Low incidence of milk fistula with continued breastfeeding following radiologic and surgical interventions on the lactating breast.

BACKGROUND: Milk fistula is a potential complication of radiologic and surgical procedures on the lactating breast, though its incidence is unknown. Some postulate that larger defects and/or closer proximity to the nipple increase the risk of fistula. OBJECTIVE: This study aimed to estimate the incidence of milk fistula and characterize risk factors in patients who continued breastfeeding after surgical or radiological procedures. METHODS: A retrospective cohort analysis of pregnant or lactating women treated at a multidisciplinary breast clinic from July 2016 through August 2019 was performed. Demographic and clinical variables were analyzed using ANOVA and Pearson's Chi-square. RESULTS: Two pregnant and 43 lactating patients underwent 71 interventions. The incidence of milk fistula within one week of intervention was 1.4%. One fistula was diagnosed six days after retroareolar abscess drainage. The fistula closed successfully with continued breastfeeding. When categorized by the caliber of the most invasive intervention (large-caliber: mass excision, n = 7; medium-caliber: percutaneous drain insertion, n = 18; small-caliber: stab incision, aspiration, core needle biopsy, n = 20), patients were similar in age, race/ethnicity, weeks postpartum, and frequency of central versus peripheral interventions. The low incidence of fistula prevented quantitative evaluation of potential risk factors. CONCLUSIONS: Milk fistula is a rare occurrence following radiologic or surgical breast interventions performed during pregnancy or lactation. Indicated procedures should not be deferred, but periareolar approaches should be avoided when possible. Cessation of lactation is not mandatory for fistula closure, and continued breastfeeding should be recommended.

A aplicação da laserterapia no tratamento de traumas mamilares: revisão de literatura / Application of laser therapy in the treatment of nipple traumas: a literature review / Aplicación de laserterapia en el tratamiento del traumatismo del pezón: revisión de literatura

OBJETIVO: Identificar na literatura científica a aplicação da laserterapia de baixa intensidade no tratamento de traumas mamilares em puérperas. MÉTODO: Trata-se de uma revisão integrativa da literatura. O levantamento das publicações ocorreu no período de setembro a novembro de 2020, utilizando os descritores "low-level light therapy" e "laser therapy", além da palavra-chave: "nipple trauma", nas bases de dados da PubMed, EMBASE, CINAHL, Scopuse Web of Science.Após a leitura e análise dos artigos, 3 artigos foram selecionados para a amostra final. RESULTADOS: Os dados analisados compuseram dois eixos temáticos denominados: "Uso da laserterapia no alívio da dor mamilar" e "Uso da laserterapia na cicatrização de fissuras mamilares". CONCLUSÃO: A aplicação da laserterapia resultou na diminuição da dor e boa regeneração tecidual mamilar, contribuindo para manutenção do aleitamento materno.

OBJECTIVE: To identify in the scientific literature the application of low-level laser therapy in the treatment of nipple traumas in puerperal women. METHOD: This is an integrative literature review.The survey of publications took place from September to November2020, using the descriptors "low-level light therapy" and "laser therapy", in addition to the keyword"nipple trauma", in the PubMed, EMBASE, CINAHL, Scopus and Web of Science databases.After reading and analyzing the articles, 3 were selected for the finalsample. RESULTS: The analyzed data composed two thematic axes, namely: "The use of laser therapy for nipple pain relief" and "The use of laser therapy in the healing of nipple fissures". CONCLUSION: The application of laser therapy resulted in pain reduction and in good nipple tissue regeneration, contributing to the maintenance of breastfeeding.

OBJETIVO: Identificar en la literatura científica la aplicación de laserterapia de baja intensidad en el tratamiento del traumatismo del pezón en mujeres posparto. MÉTODO: Se trata de una revisión integradora de la literatura. El levantamiento de publicaciones se realizó de septiembre a noviembre de 2020, utilizando los descriptores "low-level light therapy" y "laser therapy", además de la palabra clave: "nipple trauma", en las bases de datos de PubMed, EMBASE, CINAHL, Scopus y Web of Science. Después de leer y analizar los artículos, se seleccionaron 3 artículos para la muestra final. RESULTADOS: Los datos analizados comprendieron dos ejes temáticos denominados: "Uso de laserterapia para aliviar el dolor del pezón" y "Uso de laserterapia para la cicatrización de las grietas del pezón". CONCLUSIÓN: La aplicación de laserterapia dio como resultado una disminución del dolor y una buena regeneración del tejido del pezón, contribuyendo al mantenimiento de la lactancia.

Efficacy of Low-Level Laser Therapy in Relieving Nipple Pain in Breastfeeding Women: A Triple-Blind, Randomized, Controlled Trial.

Pain accruing from nipple lesions caused by inadequate latching by the baby is a common complaint among breastfeeding women and an important obstacle to successful breastfeeding. Nipple pain occurs during the first days after delivery and is considered one of the main causes for early weaning. To investigate the efficacy of low-level laser therapy as a treatment for nipple pain due to breastfeeding. A triple-blind, randomized, clinical study. A university-affiliated hospital in São Paulo, Brazil. Fifty-nine women with nipple lesions at the time of their admission. Thirty women (intervention group) received three sessions of laser therapy (InGaAIP laser, 660 nanometer, 40 milliwatts of power, 5 Joules per square centimeter of energy density for 5 seconds each, total energy = 0.6 Joules) in the region of the nipples at three different points in time (0 hour, 24 hours, and 48 hours after diagnosis of nipple lesion). Twenty-nine women with similar clinical conditions were randomly assigned to the control group. Self-reported pain was recorded before and after laser therapy using a visual analogue scale. The intervention group experienced a decrease of 2.0 centimeters in intensity of pain (p = .016) 24 hours after the first intervention and also presented lower levels of pain compared with the control group. Low-level laser therapy was considered effective for treating nipple lesions in breastfeeding women with pain, providing relief and prolonging exclusive breastfeeding. More clinical trials with different laser dosimetry and parameters are necessary to optimize laser therapy protocols for breastfeeding women.

Low level laser therapy for breastfeeding problems.

Breast and nipple pain, nipple damage and mastitis are common reasons given by women for their early cessation of breastfeeding. There are a limited number of effective therapies available to support healing of damaged nipples during lactation. Low level laser therapy is a painless treatment, which appears to accelerate wound healing and ease pain. We present two case studies, which demonstrate the use of low level laser therapy in clinical practice.

Evaluation of dosimetric consequences of seroma contour variability in accelerated partial breast irradiation using a constructed representative seroma contour.

PURPOSE: Contouring variability of the seroma can have important implications in the planning and delivery of accelerated partial breast irradiation (APBI). This study aimed to quantify the dosimetric impact of these interobserver and intraobserver contouring variations by construction of a representative seroma contour (RSC). METHODS AND MATERIALS: Twenty-one patients with a seroma suitable for APBI underwent four computed tomography (CT) scans: one planning CT and three additional CTs on the first, third, and fifth days of treatment. Three radiation oncologists contoured the seroma on each CT scan. For 3 patients, oncologists repeated contouring twice to assess intraobserver variations. Seroma contour variability was quantified by construction of an RSC. In addition, the percent volume overlap (PVO) was calculated. Root-mean-square (RMS) differences in seroma volume, size, and center of mass position compared to those of the RSC were calculated. Treatment fields from the original plan were applied to the repeated CTs by using the same isocenter shifts as the original plan. The dosimetric impact of the contour variations was assessed using V(95) (volume receiving at least 95% of the prescribed dose) and equivalent uniform dose (EUD). RESULTS: Interobserver RMS volume differences were, on average, 5.6 times larger than intraobserver differences. The median interobserver RMS seroma volume difference was 1.48 cm(3). The median PVO was 51.6%. V(95) and EUD of the seroma contours were similar for all patients. The median RMS differences of the seroma V(95) and EUD were 0.01% (range, 0%-3.99%) and 0.05 Gy (range, 0-0.98 Gy). CONCLUSIONS: Construction of the RSC showed that interobserver variations were most responsible for contour variations of the seroma. Current planning margins provided adequate dose coverage of the seroma despite these contour variations.

LED phototherapy improves healing of nipple trauma: a pilot study.

OBJECTIVE: The purpose of this study was to evaluate the clinical effectiveness of a LED phototherapy prototype apparatus in the healing of nipple trauma in breastfeeding women. BACKGROUND DATA: There is no scientific evidence of an effective treatment for nipple trauma. METHODS: The experimental group was treated with orientation on nipple care and adequate breastfeeding techniques in addition to active LED phototherapy. The control group was treated with orientation on nipple care and adequate breastfeeding techniques in addition to placebo LED phototherapy. Participants were treated twice a week, for a total of eight sessions. Healing of the nipple lesions was measured by a reduction in their area, and decrease in pain intensity was measured in accordance with an 11-point Pain Intensity Numerical Rating Scale and a standard 7-point patient global impression of change. RESULTS: Statistically significant reductions in measured nipple lesion area (p<0.001) were observed for both the experimental and control groups with an increase in the number of treatment sessions. A significant difference between the experimental and control groups was observed for the healing of nipple lesions (p<0.001). The pain intensity was significantly reduced only in the experimental group (p<0.001). CONCLUSIONS: Preliminary results demonstrated the prototype apparatus for LED phototherapy to be an effective tool in accelerating the healing of nipple trauma.

Low intensity laser therapy is comparable to bromocriptine-evening primrose oil for the treatment of cyclical mastalgia in Egyptian females.

One of the successful treatments for cyclical mastalgia is bromocriptine evening primrose combination. A double blind study was applied on 80 patients with cyclical mastalgia. They were randomly divided into two groups (A and B). In group A, patients were treated by bromocriptine/evening primrose. To group B, LILT with specified dosimetry was applied, using a device that delivers He-Ne laser combined with 4 infra-red diode laser. Evaluation of treatment was both subjective (using VAS) and objective (studying the degree of drop in plasma cortisol level). The drop of plasma cortisol with treatment was studied using the student -t distribution. A good response was observed in the laser group in 82.5%, compared to 63.9% in the bromocriptine/evening primrose group. There was a significant deference before and after treatment in both groups (P<0.05). This difference was more for the drug treated group than for the laser treated group, but in the latter, it acted on a wider sector of patients. In conclusion, LILT is recommended as a new treatment modality for cyclical mastalgia.

Comparison of 4 MV photon surface dose among Varian, Siemens, and Elekta linear accelerators for tangential breast treatment: a phantom study.

PURPOSE: We have compared the differences in a 4-MV photon surface dose among Varian, Siemens, and Elekta linear accelerators (linacs) with wedges for tangential breast treatment. MATERIALS AND METHODS: The wedge factor and the surface dose were measured using a solid water phantom and an ion chamber for each linear accelerator with various field sizes and wedge angles. A tangential treatment plan was applied to an elliptical hollow cylinder water phantom with a radiochromic film placed thereon. A dose was delivered to a simulated target in the phantom, and the resulting dose distribution was analyzed using a film scanner. RESULTS: Varian's wedges resulted in the highest wedge factors, ranging from 0.37 to 0.75 depending on the wedge angles. Varian's wedges led to the highest normalized skin doses, ranging between 0.40 and 0.73 depending on the wedge angles and field sizes. In the cylinder phantom test with two tangential beams, the Varian linac provided a nearly 20% higher maximum dose than the Siemens and Elekta linacs. CONCLUSION: The Varian linac resulted in the highest surface doses, and the Elekta linac led to the lowest for nearly all the measurement conditions we employed, including open beams.

Prophylactic breast irradiation with a single dose of electron beam radiotherapy (10 Gy) significantly reduces the incidence of bicalutamide-induced gynecomastia.

PURPOSE: To evaluate the efficacy and tolerability of prophylactic breast irradiation in reducing the incidence and severity of bicalutamide-induced gynecomastia and breast pain. METHODS AND MATERIALS: In all, 106 men with prostate cancer (T1b-T4/Nx/M0) and no current gynecomastia/breast pain were enrolled in this randomized, sham-controlled, double-blind, parallel-group multicenter trial. Patients received either a single dose of electron beam radiotherapy (10 Gy) or sham radiotherapy. Bicalutamide (Casodex) 150 mg/day was administered for 12 months from the day of radiotherapy. Every 3 months, patients underwent physical examination and questioning about gynecomastia and breast pain. RESULTS: The incidence of investigator-assessed gynecomastia was significantly lower with radiotherapy vs. sham radiotherapy (52% vs. 85%; odds ratio [OR], 0.13; 95% confidence interval [CI], 0.04, 0.38; p < 0.001); direct questioning showed similar results. Fewer radiotherapy patients had >/=5 cm gynecomastia (measured by calipers; 11.5% vs. 50.0% for sham radiotherapy), and fewer cases were moderate-to-severe in intensity (21% vs. 48%). Similar proportions of radiotherapy and sham radiotherapy patients experienced breast pain (83% vs. 91%; OR, 0.25; 95% CI, 0.05, 1.27; p = 0.221); patients receiving radiotherapy experienced some reduction in its severity (OR, 0.44; 95% CI, 0.20, 0.97; p = 0.0429). CONCLUSIONS: Prophylactic breast irradiation is an effective and well-tolerated strategy for prevention of bicalutamide-induced gynecomastia.

Breast cancer risk among the survivors of atomic bomb and patients exposed to therapeutic ionising radiation.

Radiation induced breast cancer is a highly complex phenomenon, which most likely involves the accumulation of several genetic and epigenetic events. Studies of atomic bomb survivors, patients who underwent multiple fluoroscopic examinations during treatment for pulmonary tuberculosis, those who received therapeutic radiation for benign breast disease, such as acute post-partum mastitis, or those with an enlarged thymus or skin haemangioma and patients with Hodgkin's disease treated by mantle radiotherapy established that the risk of breast cancer increases with exposure to ionising radiation. The carcinogenic effect of therapeutic or accidental radiation is highest when exposure occurs during childhood and exposure after age 40 imparts low or minimal risk. The risk of bilateral breast cancer is not significantly increased in the survivors of atomic bomb and therapeutic radiations. Fractionated exposures for therapeutic radiation are similar to a single exposure of the same total dose in their ability to induce breast cancer; this risk remains high for many years after exposure. Younger age at first full term pregnancy confers a protective effect against the risk of breast cancer in the survivors of atomic bomb but long-term data on this beneficial effect after therapeutic radiation is not available.

Laser scanning of patient outlines for three-dimensional radiotherapy treatment planning.

In the planning of radiation treatments it is important to have a knowledge of the patient outline in order to correctly calculate the dose distribution that can be expected within the patient. This information is routinely obtained using x-ray computed tomography (CT). Although the CT data set is the ultimate data set, it can be impractical for economic and physical reasons. These impracticalities have been overcome using a commercial three dimensional (3D) laser scanning system. The system scans a laser line across the surface of the patient while a CCD camera views the patient from an offset angle. From a knowledge of the spatial orientation of the camera and the laser source, the system is able to detect the patient's surface and generate an equivalent 3D point cloud. Manipulation of 3D data sets allows the appropriate outlines of the patient to be obtained, that can then be used with the radiotherapy planning system. This has enabled the evaluation of 3D dose distributions for patients, and hence will allow the development of techniques for improving the uniformity of dose in breast treatments. The technique has no radiation overhead associated with it, is quick and is relatively cheap.

Ductal carcinoma in situ (DCIS) of the breast: thirty-two consecutive cases under 50 yrs detected by mammography: treatment and results.

Thirty-two consecutive cases of ductal carcinoma in situ of the breast in women under fifty are presented. Diagnostic procedure, pathological aspects, treatment and outcome are reported. All the patients had their cancer diagnosed by mammography. The tumor was marked by stereotactic or ultrasound guided localization. Lumpectomy without axillary node dissection was the surgical treatment of thirty lesions with good cosmetic results; radiation therapy was advised in all of these cases. In two cases mastectomy with immediate reconstruction was performed because of the multifocality of the cancer, none of the patients experienced local or distant recurrence. This experience emphasizes the importance of mammographic screening for women 40 years of age, in fact this approach allowed the diagnosis of a large number of DCIS. A correct definition of the problem and a multidisciplinary therapeutical approach is warranted to prevent the high local recurrence rate reported in the past.

The role of ultrasound in breast imaging.

Sonography has become an important tool for evaluating breast abnormalities, including inflammatory processes, hematomas, ductal ectasia, cysts and solid lesions. This article describes protocols for ultrasound imaging of the breast and the sonographic appearance of common breast conditions, with particular attention to differentiating benign from malignant lesions. Ultrasound's role in interventional breast procedures and radiation therapy planning also are discussed.

Incidence of primary malignancies other than breast cancer among women treated with radiation therapy for benign breast disease.

This report presents data on the long-term risks of developing malignancies other than breast cancer after exposure to scattered doses of ionizing radiation. The estimates were based on a cohort of 3,090 women who were diagnosed clinically with benign breast disease between 1925 and 1961. A total of 1,216 women were treated with radiation therapy. The breasts received a mean absorbed dose of 5.84 Gy. Mean absorbed doses owing to scatter to 14 other organs were also determined. The lung received the highest mean scattered dose (0.75 Gy; range 0.004-8.98 Gy) and rectum the lowest (0.008 Gy; range 0-0.06 Gy). Median age at first exposure was 40 years. The follow-up lasted up to 61 years after treatment (mean follow-up 27 years). End-point data were obtained from population-based registers. With internal reference the relative risk for non-breast solid tumors was 1.2 (95% confidence interval 1.0-1.5). However, this excess was not apparent when comparison with the general population was made (standardized incidence ratio = 0.95; 95% confidence interval 0.84-1.07). Among individual sites no significantly increased risks were observed. For stomach cancer there was a linear increase with dose (ERR/Gy = 1.3; two-sided P = 0.05). No increased risk was observed for leukemias. In two earlier reports, breast cancer incidence has been shown to be significantly increased in this cohort of irradiated women. Our results suggest that the scattered doses from the breast irradiation may have increased the risk of cancers of other sites, but the small number of cases in different locations precludes strong interpretations.

Healthful radiation.

This title of this article sounds paradoxical to most people because the general public is not fully aware of the many benefits radiation has brought to people's healthcare. Radiation has provided the most effective means of noninvasive diagnosis of many diseases, thus reducing the need for exploratory surgery, at significantly reduced risks. Furthermore, radiotherapy has been effective in treating many diseases without surgical removal of the diseased part. The breast is one excellent example of the benefits of radiation in both diagnosis and treatment with preservation. Yet the public still regards radiation as mysterious and dangerous, while trained experts regard it as beneficial with manageable risks. This article suggests ways of presenting this material to the public in a manner that is interesting and informative.

Dose- and time-response for breast cancer risk after radiation therapy for benign breast disease.

Exposure of the breast to ionising radiation increases the risk of breast cancer, especially among young women. However, some issues remain controversial, for instance the shape of the dose-response curve and the expression of time-related excess. The main purpose of this report was to examine the dose-response curves for radiation-induced breast cancer formulated according to radiobiological target theories. Another purpose was to analyse the time-related excess of breast cancer risk after exposure when dose and age at first exposure were held constant. Breast cancer incidence was analysed in a cohort of 3090 women diagnosed with benign breast disease during 1925-61 (median age 37 years). Of these, 1216 were treated with radiation therapy. The dose range was 0-50 Gy (mean 5.8 Gy). The incidence rate as function of dose was analysed using a linear-quadratic Poisson regression model. Cell-killing effects and other modifying effects were incorporated through additional log-linear terms. Additive and multiplicative models were compared in estimating the time-related excess. The analysis, which was based on 278 breast cancer cases, showed a linear dose-response relationship at low to medium dose levels with a cell-killing effect of 5% Gy-1 (95% confidence interval 2-9%). For a given absorbed dose and age at first exposure the time-related excess was proportional to the background rates with a suggestion that the excess remains throughout life.

Radiation-induced breast cancer: long-term follow-up of radiation therapy for benign breast disease.

BACKGROUND: From the 1920s through the 1950s, radiation therapy was used in Sweden as a treatment for benign breast diseases. It is now known that exposure of the breast to ionizing radiation increases the relative risk of subsequent breast cancer, especially for younger women. However, the degree to which the patient's age contributes to the elevation of risk for subsequent development of breast cancer is not yet completely understood. PURPOSE: The purpose was to study the risk of breast cancer after irradiation of the female breast and, in particular, to analyze the duration of the effect and the risk for women older than 40 years at first exposure. METHODS: In this cohort study, data were obtained through population-based registers. The exposed group consisted of 1216 women (median age, 40 years) who, during the period spanning 1925 through 1954, received radiation therapy for benign breast disease. The reference group consisted of 1874 women (median age, 36 years) who had the same diagnosis during that time period but did not receive radiation therapy. The radiation doses were determined from the original medical records (mean dose, 5.8 Gy; range, 0.003-50.1 Gy). The follow-up lasted up to 60 years after first exposure. The incidence rate ratio was analyzed with Poisson regression models. RESULTS: The total number of breast cancers in the exposed cohort was 198 versus 101 in the unexposed cohort. Overall, the radiation-associated incidence rate ratio was 3.58 (95% confidence interval = 2.77-4.63). The dose-response gradient was statistically significant (P < .001) but leveled off at higher doses. The incidence rate ratios decreased starting about 25 years after first exposure but were at increased levels throughout the entire follow-up period. The incidence rate ratio decreased with age at first exposure but was significantly increased (P < .001) even when the age at time of first exposure was greater than 40 years. CONCLUSIONS: Total dose, age at first exposure, and time since first exposure were all determinants of the incidence rate ratio of breast cancer after exposure of the breast to ionizing radiation. A statistically significant increase in the incidence of breast cancer following radiation treatment of various benign breast diseases was observed even among women older than 40 years at the time of first treatment. IMPLICATIONS: These findings need to be considered when weighing the relative benefits versus risks of generalized screening of younger women for breast cancer by mammography.