Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey.

BACKGROUND: Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI. METHODS: A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014. RESULTS: A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI. CONCLUSION: The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.

Paranasal sinus metastasis of breast cancer.

A 76-year-old woman presented with symptoms suggestive of acute sinusitis. Previously, her breast carcinoma was treated with right lumpectomy, adjuvant chemotherapy and breast radiotherapy. She remained free from recurrence for the following 8 years. After initial treatment with antibiotics, the local symptom worsened with exophthalmos, eye blindness and development of an ulceration of the hard palate. MRI showed irregular enhancement of the nasal cavity extended to the maxillary sinus and ethmoidal lamina and concomitant infiltration of the orbit and skull base. A biopsy of the palatal ulcer showed a poorly differentiated adenocarcinoma and was compared with the histology of the primary breast tumour and it was concluded for the same morphology. After discussion at the multidisciplinary team, a specific chemotherapy has been activated with an initial local response. Further surgical resection was not thought appropriate and the patient has subsequently undergone palliative radiotherapy to the right paranasal lesions to improve local disease control.

Ocular metastases from breast carcinoma: A multicentric retrospective study.

Breast cancer may affect the eye and orbit by metastatic neoplastic infiltration, uvea being the most common site of presentation. Management of these cases with radiotherapy is usually gratifying with reported response rate of approximately 75%. A retrospective evaluation of cases treated in five Institutions participating in a collaborative radiation therapy group of north-Italy is reported. Fifty-four cases of metastases to the eye or orbit were referred for radiation therapy to the Departments participating in the survey in the period 1977-1995. There were 49 female patients aged between 28 and 75 years (median, 44 years) at presentation of orbital metastasis. Thirty-eight lesions (70%) were metastases to the choroid, 9 involved other parts of the eye, and 7 patients had orbital metastases. Five of the 49 patients had bilateral choroidal metastases. Radiotherapy was employed with megavoltage equipment. The median total dose delivered was 40 Gy (range, 16-60 Gy). All the patients were treated 5 times per week with fraction sizes ranging from 1.8 to 3.0 Gy (median, 2.0 Gy). Of the 43 evaluable eyes, 34 (79%) showed a definite improvement after radiotherapy. There was a stabilization of the process in 4 patients. The rest (11 lesions) were lost to detailed follow-up of the response of the eye metastases. Twelve patients experienced acute transient cheratoconjunctivitis and in a case a subconjunctival haemorrhage was observed; as late side effects, two cases of chataract were observed during a period of observation of 37 and 117 months. A median survival time of 17 months was observed. The goal of irradiation was to improve vision or at least prevent blindness and enucleation. The palliative effect of irradiation was confirmed with a response rate consistent with the data of the literature on this subject.

Clinical application of integrated treatments in breast cancer.

In this paper we analyse the problems related to the "state of the art" in the treatment of stage I and II breast cancer which has become, in Italy too, an increasingly prominent problem: it is the most frequently diagnosed female cancer, accounting for about 45,000 new cases/year (150/100,000 women). In the last decade the approach to this disease has greatly evolved because of new surgical techniques, advances in adjuvant medical therapies, innovations in the field of radiotherapy, and wider use of biological parameters. We emphasize the emerging problem of ductal and lobular carcinoma in situ, because their biological patterns will be better identified and the related treatment extensively practiced in the next future. The innovations in surgery, which has now a less demolishing role, are reviewed focusing on the "sentinel axillary node" and the actual need for axillary dissection. In relation to chemotherapy (CT), we evaluate the role of adjuvant treatment also in node negative patients, and the impact of neoadjuvant schedules on survival and toxicity. Radiotherapy (RT) is complementary to conservative surgery, and its important role in preventing local relapse and in increasing OS (overall survival) has been established; recent and more sophisticated techniques have reduced its acute and late toxicity. We are however waiting for answers concerning the usefulness of a booster dose, the impact of RT on local relapse in DCIS, and the impact of RT to the breast regional lymph nodes on OS and disease-free survival (DFS). The optimal sequencing and timing of postoperative RT and CT are unknown, both concerning each other and surgery. Some possibilities include giving all planned CT before RT, all CT after RT, giving both concurrently, or giving a portion of CT before RT and then completing CT afterwards (sandwich technique): we analyse the advantages and the problems of these different therapeutic schedules in relation to the OS, the DFS and cosmesis. In conclusion, there are very few certainties to guide us in the clinical practice: the general feeling is that we need to collect more data on homogeneous groups of patients to better understand which are the prognostic factors we can rely on, in order to choose the best treatment strategy, and which are the optimal schedules of adjuvant treatments (CT and RT), with the aim of improving OS, DFS and cosmesis.

Radiological findings when very small lung volumes are irradiated in breast and chest wall treatment.

Acute pneumonitis following breast irradiation is a rare and transient phenomenon that can be easily managed by drugs. The aim of this study is to evaluate late sequelae on lung, after postoperative radiotherapy (RT) for breast cancer. We were concerned with investigating late radiological findings when very small lung volumes are involved in the irradiated volume. We studied 28 consecutive patients. They underwent clinical examination and all staging procedures before surgery, evaluation of pulmonary function with spirometry, postoperative chest x-ray and high resolution computed tomography (HRCT) of the lung before RT. Clinical examinations were usually performed every 3 months after RT. A second chest x-ray, HRCT and spirometry were carried out after nearly 7 months from the end of RT. We estimated the irradiated lung volume by measuring the area of the lung surface enclosed by the 50% isodose (LA50) in each profile. We found a significant correlation between LA50 and the score of radiological findings after RT. No correlations were found between other factors (i.e., adjuvant chemotherapy, age, weight, smoking) and lung fibrosis. No woman developed radiation pneumonitis syndrome or respiratory symptoms. Our results indicate that irradiation of the breast and/or chest wall is well tolerated if treatment planning is done accurately. The fibrosis likelihood is strongly correlated to the irradiated lung volume. The use of tangential fields limits radiological changes that can be detected only by HRCT examination and are not associated with clinical symptoms.

An ICRU 50 radiotherapy treatment chart.

We illustrate a radiotherapy treatment chart elaborated to fulfil the necessity for clarity in reporting information about radiotherapeutic treatment. The schematic configuration of the chart results from the experience and the cooperation of physicists, physicians and technicians, and an effort has been made to satisfy Levels 2/3 of the ICRU 50 recommendations. The chart has been divided into four sections corresponding to different kinds of information: a cover sheet, a section containing data about the treatment planning geometry and the console parameters adopted, a section showing dosimetric data, and a section showing treatment data. The chart seems to give a good level of accuracy in reporting treatment plan information.

Evaluation of most frequent errors in daily compilation and use of a radiation treatment chart.

Between 1 March and 30 April (1994) we recorded the errors detected by the physician, the radiographer or the physicist during prescription, preparation and execution phases of 227 treatment plans. The radiation treatment modalities used were the following: (i) single or opposed fields, moulded or not; and (ii) multiple fields or kinetic techniques. The total number of sessions performed is 1613 with the cobalt unit and 2131 with the linear accelerator (total, 3744). The total number of wrong data is 155, consisting of 24/227 (10.5%) in compilation, 22/3744 (0.58%) in execution and 109/3744 (2.9%) in registration phases. The number of missing data is 140, consisting of 10/227 (4.4%) in compilation, 9/3744 (0.2%) in execution and 121/3744 (3.2%) in registration phases. Wrong data of compilation, even if in high rate (10.5%), were all found during the same compilation phase or at the first treatment, so that they did not alter the exactness of the treatment plan. Wrong and missing data, found in the registration phase (2.9% and 3.2%, respectively), depend on the repetition of daily treatment and on the registration of data on the chart after having digitized them on the display.

[The irradiated volume in stage III non-small-cell carcinoma of the lung. Comparison of outdated and new techniques]. / Il volume irradiato nel carcinoma non-microcitoma del polmone allo stadio III. Confronto tra vecchie e nuove metodiche.

March 1988 through April 1992, three hundred and ninety-six patients affected with bronchogenic carcinoma were treated at the Department of Radiation Oncology of the S. Anna Hospital, Como, Italy. A hundred and ten patients presenting stage-III non-small-cell lung carcinoma were evaluable. All evaluable patients underwent radiation therapy alone, with either palliative or curative purposes. Two main periods can be distinguished: in period A, before June 30th, 1990, treatment planning included conventional techniques, with no simulators; the patients were treated with opposing anteroposterior fields only. In period B, after July 1st, 1990, either the simulator alone was used or a simulator, a CT unit and a treatment planning computer system were combined; anteroposterior opposing fields or multiportal technique were used. Median overall survival was 10 months. Independent of treatment goals, the irradiated volume was markedly different in the patients treated in period A than in those treated in period B. A marked and statistically significant increase in survival was observed in group B. Survival also increased in patients treated with doses > 40 Gy, but only if treatment planning had used adequate technology and accuracy. To conclude, better survival can be achieved only by improving treatment accuracy and quality.