Ciliary Body and Iris Metastases With Anterior Chamber Angle Infiltration: A Rare Complication From Invasive Ductal Breast Cancer.

A 54-year-old woman who presented with photopsia was found to have elevated intraocular pressure in both eyes and optic disc cupping in the right eye. Angle infiltration was noted on gonioscopy. She was previously been diagnosed with metastatic breast cancer. This case report describes a rare case of glaucoma as a complication of ciliary body and iris metastases secondary to invasive ductal breast cancer.

Complex Decongestive Therapy in Breast Cancer-Related Lymphedema: Does Obesity Affect the Outcome Negatively?

BACKGROUND: The aim of this prospective clinical study was to compare the long-term efficacy of complex decongestive therapy (CDT) in obese and nonobese patients with breast cancer-related lymphedema (BCRL). MATERIALS AND METHODS: A total of 59 patients (29 obese patients group 1, 30 normoweight overweight patients group 2) with unilateral BCRL were enrolled. All patients underwent CDT that included manual lymphatic drainage, intermittent pneumatic compression pump, multilayer compression bandaging, lymphedema exercises, and skin care. The CDT was performed for 1 hour a day, 5 days a week for 3 weeks. Patients were assessed according to limb volume difference before CDT, after CDT, and after 1 year. RESULTS: The initial lymphedema volume of group 1 was 866.34 ± 389.34 mL and that of group 2 was 661.84 ± 470.6 mL (p = 0.031). The lymphedema severity percentage of excess volume (PEV) of group 1 was 33.37 ± 15.71 and that of group 2 was 31.86 ± 19.63, which was moderate lymphedema. After 15 sessions of CDT program, in group 1, lymphedema volume decreased to 771.46 ± 389.14 mL (post-CDT p = 0.013) and in group 2, lymphedema volume decreased to 468.38 ± 417.36 mL (post-CDT p < 0.0001), and in group 1, PEV decreased to 28.54 ± 16.84 (post-CDT p = 0.002) and that in group 2 decreased to 22.1 ± 16.87 (post-CDT p < 0.0001). After 1 year, group 1 reached the baseline values of the extremity volumes, but in group 2, the volumes of extremities could maintain their post-CDT values. CONCLUSION: Obesity is a factor that deteriorates the CDT efficacy. Early treatment, before developing fat accumulation and fibrosis, must be primary goal in the treatment of BCRL.

Is Complex Decongestive Physical Therapy Safe for Median Nerve at the Level of Carpal Tunnel in Breast Cancer Related Lymphedema?

BACKGROUND: Multilayer bandaging used in complex decongestive therapy (CDT) may increase tissue pressure resulting in nerve entrapments. The aim of this study was to discover if median nerve damage is a consequence of CDT in patients with breast cancer-related lymphedema (BCRL). METHODS AND RESULTS: Eighty-two arms of 41 patients with BCRL were included. Mean age was 56.05 (8.16) years and all stages of lymphedema were equally included. Fifteen sessions of CDT was applied to all patients. The calculated volume of extremities, the quality of life (cancer adaptation of Ferrans-Powell), neuropathic pain (NP; Douleur Neuropathique 4), and disability (quick disabilities of arm, shoulder, and hand [Q-DASH]) tests were recorded before and after therapy. Skin and subcutaneous tissue thicknesses of volar and dorsal sides and median nerve cross-sectional area (CSA) at the level of carpal tunnel were measured using ultrasonography (US), before and after therapy. Carpal tunnel syndrome (CTS; 41.37%) and polyneuropathy (10.34%) were common findings confirmed by electromyography. Neuropathic pain profile was also found in 34.14% of patients. The arm volume of affected side, quality of life, and skin and subcutaneous tissue thicknesses were improved after therapy (p < 0.05). However, median nerve CSA, the NP, and Q-DASH scores were not changed after therapy. CONCLUSIONS: Although lymphedema is a painless condition, NP and CTS should not be ignored in patients with BCRL. US is an alternative, precise, and high technological method for evaluating treatment response. CDT is an effective and safe treatment according to volumetric calculations, US measurements of tissue thicknesses, and median nerve size.

Angiosarcoma de mama radioinducido / Radiotherapy-induced angiosarcoma of the breast

El angiosarcoma radioinducido de mama tras tratamiento quirúrgico conservador y radioterapia complementaria en una paciente con cáncer de mama es una entidad poco frecuente, de difícil diagnóstico y mal pronóstico. Se presenta el caso de una mujer de 71 años, con antecedentes personales de carcinoma ductal infiltrante de mama izquierda, a la que se practicó tumorectomía y linfadenectomía axilar (pT1cpN0M0), y recibió tratamiento adyuvante con radioterapia y hormonoterapia. 77 meses después del tratamiento, la paciente consultó al presentar una lesión cutánea en la mama izquierda. Tras valoración clínica, radiológica e histológica y con el diagnóstico de angiosarcoma de mama, se practicó mastectomía izquierda. Posteriormente no recibió tratamiento complementario

Radiotherapy-induced angiosarcoma of the breast after conservative surgical treatment and complementary radiotherapy in a patient with breast cancer is a rare condition, with both difficult diagnosis and poor prognosis. We present the case of a 71-year-old woman with a personal history of infiltrating ductal carcinoma of the left breast, who underwent tumorectomy and axillary lymphadenectomy (pT1cpN0M0), and received adjuvant treatment with radiotherapy and hormone therapy. 77 months after treatment, the patient consulted with a skin lesion on her left breast. After clinical, radiological and histological assessment and with the diagnosis of angiosarcoma of the breast, a mastectomy of her left breast was performed. The patient did not receive complementary treatment

Carcinoma in situ de mama: análisis de los casos y evaluación de las recidivas en nuestro centro, 1999-2012 / Ductal carcinoma in situ: analysis of cases and assessment of recurrences in our center from 1999-2012

Objetivo. Analizar las recidivas de las pacientes diagnosticadas, tratadas y seguidas en nuestro centro por carcinoma ductal in situ de mama, y establecer qué variables se asocian a un mayor riesgo de desarrollarlas. Pacientes y métodos. Se ha realizado un estudio descriptivo retrospectivo de los casos de carcinoma ductal in situ diagnosticados y tratados en nuestro centro desde enero de 1999 hasta enero de 2012. Se excluyeron los casos en que coexistía componente infiltrante y aquellos con antecedente de neoplasia y/o radioterapia previa en la mama afecta. Las variables que se analizaron fueron: la edad de la paciente, el tamaño tumoral, el grado nuclear, el estado de los márgenes quirúrgicos, el tipo de cirugía y el tratamiento complementario (radioterapia y hormonoterapia). Resultados. Se estudiaron 162 casos de carcinomas in situ en el periodo 1999-2012. De estos, 117 (72,2%) fueron tratados con cirugía conservadora y 45 (27,7%) mediante mastectomía. Se produjeron 16 recidivas (9,9%) en el periodo estudiado. No se encuentran diferencias estadísticamente significativas en la tasa de recidivas en función del tamaño tumoral, la distancia quirúrgica al margen, el grado histológico ni la edad de la paciente. En el subgrupo de pacientes tratadas con tumorectomía, la supervivencia libre de enfermedad fue mayor en las que recibieron de forma complementaria radioterapia y hormonoterapia que en aquellas que solo recibieron uno o ninguno de los tratamientos (p=0,001). Conclusión. En el subgrupo de pacientes con carcinoma in situ tratadas con tumorectomía el riesgo de recidiva es 19 veces superior en los casos que no recibieron ningún tratamiento complementario que en aquellos tratados con tumorectomía, radioterapia y hormonoterapia (p=0,001) (AU)

Objective. To analyse recurrences in patients diagnosed, treated and followed up in our centre for ductal carcinoma in situ and to identify the variables associated with an increased risk of their development. Patients and methods. We performed a retrospective study of cases of ductal carcinoma in situ diagnosed and treated in our hospital from January 1999 to January 2012. We excluded cases with coexistence of an infiltrating component, a history of neoplasia, and/or prior radiation to the affected breast. The variables analysed were patient age, tumour size, nuclear grade, surgical margin status, type of surgery, and adjuvant therapy (radiation and hormone therapy). Results. We studied 162 cases of ductal carcinoma in situ occurring between 1999 and 2012. Of these, 117 cases (72.2%) were treated with conservative surgery and 45 (27.7%) by mastectomy. In that period, we found 16 recurrences (9.9%). We found no statistically significant difference in the recurrence rate according to tumour size, surgical distance from the margin, histological grade, or patient age. In the subgroup of patients treated with lumpectomy, disease-free survival was higher in patients receiving radiation therapy and hormone therapy as a complementary treatment than in those who received only one or no treatment at all (P=.001). Conclusion. In the subgroup of patients with ductal carcinoma in situ treated with lumpectomy, the recurrence risk was 19 times higher in patients who received no adjuvant treatment than in those treated with lumpectomy, radiation and hormone therapy (P=.001) (AU)

Ductal Carcinoma In Situ of the Breast: Should Breast Irradiation Be Routinely Added to Surgical Excision?

Confusion exists among women with a new diagnosis of ductal carcinoma in situ and their physicians regarding choice of treatment. The press has accused the medical community of overtreatment and found many physicians eager to support or deny the charge. Improvements in treatment delivery have been matched with better definitions of risk on the basis of biology as defined by genomic analysis rather than only lesion size, margins, receptor status, and patient age. Understanding both the risk of a specific ductal carcinoma in situ progressing to invasive breast cancer and the risks of the treatment options allows tailored recommendations.

Double-Chamber Tissue Expanders Optimize Lower Pole Expansion in Immediate Breast Reconstruction Requiring Adjuvant Radiation Therapy.

INTRODUCTION: Tissue expander-based reconstruction in the irradiated breast has been associated with significant complications, including infection, skin breakdown and implant extrusion, and poor aesthetic outcome. These complications may be attributed to inadequate lower pole expansion causing increased pressure on the suture line. Achieving and maintaining adequate lower pole expansion in the reconstructed breast requiring adjuvant radiation therapy may reduce the pressure/strain on the suture line and preserve the natural appearance of the breast. We describe the effective use of a double-chamber tissue expander to control lower pole expansion in immediate breast reconstruction requiring adjuvant radiation therapy. METHODS: We performed a retrospective chart review of patients who underwent postoperative radiation therapy after immediate breast reconstruction using Sientra's double-chamber tissue expander, performed by a single plastic surgeon from 2012 to 2014. RESULTS: A total of 22 patients met our inclusion criteria. Seventeen patients had bilateral, and 5 patients had unilateral reconstruction (n = 39 total breasts). All patients were over expanded by 20% on the side affected by cancer before the start of radiation, which started by the sixth postoperative week. There was no expansion during radiation therapy. Two patients had further expansion after radiation therapy was completed. The tissue expanders were exchanged for shaped silicone gel implants 3 to 4 months after completion of radiation. A total of 2 complications occurred in 2 patients (9.0%) and 2 breasts (5.1%). These included an infection in one patient and a tissue expander leak in another. No patient developed Baker grade 3 or 4 capsular contracture, seroma, or device malposition. Good lower pole contour and projection was maintained in all breasts at 9 to 12 months of follow-up. CONCLUSIONS: The double-chamber tissue expander is effective in controlling shape, contour, and position of the breast following immediate tissue expander reconstruction requiring adjuvant radiation therapy, with decreased complication rates compared to standard expanders. These results suggest that double-chamber tissue expanders may be the preferred expander option in patients requiring adjuvant radiation therapy. Prospective clinical studies are needed to better evaluate the advantages of this reconstructive approach.

Elevated ARG1 expression in primary monocytes-derived macrophages as a predictor of radiation-induced acute skin toxicities in early breast cancer patients.

Radiation therapy (RT) the front-line treatment after surgery for early breast cancer patients is associated with acute skin toxicities in at least 40% of treated patients. Monocyte-derived macrophages are polarized into functionally distinct (M1 or M2) activated phenotypes at injury sites by specific systemic cytokines known to play a key role in the transition between damage and repair in irradiated tissues. The role of M1 and M2 macrophages in RT-induced acute skin toxicities remains to be defined. We investigated the potential value of M1 and M2 macrophages as predictive factors of RT-induced skin toxicities in early breast cancer patients treated with adjuvant RT after lumpectomy. Blood samples collected from patients enrolled in a prospective clinical study (n = 49) were analyzed at baseline and after the first delivered 2Gy RT dose. We designed an ex vivo culture system to differentiate patient blood monocytes into macrophages and treated them with M1 or M2-inducing cytokines before quantitative analysis of their "M1/M2" activation markers, iNOS, Arg1, and TGFß1. Statistical analysis was performed to correlate experimental data to clinical assessment of acute skin toxicity using Common Toxicity Criteria (CTC) grade for objective evaluation of skin reactions. Increased ARG1 mRNA significantly correlated with higher grades of erythema, moist desquamation, and CTC grade. Multivariate analysis revealed that increased ARG1 expression in macrophages after a single RT dose was an independent prognostic factor of erythema (p = 0 .032), moist desquamation (p = 0 .027), and CTC grade (p = 0 .056). Interestingly, multivariate analysis of ARG1 mRNA expression in macrophages stimulated with IL-4 also revealed independent prognostic value for predicting acute RT-induced toxicity factors, erythema (p = 0 .069), moist desquamation (p = 0 .037), and CTC grade (p = 0 .046). To conclude, our findings underline for the first time the biological significance of increased ARG1 mRNA levels as an early independent predictive biomarker of RT-induced acute skin toxicities.

Double-Blind, Placebo-Controlled Pilot Study of Processed Ultra Emu Oil Versus Placebo in the Prevention of Radiation Dermatitis.

PURPOSE: The purpose of this single-institution pilot study was to evaluate the feasibility and safety of an oil-based skin agent, Ultra Emu Oil, on skin-related toxicity in patients undergoing radiation therapy to the breast or chest wall. METHODS AND MATERIALS: Patients were randomized 2:1 in a double-blind fashion and were instructed to apply processed Ultra Emu Oil or placebo (cottonseed oil) twice daily during the course of radiation therapy. The oils were applied before the third fraction and continued for 6 weeks after completion of treatment. The primary endpoint was the area under the curve (AUC) of Skindex-16 scale scores over time. Secondary outcomes included maximum grade of radiation dermatitis using the Common Terminology Criteria (CTC) for Adverse Events (CTCAE 3.0), the Skin Toxicity Assessment Tool, quality of life (QOL) measured by Linear Analogue Self-Assessment, and a symptom experience diary (SED). RESULTS: In all, 42 of 45 patients completed the study and were evaluable. The median times to peak rash, skin redness, peeling, and skin swelling were weeks 6, 6, 7, and 7, respectively as measured by the SED. The Skindex AUC scores tended to be lower in emu oil patients than in placebo patients (mean total AUC 7.2 vs 10.4, respectively). This trend was also seen in all the Skindex subdomains. The overall QOL was slightly better in the emu oil group but remained stable throughout the study for both arms. Peak CTC toxicity occurred at week 6. Patients using emu oil appeared slightly worse on maximum CTC grade, but the difference was not significant. CONCLUSIONS: This pilot study confirmed the safety of oil-based skin treatments during radiation therapy and suggests a trend for reduced skin toxicity for patients receiving emu oil. A larger study is needed to evaluate the efficacy of emu oil in reducing radiation dermatitis in patients receiving breast radiation.

Actualización del cáncer de mama en atención primaria (IV/V) / Update of breast cancer in primary care (IV/V)

El cáncer de mama es una enfermedad prevalente con implicaciones en todas las esferas de la vida de las pacientes, por lo que el médico de familia debe conocer en profundidad esta patología para optimizar la atención con los mejores recursos disponibles. Los 5 artículos que componen esta revisión ofrecen un resumen de la literatura sobre el cáncer de mama publicada en los últimos 10 años. Este cuarto artículo aborda el tratamiento de la enfermedad, el papel del médico de atención primaria al respecto y el manejo de las principales complicaciones. Esta revisión pretende ofrecer una visión global, actualizada y práctica sobre esta enfermedad que permita resolver los interrogantes que se presentan en la consulta de atención primaria, facilitar respuestas a las mujeres que las soliciten y en definitiva, permanecer al lado de las pacientes a lo largo de su enfermedad con la tranquilidad del conocimiento (AU)

Breast cancer is a prevalent disease affecting all areas of patients’ lives. Therefore, family physicians must thoroughly understand this pathology in order to optimize the health care services and make the best use of available resources, for these patients. A series of 5 articles on breast cancer is presented below. It is based on a review of the scientific literature over the last 10 years. This fourth article deals with the treatment of the disease, the role of the primary care physician, and management of major complications. This summary report aims to provide a current and practical review about this problem, providing answers to family doctors and helping them to support their patients and care for them throughout their illness (AU)

Radiation delivery in patients undergoing therapeutic nipple-sparing mastectomy.

BACKGROUND: Although guidelines exist for radiation delivery in the setting of mastectomy or breast-conservation therapy, radiation delivery after nipple-sparing mastectomy (NSM) remains variable. Our goal is to determine whether patients who undergo therapeutic NSM are more likely to receive radiation than patients who undergo non-NSM and whether National Comprehensive Cancer Network (NCCN) guidelines for radiation after mastectomy are observed in NSM patients. METHODS: Female patients who underwent NSM or non-NSM for breast cancer from 2006 to 2010 were isolated from the Surveillance, Epidemiology, and End Results database. Univariate analysis stratified by tumor size and lymph node status, and multivariate analyses were used to compare odds of radiation in NSM and mastectomy patients. Adherence to NCCN guidelines based on tumor size and lymph node status was also investigated. RESULTS: A total of 112,817 patients were included: 470 (0.4 %) underwent NSM, and 112,347 (99.6 %) underwent non-NSM. NSM patients with 0 nodes/size ≤2 cm, 0 nodes/size 2-5 cm, and unexamined axilla/size ≤2 cm had higher odds of radiation when compared with size- and node-matched mastectomy patients. Multivariate logistic regression showed that NSM patients had higher odds of radiation (odds ratio 2.01, p < 0.001) than mastectomy patients. Radiation was given to 18 % of NSM patients who did not meet NCCN guidelines according to size or lymph node involvement, compared with 6 % of mastectomy patients. CONCLUSIONS: Patients who undergo therapeutic NSM are more likely to receive radiation compared with mastectomy patients. This may reflect a concern with leaving ductal tissue in the nipple-areolar complex.

Long-term outcome of accelerated partial breast irradiation using a multilumen balloon applicator in a patient with existing breast implants.

PURPOSE: Accelerated partial breast irradiation is now an accepted component of breast-conserving therapy. However, data regarding long-term outcomes of patients treated with multilumen catheter systems who have existing breast implants are limited. METHODS AND MATERIALS: We report the treatment and outcome of our patient who had existing bilateral silicone subpectoral implants at the time of presentation. Ultrasound-guided core needle biopsy of the right breast showed infiltrating mucinous carcinoma. Right breast lumpectomy revealed an 8 mm area of infiltrating ductal carcinoma with mucinous features and nuclear grade 1. A 4-5 cm Contura (Bard Biopsy Systems, Tempe, AZ) device was placed, and she was treated over the course of 5 days twice daily to a dose of 34 Gy using a high-dose-rate iridium-192 source. RESULTS: The planning target volume for evaluation was 73.9 cc. The percentage of the planning target volume for evaluation receiving 90%, 95%, and 100% of the prescribed dose was 99.9%, 99.3%, and 97.8%, respectively. The total implant volume was 234.5 cc and received a mean dose of 15.4 Gy and a maximum dose of 72.8 Gy. The percentage of implant volume receiving 50%, 75%, 100%, and 200% of the prescribed dose was 31.1%, 16.5%, 8.6%, 2.0%, and 0%, respectively. Maximum skin dose was 97% of the prescribed dose. With a followup of nearly 5 years, she continues to be cancer free with minimal late toxicities and good to excellent cosmetic outcome. CONCLUSIONS: Accelerated partial breast irradiation using a multilumen balloon applicator in patients with existing breast implants can safely be performed with excellent long-term cosmetic outcome. Further studies are needed to establish the absolute dosimetric tolerance of breast implants.

Letrozole combined with gonadotropin-releasing hormone analog for metastatic male breast cancer.

The role of aromatase inhibitors combined with gonadotropin-releasing hormone analog in metastatic male breast cancer patients remains unknown. In this retrospective study we evaluated the activity of letrozole combined with a gonadotropin-releasing hormone analog as a first- or second-line therapy for metastatic male breast cancer patients. 19 men entered the study. We did not observe any grade 3 or 4 adverse events. 2 patients (10.5 %) had complete response, 7 patients (36.8 %) experienced a partial response, 7 patients (36.8 %) had stable disease lasting ≥ 6 months, and 3 patients (15.8 %) had progressive disease. Overall, the disease control rate was 84.2 %. Median progression-free survival was 12.5 months (95 % CI 8.2-16.9), median overall survival was 35.8 months (95 % CI 24.4-49.2), 1- and 2-year survival rates were 89.5 and 67 %, respectively. Interestingly, 3 out of 4 patients treated with the combination following disease progression while on aromatase inhibitor monotherapy confirmed or improved the best overall response observed in the first-line setting. The combination of letrozole and gonadotropin-releasing hormone analog is effective and safe in hormone-receptor positive, metastatic male breast cancer patients.

[Long-term results of personalized treatment in 72 breast cancer patients who failed chemotherapy].

OBJECTIVE: To evaluate the efficacy and prognostic factors of personalized treatment for breast cancer patients who failed chemotherapy. METHODS: Seventy-two patients with breast cancer who failed chemotherapy were treated at the Tumor Hospital of Harbin Medical University from January 2001 to January 2012. Among them, 42 cases received 5.6 cycles (range, 4-8 cycles) of postoperative adjuvant chemotherapy, and 30 cases received 12.2 cycles (range, 6-22 cycles), both postoperative adjuvant and salvage chemotherapy. All of the 72 patients of stage IV were given personalized treatment. Under guidance of the principle that multidisciplinary treatment improves control rate but does not or less damage the normal tissues and host immune function, precise radiotherapy combined with Chinese herbal medicine (CHM), biological agent and others were chosen for the patients. RESULTS: The median survival time was 20 months. Univariate analysis showed that non-invasive ductal carcinoma, less metastasized organs, without brain, liver and lung metastasis, Karnofsky performance scores ≥ 80, not combined with chemotherapy, and multiple courses of Chinese herbal medicine and biolojical agent treatment had significant impact on survival (P < 0.05). Multivariate analysis showed that no brain metastasis, non-invasive ductal carcinoma, and Chinese herbal medicine and biological agent treatment ≥ 7 courses and not combined with chemotherapy had obvious significance (P < 0.05). The rate of grade 3 and 4 treatment-related hematological toxicity was 8.3% (6/72) and 5.6% (4/72), respectively. All the patients with grade 4 hematological toxicity were the cases of grade 3 at hospital admission. No grade 3 and 4 acute radiation damages of the lung and liver were noticed. CONCLUSION: Chinese herbal medicine combined with biological agents and others prolongs survival time in breast cancer patients who failed chemotherapy, and provides an alternative treatment modality for them.

Exclusive alternating chemotherapy and radiotherapy in nonmetastatic inflammatory breast cancer: 20 years of follow-up.

BACKGROUND: Locoregional treatment of inflammatory breast cancer (IBC) is crucial because local relapses may be highly symptomatic and are commonly associated with distant metastasis. With a median follow-up of 20 years, we report here the long-term results of a monocentric clinical trial combining primary chemotherapy (CT) with a schedule of anthracycline-based CT and an alternating split-course of radiotherapy (RT*CT) without mastectomy. METHODS AND MATERIALS: From September 1983 to December 1989, 124 women with nonmetastatic IBC (T4d M0) were treated with three cycles of primary AVCMF chemotherapy (anthracycline, vincristine, cyclophosphamide, methotrexate, and 5-fluorouracil) and then an alternating RT*CT schedule followed by three cycles of FAC. Hormonal therapy was systematically administered: ovarian irradiation (12 Gy in four fractions) or tamoxifen 20 mg daily. RESULTS: Local control was achieved in 82% of patients. The 10- and 20-year local relapse rates were 26% and 33%, respectively, but only 10% of locally controlled cases were not associated with concurrent distant metastasis. The 10- and 20-year overall survival rates were 39% and 19%, respectively. Severe fibrosis occurred in 54% of patients, grade 3 brachial plexus neuropathy in 4%, grade 2 pneumonitis in 9%. Grade 1, 2 and 3 cardiac toxicity was observed in 3.8%, 3.8% and 1.2% of cases respectively. CONCLUSIONS: This combined regimen allowed good long-term local control without surgery. Survival rates were similar to those obtained with conventional regimens (primary chemotherapy, total mastectomy, and adjuvant radiotherapy). Since IBC continues to be an entity with a dismal prognosis, this approach, safely combining preoperative or postoperative radiation therapy and systemic treatments, should be reassessed when suitable targeted agents are available.

Spinal cord stimulators and radiotherapy: first case report and practice guidelines.

Spinal cord stimulators (SCS) are a well-recognised treatment modality in the management of a number of chronic neuropathic pain conditions, particularly failed back syndrome and radiculopathies. The implantable pulse generator (IPG) component of the SCS is designed and operates in a similar fashion to that of a cardiac pacemaker. The IPG consists of an electrical generator, lithium battery, transmitter/receiver and a minicomputer. When stimulated, it generates pulsed electrical signals which stimulate the dorsal columns of the spinal cord, thus alleviating pain. Analogous to a cardiac pacemaker, it can be potentially damaged by ionising radiation from a linear accelerator, in patients undergoing radiotherapy. Herein we report our clinical management of the first reported case of a patient requiring adjuvant breast radiotherapy who had a SCS in situ. We also provide useful practical recommendations on the management of this scenario within a radiation oncology department.

Concurrent versus sequential administration of CMF chemotherapy and radiotherapy after breast-conserving surgery in early breast cancer.

AIMS AND BACKGROUND: To compare the outcome of concurrent versus sequential administration of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) chemotherapy and radiotherapy after breast-conserving surgery in early breast cancer. METHODS: From February 1992 to January 2002, 156 patients underwent CMF chemotherapy and radiotherapy, either concurrently (CCRT group, 88 patients) or sequentially (SCRT group, 68 patients). There was a predilection of patients with a larger tumor (P = 0.0035), with more frequent nodal involvement (P = 0.0686), and younger age (P = 0.0776) in the CCRT group. RESULTS: The planned radiotherapy was completed in every patient. No grade 3 or 4 late treatment-related toxicity was observed in the CCRT or SCRT group. Compliance to the treatment as well as cosmetic outcome of the two groups were comparable. Despite more adverse factors for local-regional recurrence in the CCRT group, the 5-year local-regional control rate of the CCRT group was similar to that of the SCRT group (97.7% vs 93.8%, respectively, P = 0.1688). On multivariate analysis, concomitant administration of chemotherapy and radiotherapy was associated with improved local-regional control (P = 0.0463). CONCLUSIONS: Concurrent administration of CMF chemotherapy and radiotherapy resulted in improved local-regional control over sequential administration without an increase in significant toxicity. Concurrent CMF chemoradiotherapy may serve as a viable option for patients at high-risk of local-regional relapse not suitable for anthracycline or taxane-based chemotherapy.

Síndrome adyuvante por implante de protesis mamarias de silicón (siliconosis): ¿una condición emergente? / Adjuvant syndrome due to silicone breast prosthesis implant (siliconosis): an emergent condition?

Los implantes mamarios de silicona se han asociado con una variedad de condiciones médicas que aparecen en coincidencia con su implantación; ello constituye la emergencia de una nueva y poco conocida patología de la modernidad. Más del 87% de los enfermos sintomáticos, presentan neuropatía desmielinizante y axonal, comprobada en la biopsia de nervio y músculo, mientras que aproximadamente el 22%-25% tienen evidencia de enfermedad tiroidea autoinmune. Un pequeño porcentaje del 10%-12%, presentan enfermedad desmielinizante primaria del sistema nervioso: esclerosis múltiple diagnósticada mediante resonancia magnética y estudios de líquido cefalorraquideo. Otros presentan condiciones inmunológicas diversas como síndrome de fibromialgia, tiroiditis de Hashimoto, polimiositis, dermatomiositis, lupus eritematoso sistémico, artritis reumatoide, esclerodermia y presencia de autoanticuerpos. Para estos pacientes sintomáticos se propone como diagnóstico unitario un síndrome adyuvante por implante de prótesis mamarias de silicon. Se presentan los casos de dos pacientes ilustrativos.

Silicone breast prosthesis has been associated with a variety of medical conditions or autoimmune diseases, which has coincidental relation with the implants insertion; it's loomed as a new and unknown pathology of the modern times. More than 87% of symptomatic patients developed demyelination axonal neuropathy demonstrated by nerve and muscle biopsy; 22% to 25% have evidence of autoimmune thyroid disease. An a small group of patients (10%-12%) have primary central nervous system demyelination disease as. multiple selerosis. The diagnosis of multiple selerosis was corroborated by magnetic resonance imaging and cerebrospinal fluid analysis. Also, an other wide spectrum of immunological diseases have been observed, such as fibromyalgia. Hashimoto's, polymyositis, dermatomyositis, lupus erythematosus, rheumatoid arthritis, scleroderma, and the presence of autoantibodies. Finally, for symptomatic patients, an adjuvant syndrome of silicone breast prosthesis or implant is proposed as a unitary diagnosis. The authors presented two patients whom illustrated this entity.