Elsevier

Brachytherapy

Volume 17, Issue 2, March–April 2018, Pages 425-431
Brachytherapy

Breast/Soft Tissue
Plesiobrachytherapy for chest wall recurrences of breast cancer after mastectomy and radiotherapy for breast cancer

https://doi.org/10.1016/j.brachy.2017.10.005Get rights and content

Abstract

Purpose

The purpose of the study was to evaluate the results of high-dose-rate plesiobrachytherapy for local relapse after mastectomy and radiotherapy in terms of both local control and survival.

Methods

We reviewed retrospectively 43 patients who experienced a chest wall relapse of breast cancer after local excision (22 patients) or not (21 patients). Patients were treated with an individually designed mold with four to six fractions of 3–6 Gy high-dose-rate brachytherapy, two fractions per week. Mean total dose was 24 Gy.

Results

After surgical resection, the 3- and 5-year local control rates were 80% and 73%, respectively. For nonresectable patients, the overall response rate was 86%, and the 3-year infield local control and chest wall local control were 51% and 26%, respectively. The 5-year survival rate was 50.5% for the whole population, 62% after surgery, and 45.4% for irresectable patients. Acute Grade 2 or 3 toxicity occurred in 43% of the patients, resolving in a few days. Two patients had a local necrosis lasting 3 to 7 months. Late toxicity was observed in 5 patients.

Conclusions

High-dose-rate plesiobrachytherapy is a simple outpatient technique to treat chest wall local relapse of breast cancer. As a reirradiation technique, its tolerance is acceptable. This technique may obtain long-term local control after incomplete surgery; in case of nonresectable disease, a high response rate was observed, which might improve the quality of life of these patients.

Introduction

A local recurrence after mastectomy and radiotherapy is a frequent event in patients treated for node-positive breast cancer. Local relapse can occur in up to 8.1% of cases (1) and is associated with distant metastases development [2], [3]. In prospective Danish studies, the rate of distant metastases after locoregional failures was 80% with a 5-year survival rate of 36% (4). Prognostic factors for distant metastases were initial T and N stages, time interval from mastectomy, and achievement of local control after local relapse [2], [3], [4]. Most of these local relapses are located on the chest wall [5], [6] and if untreated could give pain, bleeding, and infection, with quality of life impairment. Moreover, psychological distress often accompanies this local evolution. Thus, palliation is an important goal in the treatment of this disease.

For local recurrence after mastectomy and radiotherapy, the treatment options are limited. If a complete resection is feasible, surgery must be accomplished (7). But some extensive chest wall relapses are nonresectable or need complex plastic surgery to cover the parietal defect. Reirradiation with or without hyperthermia has been evaluated in prospective and retrospectives series (Table 5).

Since 1995, we regularly proposed in this setting plesiobrachytherapy (PBT), which is a simple noninvasive method to reirradiate the chest wall, as a curative or palliative treatment. Contrary to external beam irradiation, the dose is mainly delivered at the skin and 5 mm deeper, sparing critical organs such as the lung or heart. This report reviewed our experience with this technique.

Section snippets

Patients and methods

We reviewed our database between 2000 and 2012 and selected patients treated with PBT. We focus our analysis on the effect of PBT alone on local relapses in previously irradiated fields and so excluded patients for whom PBT was performed as an adjuvant treatment after mastectomy or those treated with a combination of external beam radiation therapy (EBRT) and PBT. In all cases, resection of the local relapse was performed when feasible. If not, thickness of the nodules must be less than 1 cm to

Description of the population

According to our database, 70 consecutive patients have been treated with PBT for chest wall disease. Eighteen patients were given adjuvant treatment after mastectomy and 9 patients for local relapses without previous radiotherapy, by a combination of EBRT and PBT: they were excluded from the analysis. The studied population consisted in 43 patients with a chest wall recurrence, in a previously irradiated field at a dose higher than 45–50 Gy (2 Gy per fraction). Indications for PBT were as

Discussion

The management of local relapses after mastectomy and radiotherapy is difficult to standardize because clinical situations and experience of the physicians are heterogeneous. Local recurrence is often one part of a generalized disease or the first event occurring before distant metastasis. In this setting, the usefulness of a systemic treatment has been demonstrated in randomized trials: tamoxifen improves survival in hormone-responsive patients (9) and chemotherapy in patients with estrogen

Conclusion

HDR-PBT is a simple treatment option to offer to patients with a chest wall local relapse after mastectomy and radiotherapy. In combination with surgery, a high rate of long-term local control could be achieved after HDR-PBT. For gross local disease, a reduction in both number and size of the nodules is regularly obtained and could alleviate distressing local symptoms without major toxicities. Long-term local control observed in our study compares favorably with that obtained after a

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    Conflict of interest: The authors declare no conflict of interest for this work.

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