Abstract
Purpose Reirradiation of breast cancer locoregional recurrence (LRR) in the setting of prior post-mastectomy radiation poses a significant clinical challenge due to the high risk for severe toxicity. In an attempt to reduce these toxicities, we have developed pulsed reduced dose-rate radiotherapy (PRDR), a reirradiation technique in which a series of 0.2 Gy pulses separated by 3-min time intervals is delivered, creating an apparent dose rate of 0.0667 Gy/min. Here we describe our early experience with PRDR. Patients and methods We reirradiated 17 patients with LRR breast cancer to the chest wall, axilla, or supraclavicular region using PRDR. The median prior radiation dose was 60 Gy. We delivered a median PRDR dose of 54 Gy (range 40–66 Gy) in 1.8–2.0 Gy per fraction. Eight patients received concomitant low dose capecitabine for radiosensitization. The median treatment volume was 2,084 cm3 (range 843–7,881 cm3). Results At a median follow-up of 18 months (range 4–75 months) only 2 patients have had tumor failure in the treatment region. Estimated 2-year local control rate is 92%. Treatment was well tolerated with 4 patients experiencing grade 3 acute skin toxicity. Despite a median cumulative dose of 110 Gy (range 80–236 Gy), there has been only one grade 3 and one grade 4 late toxicity. Conclusions With a median follow-up of 18 months, PRDR appears to be an effective method to reirradiate large volumes of previously irradiated tissue in selected patients with locoregional chest wall, axilla, and supraclavicular recurrences.
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References
Clarke M, Collins R, Darby S et al (2005) Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 366(9503):2087–2106
Nielsen HM, Overgaard M, Grau C et al (2006) Study of failure pattern among high-risk breast cancer patients with or without postmastectomy radiotherapy in addition to adjuvant systemic therapy: long-term results from the Danish Breast Cancer Cooperative Group DBCG 82 b and c randomized studies. J Clin Oncol 24(15):2268–2275
Nielsen HM, Overgaard M, Grau C et al (2006) Loco-regional recurrence after mastectomy in high-risk breast cancer—risk and prognosis. An analysis of patients from the DBCG 82 b&c randomization trials. Radiother Oncol 79(2):147–155
Hall EJ, Giaccia AJ (2006) Radiobiology for the radiologist, 6th edn. Lippincott Williams & Wilkins, Philadelphia
Brenner DJ, Hall EJ (1991) Conditions for the equivalence of continuous to pulsed low dose rate brachytherapy. Int J Radiat Oncol Biol Phys 20(1):181–190
Pierquin B, Calitchi E, Mazeron JJ et al (1985) A comparison between low dose rate radiotherapy and conventionally fractionated irradiation in moderately extensive cancers of the oropharynx. Int J Radiat Oncol Biol Phys 11(3):431–439
Pierquin B, Calitchi E, Mazeron JJ et al (1987) Update on low dose rate irradiation for cancers of the oropharynx—May 1986. Int J Radiat Oncol Biol Phys 13(2):259–261
Pierquin B (2001) Curie medal lecture 2000. The optimization of delivered dose in radiotherapy: is it related to low dose rate? Radiother Oncol 58(1):7–9
Pierquin B, Tubiana M, Pan C et al (2007) Long-term results of breast cancer irradiation treatment with low-dose-rate external irradiation. Int J Radiat Oncol Biol Phys 67(1):117–121
Joiner MC, Marples B, Lambin P et al (2001) Low-dose hypersensitivity: current status and possible mechanisms. Int J Radiat Oncol Biol Phys 49(2):379–389
Marples B (2004) Is low-dose hyper-radiosensitivity a measure of G2-phase cell radiosensitivity? Cancer Metastasis Rev 23(3–4):197–207
Harney J, Short SC, Shah N et al (2004) Low dose hyper-radiosensitivity in metastatic tumors. Int J Radiat Oncol Biol Phys 59(4):1190–1195
Tome WA, Howard SP (2007) On the possible increase in local tumour control probability for gliomas exhibiting low dose hyper-radiosensitivity using a pulsed schedule. Br J Radiol 80(949):32–37
Cannon GM, Tome WA, Robins HI et al (2007) Pulsed reduced dose-rate radiotherapy: case report: a novel re-treatment strategy in the management of recurrent glioblastoma multiforme. J Neurooncol 83(3):307–311
Chagpar A, Langstein HN, Kronowitz SJ et al (2004) Treatment and outcome of patients with chest wall recurrence after mastectomy and breast reconstruction. Am J Surg 187(2):164–169
Laramore GE, Griffin TW, Parker RG et al (1978) The use of electron beams in treating local recurrence of breast cancer in previously irradiated fields. Cancer 41(3):991–995
Harms W, Krempien R, Hensley FW et al (2001) Results of chest wall reirradiation using pulsed-dose-rate (PDR) brachytherapy molds for breast cancer local recurrences. Int J Radiat Oncol Biol Phys 49(1):205–210
Niehoff P, Dietrich J, Ostertag H et al (2006) High-dose-rate (HDR) or pulsed-dose-rate (PDR) perioperative interstitial intensity-modulated brachytherapy (IMBT) for local recurrences of previously irradiated breast or thoracic wall following breast cancer. Strahlenther Onkol 182(2):102–107
van der Zee J, van der Holt B, Rietveld PJ et al (1999) Reirradiation combined with hyperthermia in recurrent breast cancer results in a worthwhile local palliation. Br J Cancer 79(3–4):483–490
Lee HK, Antell AG, Perez CA et al (1998) Superficial hyperthermia and irradiation for recurrent breast carcinoma of the chest wall: prognostic factors in 196 tumors. Int J Radiat Oncol Biol Phys 40(2):365–375
Halverson KJ, Perez CA, Kuske RR et al (1990) Isolated local-regional recurrence of breast cancer following mastectomy: radiotherapeutic management. Int J Radiat Oncol Biol Phys 19(4):851–858
Willner J, Kiricuta IC, Kolbl O (1997) Locoregional recurrence of breast cancer following mastectomy: always a fatal event? Results of univariate and multivariate analysis. Int J Radiat Oncol Biol Phys 37(4):853–863
Lin PS, Wu A (2005) Not all 2 Gray radiation prescriptions are equivalent: cytotoxic effect depends on delivery sequences of partial fractionated doses. Int J Radiat Oncol Biol Phys 63(2):536–544
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Richards, G.M., Tomé, W.A., Robins, H.I. et al. Pulsed reduced dose-rate radiotherapy: a novel locoregional retreatment strategy for breast cancer recurrence in the previously irradiated chest wall, axilla, or supraclavicular region. Breast Cancer Res Treat 114, 307–313 (2009). https://doi.org/10.1007/s10549-008-9995-3
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DOI: https://doi.org/10.1007/s10549-008-9995-3