Toxicity and Cosmetic Outcome of Breast Irradiation in Women with Breast Cancer and Autoimmune Connective Tissue Disease: The Role of Fraction and Field Size.

PURPOSE: Hypofractionation has historically been underused among breast cancer patients with connective tissue diseases given a theoretical risk of increased toxicity and their overall underrepresentation in clinical trials that established hypofractionation as standard of care. We aim to compare the rates of toxicity in patients with autoimmune connective tissue diseases treated with conventionally fractioned radiation therapy (CF-RT) and hypofractionated radiation therapy (HF-RT) including accelerated partial breast irradiation. METHODS: A total of 1983 patients treated with breast conservation between 2012 and 2016 were reviewed for diagnosis of autoimmune disease. Univariate analysis using binary logistic regression was performed to evaluate the effect of disease and treatment variables on acute and late toxicity. Multivariate analyses using Cox regression models were used to evaluate the independent associations between covariates and the primary end points. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for reach risk group. RESULTS: Ninety-two patients with autoimmune disease were identified. Median follow-up was 59 months. Of the patients 35% received CF-RT and 65% received HF-RT, of whom 70% received whole breast radiation (WBI) without regional nodal irradiation, 12% received WBI with regional nodal irradiation, and 18% received accelerated partial breast radiation. Patients who received CF-RT were significantly more likely to have autoimmune disease (AD) symptoms (78% vs 37%, P <.001), to be managed on disease-modifying antirheumatic drugs (DMARDs; 41% vs 15%, P = .013), and to have active autoimmune disease (84% vs 43%, P <.001). On multivariate analysis, HF-RT was associated with a significantly decreased odds of acute and late grade 2/3 toxicity compared with CF-RT fractionation (acute: OR 0.200, 95% CI 0.064-0.622, P = .005; late: OR 0.127, 95% CI 0.031-0.546, P = .005). CONCLUSIONS: Hypofractionation including accelerated partial-breast irradiation is associated with less acute or late grade 2/3 toxicity in this population.

Radiotherapy in patients with connective tissue diseases.

The decision to offer radiotherapy in patients with connective tissue diseases continues to be challenging. Radiotherapy might trigger the onset of connective tissue diseases by increasing the expression of self-antigens, diminishing regulatory T-cell activity, and activating effectors of innate immunity (dendritic cells) through Toll-like receptor-dependent mechanisms, all of which could potentially lead to breaks of immune tolerance. This potential risk has raised some debate among radiation oncologists about whether patients with connective tissue diseases can tolerate radiation as well as people without connective tissue diseases. Because the number of patients with cancer and connective tissue diseases needing radiotherapy will probably increase due to improvements in medical treatment and longer life expectancy, the issue of interactions between radiotherapy and connective tissue diseases needs to be clearer. In this Review, we discuss available data and evidence for patients with connective tissue diseases treated with radiotherapy.

DEGRO guidelines for the radiotherapy of non-malignant disorders : part III: hyperproliferative disorders.

BACKGROUND AND PURPOSE: Radiation therapy (RT) is an established and effective treatment modality in the management of a large variety of hyperproliferative disorders and benign neoplasms. Objective of this article is to summarize the updated DEGRO consensus S2e guideline recommendations. MATERIALS AND METHODS: This report comprises an overview of the relevant aspects of the updated guidelines with regard to treatment decision, dose prescription, and RT technique for a selected group of disorders including Morbus Dupuytren (MD)/Morbus Ledderhose (ML), keloids, Peyronie's disease (induratio penis plastica, IPP), desmoid tumors, pigmented villonodular synovitis (PVNS), symptomatic vertebral hemangiomas (sVH), and Gorham-Stout syndrome (GSS). On the basis of results in the literature, we attempted to classify the level of evidence (LoE) and the grade of recommendation (GR) according to the Oxford criteria. RESULTS: There is comprehensive evidence in the literature that RT is a reasonable and effective treatment modality for the treatment of all the above-mentioned disorders. The LoE varies from 2c to 4, and GR varies from A to C. CONCLUSIONS: The use of RT can be recommended for the interdisciplinary management of most of the reported disorders. It can be used in the primary treatment approach and as an effective adjunct to other treatment modalities or in some indications as a valuable alternative treatment option. We hope that the updated DEGRO S2e consensus guideline recommendations are a helpful tool for radiation oncologists in the clinical decision-making process.

Treatment of fibroelastolytic papulosis with fractionated carbon dioxide laser.

Fibroelastolytic papulosis (FEP) is an acquired elastic tissue disorder that presents as white-to-yellow papules and plaques usually occurring on the neck. Although the lesions are often asymptomatic, their appearance may be distressing to patients. FEP has been treated with topical tretinoin in one case report ( 1 ). Other reports have not mentioned treatment for this rare disorder ( 1-6 ). We present a case of FEP successfully treated with a fractionated carbon dioxide (CO2) laser.

The use of adjuvant high-dose-rate breast brachytherapy in patients with collagen vascular disease: a collaborative experience.

PURPOSE: To analyze toxicity and cosmesis in patients with collagen vascular disease (CVD) treated with accelerated partial breast irradiation (APBI) via high-dose-rate (HDR) brachytherapy. METHODS AND MATERIALS: This is a pooled analysis of patients with early stage and in situ breast cancer with CVD treated with adjuvant multicatheter or balloon brachytherapy. Physicians at multiple institutions were asked to review their experience and report data regarding toxicity and cosmesis in patients with CVD. All patients fit American Society of Breast Surgeons recommendations for APBI and were treated with HDR brachytherapy with ≥ 3 months followup. RESULTS: Nine cases from five institutions are the subject of this analysis. The median patient age was 54 years and median followup was 31 months. All patients had documented history and active signs/symptoms of rheumatoid arthritis, systemic lupus erythematosis, psoriatic arthritis, or scleroderma. All patients had received medical therapy for CVD in the past, and 78% were under active treatment at the time of brachytherapy. All the patients were treated with multicatheter or balloon (MammoSite [Hologic, Inc., Marlboro, MA], MammoSite ML [Hologic, Inc., Marlboro, MA], or Contura [Senorx, Irvine, CA]) brachytherapy with a median volume of 45.5 cc and a median skin distance of 7.5mm. Acute toxicity included Grade 1 skin erythema (5) and catheter-site wound dehiscence (1). Late toxicity included seroma (5), induration (5), pain (2), telangectasia (2), and superficial infection (1). Cosmesis was excellent or good for all the patients. CONCLUSIONS: Women with CVD have a toxicity and cosmesis profile consistent with other APBI series. Although confirmatory data is needed, it may not be necessary to exclude these patients from clinical trials of APBI.

[Treatment of connective tissue disorder-related acral syndromes using UVA-1 phototherapy. An open study of 11 cases]. / Traitement des acrosyndromes des connectivites par photothérapie UVA-1. Etude ouverte de 11 cas.

BACKGROUND: UVA-1 phototherapy is used to treat various connective tissues disorders including systemic lupus erythematosus (SLE) and systemic sclerosis (SS). We conducted an open study to investigate the efficacy of this therapy on connective tissue disorder-related acrosyndrome. MATERIAL AND METHODS: Eleven patients with Raynaud's phenomenon refractory to the standard therapy (six SLE and five SS) were treated with UVA-1 in an open study. Whole-body phototherapy was given in seven cases but was restricted to the hands in four cases. The results were evaluated by comparing status before and after treatment using semi-quantitative tools in terms of daily frequency and intensity of spastic phenomena, pain, overall patient satisfaction, improvement of cutaneous lesions, trophic disorders and distal cutaneous flexibility for patients with ScS. RESULTS: After treatment, Raynaud's phenomenon improved in terms of both frequency and severity in 9/11 patients (82%: 4/6 SS and 5/5 SLE). Likewise, pain decreased in 8/11 cases (73%: 3/6 SS and 5/5 SLE). 7/12 patients felt their condition had improved (64%: 3/6 SS and 4/5 SLE). Cutaneous lesions improved in 5/11 patients (45%: 2/6 SS and 3/5 SLE), especially for lupus-related lesions including chilblains and in idiopathic chilblains that totally subsided within one month. Digital ulcers improved in all cases, with complete healing in 3/4 patients (75%). In SS, cutaneous flexibility significantly improved in 2/6 cases (33%). No major adverse effects were seen in patients treated with hand-only phototherapy but a slight and spontaneously reversible cutaneous rash, reminiscent of lupus lesions, occurred in one female patient receiving whole-body phototherapy. DISCUSSION: This study is the first to provide a precise evaluation of the efficiency of UVA-1 phototherapy on connective tissue disorder-related acrosyndrome. This therapeutic effect is not necessarily restricted to the laboratory effects of UVA-1 since the favourable impact of infrared radiation and a placebo effect cannot be ruled out. Although its methodological limitations are obvious, our study also confirms dare data in the recent literature data by demonstrating significant improvement in cutaneous lesions, trophic ulcers and Raynaud's phenomenon in patients presenting connective tissue disorders, including SS, without any major adverse effects. CONCLUSION: Although these preliminary results remain to be confirmed by large-scale, randomized studies, UVA-1 phototherapy clearly offers a new and valuable therapeutic option in connective tissue disorders associated with acral manifestations and/or lesions, including SLE and SS.

UVA/UVA1 phototherapy and PUVA photochemotherapy in connective tissue diseases and related disorders: a research based review.

BACKGROUND: Broad-band UVA, long-wave UVA1 and PUVA treatment have been described as an alternative/adjunct therapeutic option in a number of inflammatory and malignant skin diseases. Nevertheless, controlled studies investigating the efficacy of UVA irradiation in connective tissue diseases and related disorders are rare. METHODS: Searching the PubMed database the current article systematically reviews established and innovative therapeutic approaches of broad-band UVA irradiation, UVA1 phototherapy and PUVA photochemotherapy in a variety of different connective tissue disorders. RESULTS: Potential pathways include immunomodulation of inflammation, induction of collagenases and initiation of apoptosis. Even though holding the risk of carcinogenesis, photoaging or UV-induced exacerbation, UVA phototherapy seems to exhibit a tolerable risk/benefit ratio at least in systemic sclerosis, localized scleroderma, extragenital lichen sclerosus et atrophicus, sclerodermoid graft-versus-host disease, lupus erythematosus and a number of sclerotic rarities. CONCLUSIONS: Based on the data retrieved from the literature, therapeutic UVA exposure seems to be effective in connective tissue diseases and related disorders. However, more controlled investigations are needed in order to establish a clear-cut catalogue of indications.

Laser therapy of stretch marks.

Striae distensae, better known as stretch marks, are a common disfiguring skin disorder of significant cosmetic concern. Many sources have reported the use of lasers to diminish the appearance of striae. Controlled clinical studies of the various treatment modalities available for striae are relatively uncommon, and much of the clinical data are anecdotal. The use of lasers alone or in combination with other therapeutic modalities can provide a safe and effective reduction in the appearance of both red and white striae distensae. Many of these therapies require special measures for darker skin phototypes. This article reviews the historical use of laser therapy for this disorder and discusses current therapeutic options.

[Radiotherapy of benign non-tumorous diseases from the viewpoint of the Hospital for Oncology (Charité): experiences, possibilities and limitations]. / Zur Strahlentherapie gutartiger nichttumoröser Erkrankungen aus der Sicht der Klinik für Onkologie (Charité): Erfahrungen, Möglichkeiten und Grenzen.

With the development of the state of medical knowledge in the special subjects and the increase of medicamentous and physiotherapeutic possibilities the indications of radiotherapy of benign nontumourous diseases changed. The application of radiotherapy altogether decreased in benign diseases. In tabular form the basic rules radiation technique of benign diseases, the indications and possibilities as well as the contraindications of the radiotherapy of benign non-tumourous diseases are described. Own experiences and evaluations confirm that the radiotherapy, for instance in acute parotitis, axillary hidradenitis, degenerative changes of the skeleton, kelloid revisions or chronic pancreatitis is an effective, rapidly acting and economic form of therapy. The knowledge about the possibilities and limits of the radiotherapy of benign non-tumourous diseases belongs to the speciality of internal medicine.