 14 patients suffering from inoperable breast cancer (Stages I I I and IV) treated with X rays alone. According to the classification current at the Institute, Stage I I I includes patients in whom : (i) The tumour, independently of its size, is immobile in relation to the pectoral muscle ; (2) T h e skin is Gedematous (peau d'orange); and (3) Axillary lymphatic glands show clinical signs of metastases. In Stage IV, patients are included who show further progress of the disease, namely: (I) Reduced mobility of the tumour in relation to the thoracic wall ; (2) Extensive lesions of the skin (ulceration or metastatic nodules) ; (3) A fixed metastasis or metastases in the axilla ; and (4) Distant metastases (infra- and supraclavicular regions, the other breast or axilla, inner organs, bones). Moreover, in the inoperable group there were included patients submitted to non-radical operation outside the Institute more than two weeks earlier. In agreement with the classification referred to above, our material included ; 32 patients in Stage I I I , 69 patients in Stage IV, and 13 patients admitted after a non-radical operation performed outside the Institute. In 14 of the cases involved no confirmation of the diagnosis was obtained by either microscopic examination, post-mortem, or fatal termination of the disease ; these cases make up 28 per cent of the entire material. Nevertheless, in each case, consultative examination of the patient by several experienced physicians, and the advanced stage of the disease reduced the chances of diagnostic errors to a minimum. X-RAY TREATMENT T h e technique of irradiation was developed over a number of years ; in the earlier period it differed little from the present form further described below. T h e breast, together with the axillary region and parasternal lymphatic glands of the side affected is irradiated from three portals: from the lateral side, from the medial side, and from below. All three fields are irradiated through applicators 15 × 20 cm. in size. The lateral and medial beams penetrate the axilla and the breast at such an angle as to reduce irradiation of the
348
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
pulmonary tissue to a minimum. The beam directed from below strikes the axilla after penetrating the breast and runs symmetrically between the lateral and medial beams. The essential difficulty presented by the irradiation method in question lies in the fact that precisely the same conditions must be reproduced each time and with regard to every patient. In order to achieve this the patient is placed each time in the same position, lying supine on a flat table, with the head inclined towards the non-treated side ; the hand is placed under the head with the elbow pointing outwards. For properly guiding the X-ray beam a special directing device fitted on to the tube is used. In addition, the inclination and rotation of the tube are noted and subsequently reproduced each time. The supra- and infraclavicular regions are irradiated separately. Conditions of irradiation, 2oo kV. ; filter, 0"2 mm. Sn q-0"25 mm. Cu q-I-O mm. A1, H V L = 1"43 ram. Cu, output 25 r/rain. Each day two fields are irradiated in succession, the dosage amounting to 250 r as measured on the skin surface. Treatment is continued until a total dose is attained of between 4500 r and 60oo r/tumour, i.e., as calculated with reference to a point corresponding to the central part of the breast and to the central part of the axilla. T h e supraclavicular region receives a dose of 450o r as measured on the skin surface. T h e treatment lasts about five weeks. Owing to the skin reaction, resulting in each case in moist desquamation of the epithelium, we use no dispersing material to fill the space between the tube and the skin. This fact must have an adverse effect oft the precision of the dosage. Consequently, for a series of 5 ° patients, we made paraffin-wax phantoms in order to determine the actual tumour dose. The results obtained were corrected by a coefficient resulting from differences between the physical properties of paraffin wax and those of human tissues. T h e results obtained demonstrated that the precision of clinical calculations was not satisfactory since the error was within i io per cent in a mere 38 per cent of the cases. I n 56 per cent of the cases the error exceeded - - i o per cent, and in 3 cases the error exceeded q - i o per cent ; the latter patients received a dose amounting to 7000 r per tumour, but none of them showed postirradiation complications in the form of necroses.
R E S U L T S OF T R E A T M E N T T h e very advanced stage of the disease in all the patients included in the series in question warrants no prognosis of definite cure. A positive result can only be temporary, even in spite of the absence of any symptoms over a period of many years. Of all the patients in question who were treated with X rays for inoperable cancer of the breast, 2o per cent survived 5 years after the treatment was concluded without symptoms of recurrence or metastases. Twenty-five per cent of patients survived 5 years irrespective of the condition of health (clinically cured with disease present). P R O G R E S S OF T R E A T M E N T A N D C O M P L I C A T I O N S In all patients the skin reaction takes the form of moist desquamation of the epithelium and lasts about four weeks. This reaction is quite painful and there is frequently a concomitant slight increase of body temperature above normal. Infectious complications were nil. In 24 cases (2i per cent) we found objective and subjective symptoms of pulmonary tissue reaction in the form of a slight cough and spitting, which lasted less than 6 months after the termination of treatment, and in the form of reduced transparency of the pulmonary tissue on the treated side, revealed by radiographs. I n 3 cases (2. 7 per cent) there were complications in the form of necrosis of the soft tissues, but this Was cured by conservative treatment.
INOPERABLE
CANCER
OF
THE
BREAST
349
SUMMARY The results of treatment of 114 cases of inoperable cancer of the breast (1947-5o) treated by X rays are presented. T u m o u r dose was 45oo-6000 r. In 2. 7 per cent of cases necrosis of soft tissues was noted. Twenty per cent of patients have survived 5 years after treatment without signs of relapse or metastases.
BOOK R E V I E W NEW REPORT
RADIATION
HANDBOOK
OF T H E I N T E R N A T I O N A L C O M M I S S I O N UNITS AND MEASUREMENTS
ON RADIOLOGICAL
THE 1956 recommendations of the International Commission on Radiological Units and Measurements (ICRU) have been published as National Bureau of Standards Handbook 62. This report covers the recommendations of the I C R U as agreed upon at its meetings in Geneva in April, i956,* and replaces its earlier report issued in 1953. ~ The new report includes an extensive amount of basic information and data necessary to make radiation dose measurements in energy units (rads), and to convert data expressed in roentgens to the equivalent in energy units. The first of the four chapters into which the Handbook is divided contains a comprehensive discussion of radiological quantities, units, and symbols. This includes some pertinent considerations with regard to the parameters involved in the various definitions. In Chapter II, guidance is provided for the clinical application of absorbed dose measurements, and examples show how the measurements may be used in practical applications. Chapter I I I presents a detailed treatment of the physical aspects of absorbed dose determination. This covers methods of calculating absorbed dose from measured ionization ; the necessary physical data are provided in the form of curves or tables. There is also a discussion of the problem of dosimetry accuracy in X- and gamma-ray therapy. Reports of the subcommittees are given in the final chapter. The results of several recent international comparisons relating to both X-rays and radio-activity are described. Chapter IV also includes lists of the primary standards, X-ray standards, and radio-activity standards available in various countries and laboratories, as well as an extensive bibliography covering much of the subject matter contained in the report. A suggested outline of an international treatment summary form is given in one of the appendices. Copies of this publication may be obtained from the Superintendent of Documents, U.S. Government Printing Office, Washington 25, D.C., at a cost of 4 ° cents each. * See Meetings on radiation units and protection, N.B.S. Tech. News Bull., (I956), 40, July, io2. t Recommendations of the International Commission on Radiological Units, Amer. J. Roentgenol., (I954,) 7I, January, i39.
CANCER
OF
THE
BREAST
347
X - R A Y T R E A T M E N T OF I N O P E R A B L E C A N C E R OF THE B R E A S T B-z WLADYSLAW JASINISKI, ANDRZEJ HLINIAK, JEREMI ~WII~CKI, AN, ZOFIA WII~CKOWSKA X-RAY THERAPY DEPARTMENT, INSTITUTE OF ONCOLOGY, GLIW1CE, POLAND
X-RAY treatment of inoperable cancer of the breast is a difficult task owing to the necessity of uniform irradiation with large doses of an extensive and irregular mass of tissue represented by the breast, together with the thoracic wall and the axillary and supraclavicular regions. In addition, th e difficulties are increased by the fact that the size of this block of tissues varies considerably with particular patients ; further complications arise from the necessity of protecting the lungs against the deleterious effects of X-rays. Attempts to find the best possible solution of the difficulties encountered are worth while, because inoperable cancer of the breast is fairly frequent and, in many cases, efficient treatment may secure to the patient many years of survival in reasonable health. Roentgentherapy in conjunction with hormonal treatment extends the useful scope of radiotherapeutic methods; positive results are obtained even in a number Of patients with disseminated cancer.
MATERIAL Between i947 and I95O , 233 patients were treated for cancer of the breast at the Institute of Oncology at Gliwice ; these included I 14 patients suffering from inoperable breast cancer (Stages I I I and IV) treated with X rays alone. According to the classification current at the Institute, Stage I I I includes patients in whom : (i) The tumour, independently of its size, is immobile in relation to the pectoral muscle ; (2) T h e skin is Gedematous (peau d'orange); and (3) Axillary lymphatic glands show clinical signs of metastases. In Stage IV, patients are included who show further progress of the disease, namely: (I) Reduced mobility of the tumour in relation to the thoracic wall ; (2) Extensive lesions of the skin (ulceration or metastatic nodules) ; (3) A fixed metastasis or metastases in the axilla ; and (4) Distant metastases (infra- and supraclavicular regions, the other breast or axilla, inner organs, bones). Moreover, in the inoperable group there were included patients submitted to non-radical operation outside the Institute more than two weeks earlier. In agreement with the classification referred to above, our material included ; 32 patients in Stage I I I , 69 patients in Stage IV, and 13 patients admitted after a non-radical operation performed outside the Institute. In 14 of the cases involved no confirmation of the diagnosis was obtained by either microscopic examination, post-mortem, or fatal termination of the disease ; these cases make up 28 per cent of the entire material. Nevertheless, in each case, consultative examination of the patient by several experienced physicians, and the advanced stage of the disease reduced the chances of diagnostic errors to a minimum. X-RAY TREATMENT T h e technique of irradiation was developed over a number of years ; in the earlier period it differed little from the present form further described below. T h e breast, together with the axillary region and parasternal lymphatic glands of the side affected is irradiated from three portals: from the lateral side, from the medial side, and from below. All three fields are irradiated through applicators 15 × 20 cm. in size. The lateral and medial beams penetrate the axilla and the breast at such an angle as to reduce irradiation of the
348
JOURNAL
OF
THE
FACULTY
OF
RADIOLOGISTS
pulmonary tissue to a minimum. The beam directed from below strikes the axilla after penetrating the breast and runs symmetrically between the lateral and medial beams. The essential difficulty presented by the irradiation method in question lies in the fact that precisely the same conditions must be reproduced each time and with regard to every patient. In order to achieve this the patient is placed each time in the same position, lying supine on a flat table, with the head inclined towards the non-treated side ; the hand is placed under the head with the elbow pointing outwards. For properly guiding the X-ray beam a special directing device fitted on to the tube is used. In addition, the inclination and rotation of the tube are noted and subsequently reproduced each time. The supra- and infraclavicular regions are irradiated separately. Conditions of irradiation, 2oo kV. ; filter, 0"2 mm. Sn q-0"25 mm. Cu q-I-O mm. A1, H V L = 1"43 ram. Cu, output 25 r/rain. Each day two fields are irradiated in succession, the dosage amounting to 250 r as measured on the skin surface. Treatment is continued until a total dose is attained of between 4500 r and 60oo r/tumour, i.e., as calculated with reference to a point corresponding to the central part of the breast and to the central part of the axilla. T h e supraclavicular region receives a dose of 450o r as measured on the skin surface. T h e treatment lasts about five weeks. Owing to the skin reaction, resulting in each case in moist desquamation of the epithelium, we use no dispersing material to fill the space between the tube and the skin. This fact must have an adverse effect oft the precision of the dosage. Consequently, for a series of 5 ° patients, we made paraffin-wax phantoms in order to determine the actual tumour dose. The results obtained were corrected by a coefficient resulting from differences between the physical properties of paraffin wax and those of human tissues. T h e results obtained demonstrated that the precision of clinical calculations was not satisfactory since the error was within i io per cent in a mere 38 per cent of the cases. I n 56 per cent of the cases the error exceeded - - i o per cent, and in 3 cases the error exceeded q - i o per cent ; the latter patients received a dose amounting to 7000 r per tumour, but none of them showed postirradiation complications in the form of necroses.
R E S U L T S OF T R E A T M E N T T h e very advanced stage of the disease in all the patients included in the series in question warrants no prognosis of definite cure. A positive result can only be temporary, even in spite of the absence of any symptoms over a period of many years. Of all the patients in question who were treated with X rays for inoperable cancer of the breast, 2o per cent survived 5 years after the treatment was concluded without symptoms of recurrence or metastases. Twenty-five per cent of patients survived 5 years irrespective of the condition of health (clinically cured with disease present). P R O G R E S S OF T R E A T M E N T A N D C O M P L I C A T I O N S In all patients the skin reaction takes the form of moist desquamation of the epithelium and lasts about four weeks. This reaction is quite painful and there is frequently a concomitant slight increase of body temperature above normal. Infectious complications were nil. In 24 cases (2i per cent) we found objective and subjective symptoms of pulmonary tissue reaction in the form of a slight cough and spitting, which lasted less than 6 months after the termination of treatment, and in the form of reduced transparency of the pulmonary tissue on the treated side, revealed by radiographs. I n 3 cases (2. 7 per cent) there were complications in the form of necrosis of the soft tissues, but this Was cured by conservative treatment.
INOPERABLE
CANCER
OF
THE
BREAST
349
SUMMARY The results of treatment of 114 cases of inoperable cancer of the breast (1947-5o) treated by X rays are presented. T u m o u r dose was 45oo-6000 r. In 2. 7 per cent of cases necrosis of soft tissues was noted. Twenty per cent of patients have survived 5 years after treatment without signs of relapse or metastases.
BOOK R E V I E W NEW REPORT
RADIATION
HANDBOOK
OF T H E I N T E R N A T I O N A L C O M M I S S I O N UNITS AND MEASUREMENTS
ON RADIOLOGICAL
THE 1956 recommendations of the International Commission on Radiological Units and Measurements (ICRU) have been published as National Bureau of Standards Handbook 62. This report covers the recommendations of the I C R U as agreed upon at its meetings in Geneva in April, i956,* and replaces its earlier report issued in 1953. ~ The new report includes an extensive amount of basic information and data necessary to make radiation dose measurements in energy units (rads), and to convert data expressed in roentgens to the equivalent in energy units. The first of the four chapters into which the Handbook is divided contains a comprehensive discussion of radiological quantities, units, and symbols. This includes some pertinent considerations with regard to the parameters involved in the various definitions. In Chapter II, guidance is provided for the clinical application of absorbed dose measurements, and examples show how the measurements may be used in practical applications. Chapter I I I presents a detailed treatment of the physical aspects of absorbed dose determination. This covers methods of calculating absorbed dose from measured ionization ; the necessary physical data are provided in the form of curves or tables. There is also a discussion of the problem of dosimetry accuracy in X- and gamma-ray therapy. Reports of the subcommittees are given in the final chapter. The results of several recent international comparisons relating to both X-rays and radio-activity are described. Chapter IV also includes lists of the primary standards, X-ray standards, and radio-activity standards available in various countries and laboratories, as well as an extensive bibliography covering much of the subject matter contained in the report. A suggested outline of an international treatment summary form is given in one of the appendices. Copies of this publication may be obtained from the Superintendent of Documents, U.S. Government Printing Office, Washington 25, D.C., at a cost of 4 ° cents each. * See Meetings on radiation units and protection, N.B.S. Tech. News Bull., (I956), 40, July, io2. t Recommendations of the International Commission on Radiological Units, Amer. J. Roentgenol., (I954,) 7I, January, i39.