👉A mastectomy is an operation to remove all of the breast tissue from a breast as a way to treat or prevent cancer.
👉Mastectomy can be a treatment option for many types of cancer:
Ductal carcinoma in situ or non-invasive breast cancer
Stage I and II (early stage) breast cancer
Stage III (locally advanced) breast cancer, after chemotherapy
Inflammatory breast cancer, after chemotherapy
Paget’s disease of the breast
Locally recurring breast cancer
👉Breast-conserving surgery (partial mastectomy/ lumpectomy), in which only the tumor is removed with negative margins, may be another option.
👉Newer mastectomy techniques can preserve the skin of the breast and allow it to have a more natural appearance – Skin sparing mastectomy
👉Newer mastectomy techniques can preserve the nipple areolar complex of the breast allowing it to have a more natural appearance – Nipple sparing mastectomy
👉Surgery to restore the shape of the breast, called breast reconstruction, can be done at the same time as the mastectomy or during a second operation.
Hialeah, Fla. – July 22, 2020 – Rodrigo Arrangoiz, MD, MS, FACS a fellowship-trained surgical oncologist with a focus in the treatment of breast cancer, thyroid cancer, hyperparathyroidism and other types of head and neck cancers has joined the Center for Advanced Surgical Oncology, a Tenet Florida Physician Services (TFPS) medical practice located in Hialeah. Dr. Arrangoiz’s professional experience includes specialization in benign and malignant thyroid diseases (thyroid cancer), parathyroid diseases (hyperparathyroidism), benign and malignant breast diseases (breast cancer), head and neck surgery (squamous cell carcinomas, salivary gland malignancies), and skin cancers. He is certified by the American Board of General Surgery and graduated from a surgical oncology fellowship accredited by the Society of Surgical Oncology. Dr. Arrangoiz is bilingual in English and Spanish and on-staff at Palmetto General Hospital in Hialeah.
Dr. Arrangoiz joins an established surgical oncology office under the direction of Adrian Legaspi, MD, FACS, Medical Director of the Center for Advanced Surgical Oncology (CASO). Prior to joining the CASO practice, Dr. Arrangoiz worked as a breast, thyroid, parathyroid, and head and neck surgeon and served as Assistant Professor of Surgery, at the American British Cowdray Medical Center located in Mexico City, Mexico. For his education and training, Dr. Arrangoiz participated in an advanced two-year fellowship in head and neck surgery, and oncology from the International Federation of Head and Neck Oncology Societies and Memorial Sloan Kettering Cancer Center. Dr. Arrangoiz completed his complex surgical oncology/head and neck training at the Fox Chase Cancer Center (FCCC) located in Philadelphia, PA.
In addition to his fellowships, Dr. Arrangoiz finished a general surgery internship and residency where he was appointed chief resident at the Michigan State University Department of Surgery in Lansing, MI.
Dr. Arrangoiz received a grant from FCCC in order for him to complete his Master’s of Science in clinical research for health care professionals from Drexel University in Philadelphia. He graduated Summa Cum Laude from Anahuac University Medical School in Mexico City. Additionally, Dr. Arrangoiz completed his medical school internships with the National Institute of Perinatology, National Institute of Pediatrics’ in Mexico and at Jackson Memorial Hospital in Miami, FL.
Dr. Arrangoiz has published numerous scientific publications relating to oncology and surgery in peer-reviewed journals. He has written numerous abstracts on his surgical oncology research and presented his findings at surgical society meetings. Dr. Arrangoiz has presented as an invited lecturer at numerous international conferences and hospital grand rounds meetings on the topics of cancer and surgical treatments of cancer diseases.
Dr. Arrangoiz is a member of the American College of Surgeons, American Society of Breast Surgeons, American Society of Clinical Oncology, American Thyroid Association, American Head and Neck Society, the Society of Surgical Oncology, and the Association for Academic Surgery. He has been practicing medicine since 2002.
Mastalgia refers to breast pain and is a common presenting complaint among female patients:
Mastalgia is the most common symptom:
In patients undergoing breast imaging
It affects approximately:
70% of women
It is usually mild and self-limited but in:
Approximately 15% of affected women will require treatment
One study of almost 1700 women (mean age 34 years) surveyed by online questionnaire:
Found that over one-half (51.5%) had experienced breast pain:
Pain was more commonly reported among:
Older women
Those with larger breast sizes
Those less fit and / or physically active
In addition, of those who reported symptoms:
41% and 35% reported negative impacts from breast pain on their sexual health and sleep, respectively
10% of those symptomatic had reported breast pain as an issue for over half of their lives
It is classified in three categories:
Cyclic:
The level of pain can:
Vary according to the menstrual cycle:
Cyclical pain is associated with:
Hormonal fluctuations of the menstrual cycle
Cyclic breast pain:
Is the most common type:
Affecting two-thirds of patients with true mastalgia
Is more common in:
Premenopausal women in the 30s
It is usually:
Bilateral
It is more often felt:
In the upper outer quadrant
Its intensity increasesjust before menstruation and decreases after menstruation
It is thought to be caused by hormonal changes:
Therefore, most cases come in those actively menstruating or using HRT
Minor cyclical breast discomfort is normal:
It begins during the late luteal phase and dissipates with the onset of menses
This is usually bilateral and diffuse pain
Cyclical breast discomfort is caused by normal hormonal changes associated with ovulation:
That stimulate the proliferation of normal glandular breast tissue and result in pain
The stimulation of:
Ductal elements by estrogen
Stroma by progesterone
Stimulation of ductal secretion by prolactin:
All contribute to cyclical pain during the menstrual cycle
Cyclical breast pain can also be associated with pharmacologic hormonal agents:
Postmenopausal hormone therapy
Oral contraceptive pills
Non-cyclic:
It is not associated with the menstrual cycle
Noncyclical pain affects one-third of women with true mastalgia:
The pain does not follow the usual menstrual pattern:
May be constant or intermittent
Is more likely to be unilateral and variable in its location in the breast
Noncyclical breast pain is more likely to be related to:
A breast or chest wall lesion
Possible etiologies include:
Large pendulous breasts:
Large pendulous breasts may cause pain due to stretching of Cooper’s ligaments
Neck, back, and shoulder pain and headache may be present, as well as a rash under the pendulous breast in the inframammary fold
Diet, lifestyle:
The role of diet and lifestyle in causing breast pain is uncertain
Although a high-fat diet, smoking, and caffeine intake have been associated with breast pain:
It is difficult to conduct randomized trials with appropriate blinding that will negate the placebo effect:
Hence, there is currently no high-quality evidence to suggest that:
A low-fat diet, smoking cessation, or caffeine avoidance reduces breast pain
Hormone replacement therapy:
Up to one-third of menopausal women receiving postmenopausal hormone therapy experience some degree of noncyclical breast pain:
Which may spontaneously resolve over time
Breast cysts:
Solitary cysts:
Particularly when the presentation is abrupt:
Are frequently painful
Ductal ectasia:
Is characterized by distention of subareolar ducts due to inflammation unrelated to infection
Ductal ectasia may be associated with fever and acute local pain and tendernesscaused by:
Penetration of the duct wall by lipid material, which may resolve to leave a subareolar nodule:
In one study, the site and degree of duct dilatation correlated with the intensity of noncyclical breast pain
Mastitis:
Mastitis or breast abscess typically presents as:
A painful, swollen, and red breast in a febrile woman
Mastitis is more prevalent during lactation but can also occur in nonlactating women:
Idiopathic granulomatous mastitis [IGM]) or smokers
Inflammatory breast cancer:
Women with de novo inflammatory breast cancer (primary disease) may present with pain and a rapidly progressing tender, firm, enlarged breast
The skin over the breast is warm and thickened, with a “peau d’orange” (orange skin) appearance, but there is often no fever or leukocytosis
Hidradenitis suppurativa:
Although primarily confined to the axilla>
Can involve the breast and present as breast nodules and pain
Other:
Other etiologies of breast pain include:
Pregnancy
Thrombophlebitis (Mondor’s disease)
Trauma
Macrocysts
Prior breast surgery
Medications, including:
Oral contraceptives
Anti-depressants:
Such as sertraline
Antipsychotic drugs:
Such as haloperidol
Cardiovascular agents
Antibiotics
Is felt as pain related to the chest wall:
Rather than the breast itself
It is not associated with the menstrual cycle
It may be felt either:
Continuously or intermittently
It is rare as compared to the cyclic type:
Around a third of mastalgia is non-cyclical pain not unrelated to the menstrual cycle
It is found in women who are in their 40s
It is usually localized to one side and felt at a single area
Extramammary:
Some women who present with breast pain actually have referred pain from sources other than the breasts
The breast is innervated by the anterolateral and anteromedial branches of the intercostal nerves (T3 to T5):
Irritation of these nerves anywhere along their course can lead to pain that is felt in the breast or nipple
Women presenting with breast pain more often have extramammary painrather than true mastalgia
Extramammary pain may be from:
Musculoskeletal sources such as:
The chest wall, spinal or paraspinal disorders, trauma, or scarring from prior biopsy
It may also be related to medical problems such as:
Biliary, pulmonary, esophageal, or cardiac disease
Chest wall pain:
Is frequently due to pectoralis major muscle injury, related to repetitive activities such as water skiing, raking, rowing, or shoveling
Chest wall pain that presents as bilateral parasternal discomfort can also arise from costochondritis (typically the second through fifth costochondral junctions) or Tietze syndrome (typically the second and third costochondral junctions)
Other etiologies of chest wall pain include slipping and clicking ribs and arthritis
Spinal and paraspinal disorders:
Radicular chest wall pain may be due to cervical arthritis:
This pain typically occurs in older women in whom vertebral, spinal, and paraspinal problems in the neck and upper thorax accumulate with age
Paraspinal muscle spasm and other impingements on the free course of the sensory nerves from the neck and upper thorax can cause a radiculopathy leading to pain or hyperesthesia
Burning pain, which is typical of nerve root pressure, is a common feature
Imaging studies of the neck may reveal the etiology of the pain
Trauma:
Breast pain can be caused by local trauma, such as seat belt injury, child or pet kicking, or intimate partner violence, to the breasts or anterior chest wall
Pain can also be caused by intercostal neuralgia due to a respiratory infection or underlying pleuritic lesions:
Additionally, gallbladder disease or ischemic heart disease may present as intermittent chest pain attributed to the breast
Post-thoracotomy syndrome:
Is an unusual disorder in which a healing chest woundsimulates the effect of a suckling infant
It can be associated with an elevated prolactin concentration, breast pain, and milk production
A similar effect can be seen with other forms of chest wall irritation, including burns and chafing from clothing overlying the nipple
Pathophysiology of breast pain is not fully elucidated:
Etiologic factors:
High levels of serum fatty acid levels
Increase in basal prolactin levels
Excessive fatty diet
Psychological factors:
Are also shown to play a role in the etiology in some studies
A primary concern for patients with mastalgia:
Is that it is related to breast cancer:
However, the incidence of a breast malignancy associated with a presenting complaint of mastalgia is low:
A thorough assessment is required to determine the cause of the pain:
Explore any potential associated symptoms, and hopefully to reassure and manage their symptoms
It is rare for men to experience mastalgia:
However, it can occur in those who have developed:
Gynaecomastia
Clinical Features:
During the history and physical one should ask about specific features that could indicate a pathological cause of mastalgia, such as:
Lumps (breast nodules)
Skin changes:
Skin erythema
Skin dimpling (retraction)
Peu de orange
Nipple retraction
Nipple discharge
Fevers
Work-up:
Breast pain in isolation with no other relevant features on history or examination:
Is not an indication for imaging
All patients within reproductive age should have a pregnancy test
The American College of Radiology Appropriateness Criteria guidelines recommend the following approach to selecting an imaging modality:
Women with cyclical or bilateral non-focal breast pain usually do not require imaging:
The yield of finding a specific cause with imaging is low
Women with noncyclical, unilateral, or focal breast pain that is not extramammary (eg, chest wall pain), as determined by physical exam:
Should undergo breast imaging to elucidate the underlying etiology and exclude breast cancer
The choice of imaging modality is based on age:
Women under 30 years of age should undergo ultrasound because it is more accurate than mammography for that age group:
Mammography is added if abnormality is found on the ultrasound and / or if a patient’s history or risk status justifies the radiation exposure (eg, family history of premenopausal breast cancer)
Women between 30 and 39 years of age should also undergo ultrasound, and unilateral or bilateral mammography should also be performed because in this age group some small cancers are found on mammography but not ultrasound.
Women age 40 and older should undergo both mammography and ultrasound
Management:
Any underlying cause suspected should be investigated and managed as appropriate
However, in most cases the mastalgia pain will be idiopathic in nature and therefore reassurance and pain control, is the primary form of management
NICE guidelines states:
The management for cyclical breast pain should include:
Wearing a better fitting bra or soft-support bra during the night
The use of oral ibuprofen or paracetamol or topical NSAIDs can help alleviate pain
Non-cyclical pain does not usually respond well to treatment but in idiopathic cases will often resolve spontaneously
If first line management options are unsuccessful, a referral to a specialist may be warranted (breast surgeon)
Second line treatment for breast pain include:
The use of Danazol:
An anti-gonadotrophin agent:
Yet these can be accompanied with unpleasant side-effects:
Such as nausea, dizziness, and weight gain
References:
Mansel RE. Clinical Assessment of mastalgia. Br J Clin Pract Suppl 1989; 43: 17-9. Gateley CA, Holland PA. Drug therapy of mastalgia. What are the options? Drugs 1994; 48: 709-16.
Watt-Boolsen S, Eskildsen PC, Blaehr H. Release of prolactin, thyro- tropin and growth hormone in women with cyclical mastalgia and fibrocystic disease of the breast. Cancer 1985; 56: 500-2. Seema A. Khan, A. Vania Apkarian. Mastalgia and breast cancer: a protective association? Cancer Detection and Prevention 2002; 26: 192-6.
Fox H, Walker LG, Heys SD, Ah-See AK, Eremin O. Are patients with mastalgia anxious, and does relaxation therapy help? The Breast 1997; 6: 138-42. Preece PE, Baum M, Mansel RE, Webster DJ, Fortt RW, Gravelle IH, et al. Importance of mastalgia in operable breast cancer. Br Med J (Clin Res Ed) 1982; 284: 1299-300.
Plu-Bureau G, Thalabard JC, Sitruk-Ware R, Asselain B, Mauvais-Jar- vis P. Cyclical mastalgia as a marker of breast cancer susceptibility: results of a case-control study among French women. Br J Cancer 1992; 65: 945-9.
Aksu G, Hocaoğlu Ç. Evaluation of Anxiety, Alexytimia and Depres- sion levels in patients undergoing Radiologic Evaluation for Mas- talgia. Klinik Psikiyatri 2004; 7: 95-102
If you’re having thyroid surgery, it’s important to know how to best prepare for your procedure and what to expect while you recover. This includes any tests you’ll need before surgery, as well as what to avoid after surgery to help ensure its success.
How should I prepare for thyroid surgery?
After your thyroidectomy or thyroid lobectomy is scheduled, you’ll have a pre-operative evaluation with members of your thyroid surgery care team. That evaluation may include blood tests, an electrocardiogram (EKG), X-rays or other imaging studies.
We’ll give you specific instructions on when to stop eating, drinking and taking medications prior to surgery. It’s very important that you follow these guidelines for your own safety, and you’ll need to have an empty stomach before any surgical procedure that requires anesthesia. If you don’t follow the instructions, your thyroid surgery might be cancelled. Please contact us with any specific questions.
What is recovery like after thyroid surgery?
After your thyroidectomy or thyroid lobectomy, you may have a temporary sore throat, neck pain, difficulty swallowing or a weak voice.
Your diet will be restricted for the evening of your surgery, but in most cases, it can return to normal the next day.
Before you leave the hospital, we’ll schedule a follow-up appointment, give instructions for your at-home recovery and go over any prescribed medications.
Most people are ready to return home within one day of surgery, but take off about two weeks from work to recover. You’ll need to refrain from heavy lifting or other tasks that can strain your neck for up to three weeks after your surgery. Soaking or scrubbing the site of your incision is also discouraged for at least one week to allow it time to properly heal. Showering is generally allowed after about one day.
Pain at the site of your incision will improve after a few days but may continue for a week or so. If you notice sudden swelling in your neck, which could signify an infection, contact our office.
Due to disturbance of the parathyroid glands, which regulate calcium balance, your calcium level may drop after surgery. If it drops, you may notice numbness and tingling of your fingers or around your mouth. We’ll monitor your calcium levels through blood tests, and give you instructions about taking calcium replacements if needed.
What are the side effects of thyroid surgery?
After a total thyroidectomy, you will take lifelong thyroid hormone replacements. Because your entire thyroid gland is removed, it will no longer supply you with the hormone you need to control your body’s metabolic processes. You might also have to take supplements after thyroidectomy to balance your calcium levels.
After a thyroid lobectomy, you’ll need to have your thyroid hormone levels checked and will be prescribed a thyroid hormone replacement, if needed.
In the weeks after your thyroid surgery, you may have neck pain, soreness of your vocal chords or a weak voice. These symptoms are usually temporary.
Will I need to follow a special diet after thyroid surgery?
For most people, a special diet after a thyroidectomy or thyroid lobectomy isn’t necessary. You’ll likely be able to eat and drink normally the morning after your surgery, but you may prefer softer foods at first. We’ll let you know if and for how long you need to restrict your eating and drinking.
Multiple groups have attempted to define a favorable subgroup of women:
In whom the omission of adjuvant irradiation following a partial mastectomy is reasonable
One study (CALGB 9343):
Randomized women:
Ages 70 years and older:
Clinical stage I (T1, N0, M0) disease
To tamoxifen for 5 years versus tamoxifen plus whole-breast irradiation
Patients with estrogen receptor-negative tumors:
Were excluded
Most tumors were 2 cm or less, and surgical margins were required to be negative (defined as the absence of tumor at the inked margin)
Adjuvant whole-breast irradiation:
Significantly reduced the risk of local or regional failure:
From 10% to 2% at 10 years
There were no significant differences in:
Distant disease-free survival or overall survival between the groups
The PRIME II trial:
Enrolled 1326 patients:
Ages 65 years and older:
With T1 to T2, node-negative tumors and clear margins
Following breast-conserving surgery:
Patients received endocrine therapy and were randomized to:
Adjuvant radiation therapy or no further treatment
At 5 years:
Those undergoing radiation demonstrated a reduction in local recurrence:
4.1% vs 1.3% with no difference in survival
Typical breast tangents, without targeted nodal irradiation, would be appropriate for a patient with pN0 disease
Adjuvant irradiation:
Reduces the risk of ipsilateral breast tumor recurrence regardless of whether the margins are positive:
A positive margin, however, significantly increases the risk of local failure despite irradiation
References:
Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow up of CALGB 9343. J Clin Oncol. 2013;31:2382-2387.
Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med. 2004;351:971-977.
Kunkler IH, William LJ, Jack WJ, Cameron DA, Dixon JM; PRIME II investigators. Breast-conserving surgery with or without irradiation in women aged 65 years or older with early breast cancer (PRIME II): a randomised controlled trial. Lancet Oncol. 2015;16:266-273.
Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88:553-564.
Patients with large breasts can be a challenge for the delivery of adjuvant radiation therapy:
They have typically had higher acute and late toxicity as well as inferior cosmesis
One potential explanation for this:
Is that they may have larger hot spots of increased dose compared to patients with smaller breasts
Several techniques have been devised to improve these hot spots and reduce toxicity:
Intensity-modulated radiation therapy:
Has been shown in randomized trials to reduce acute and chronic toxicity:
With institutional data demonstrating reductions in toxicity in women with large breasts:
By reducing hot spots and improving homogeneity
Proton therapy:
Is not widely utilized to deliver WBI with no data supporting improvement in toxicity in women with large breasts with WBI
Electrons:
Are typically utilized in treating the chest wall or as part of a tumor bed boost and are not utilized to deliver WBI
Neutron therapy:
Is limited in its availability and is not routinely used to deliver WBI
References:
Donovan E, Bleakley N, Denholm E, et al; Breast Technology Group. Randomised trial of standard 2D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiother Oncol. 2007;82:254-264.
Hille-Betz U, Baske B, Bremer M, et al. Late radiation side effects, cosmetic outcomes, and pain in breast cancer patients after breast-conserving surgery and three-dimensional conformal radiotherapy: risk modifying factors. Strahlenther Onkol. 2016;192:8-16.
Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008;26:2085-2092.
Shah C, Wobb J, Grills I, Wallace M, Mitchell C, Vicini FA. Use of intensity modulated radiation therapy to reduce acute and chronic toxicities of breast cancer patients treated with traditional and accelerated whole breast irradiation. Pract Radiat Oncol. 2012;2:e45-51.
Multiple techniques have been used to aid in cardiac sparing including:
Assisted breathing control
Accelerated partial breast irradiation
Intensity-modulated radiation therapy
Prone breast irradiation
A recent study from Mulliez et al:
Found that prone technique in conjunction with respiratory gating was associated with a:
Reduction in mean heart dose as well as dose to the left anterior descending coronary artery
At this time:
There are limited data regarding long-term cardiac outcomes (eg, myocardial infarctions) with any cardiac sparing technique:
Due to the length of follow-up required
Outcomes with prone breast irradiation have demonstrated:
Low rates of local recurrence
Excellent cosmetic outcomes
No suggestion of higher rates of skin toxicity
Lower doses to the lungs and heart
No suggestion of higher rates of pneumonitis
References:
Mulliez T, Speleers B, Mahjoubi K, et al. Prone left-sided whole-breast irradiation: significant heart dose reduction using end-inspiratory versus end-expiratory gating. Cancer Radiother. 2014;18:672-677.
Mulliez T, Veldeman L, Speleers B, et al. Heart dose reduction by prone deep inspiration breath hold in left-sided breast irradiation. Radiother Oncol. 2015;114:79-84.
Osa EO, DeWyngaert K, Roses D, et al. Prone breast intensity modulated radiation therapy: 5-year results. Int J Radiat Oncol Biol Phys. 2014;89:899-906.
Shah C, Badiyan S, Berry S, et al. Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy. Radiother Oncol. 2014;112:9-16.
71.3% of women in the control group compared with 69.8% of the women in the hypofractionated radiation group had a good or excellent cosmetic outcome:
Absolute difference, 1.5 percentage points; 95% CI, −6.9 to 9.8)
In the START-B trial:
The proportion of patients with local-regional relapse at 10 years did not differ significantly:
Between the 40 Gy (hypofractionation) group (4.3%, 95% CI, 3.2–5.9) and the 50 Gy (standard) group (5.5%, 95% CI, 4.2–7.2; hazard ratio, 0.77, 95% CI, 0.51–1.6; P=0.21)
There was less breast shrinkage, telangiectasia, and edema in the 40 Gy/15 fraction arm
Traditionally:
A separation (the distance from the medial to the lateral border of the tangential beam) of:
25 cm was utilized as a cut off:
But now a maximum dose of 107% of prescription is used in light of advancements in planning techniques
Current evidence-based American Society for Radiation Oncology (ASTRO) guidelines on fractionation recommend hypofractionated WBI be considered in:
Patients age 50 years and older:
With T1 to T2, N0 disease:
Who do not receive chemotherapy
It should be noted that the percentage of patients with nodal positivity in these trials was quite low:
So the role of hypofractionated regimens in node-positive patients remains unanswered
References:
Haviland JS, Owen JR, Dewar JA, et al; START Trialists’ Group. The UK Standardization of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early stage breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14:1086-1094.
Smith BD, Bentzen SM, Correa CR, et al. Fractionation for whole breast irradiation: an American Society for Radiation Oncology (ASTRO) evidence-based guideline. Int J Radiat Oncol Biol Phys. 2011;81:59-68.
Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362:513-520.
Irradiation is an integral part of the tri-modality treatment of inflammatory breast cancer
Rarely:
Radiation may be administered preoperatively:
Particularly in the context of a suboptimal response to neoadjuvant systemic therapy or progressive disease
Following a mastectomy:
Postmastectomy irradiation is routinely given
Data from British Columbia:
Have demonstrated mastectomy with modern chemotherapy and radiation techniques:
Is associated with improved locoregional control
Radiotherapy comprises:
Whole breast with comprehensive nodal irradiation:
In the setting of preoperative treatment
Chest wall with comprehensive nodal irradiation:
Following a mastectomy
Most series report inclusion of the internal mammary lymph node chain in radiation portals:
Even if clinically negative
For left-sided treatment:
Modern techniques, including:
Intensity-modulated radiation therapy:
May be employed to avoid dose to the heart and lungs while appropriately covering the regional lymph nodes
References:
Panades M, Olivotto IA, Speers CH, et al. Evolving treatment strategies for inflammatory breast cancer: a population-based survival analysis. J Clin Oncol. 2005;23:1941-1950.
Scotti V, Desideri I, Meattini I, et al. Management of inflammatory breast cancer: focus on radiotherapy with an evidence-based approach. Cancer Treat Rev. 2012;39:119-124.
Ueno NT, Buzdar AU, Singletary SE, et al. Combined-modality treatment of inflammatory breast carcinoma: twenty years of experience at M.D. Anderson Cancer Center. Cancer Chemother Pharmacol. 1997;40:321-329.
Yim J, Suttie C, Bromley R, Morgia M, Lamoury G. Intensity modulated radiotherapy and 3D conformal radiotherapy for whole breast irradiation: a comparative dosimetric study and introduction of a novel qualitative index for plan evaluation, the normal tissue index. J Med Radiat Sci. 2015;62:184-191.
Patients with left-sided breast cancers in particular:
Are candidates for cardiac sparing breast radiation techniques
Multiple techniques exist to spare cardiac dose and include:
Active breathing coordinator techniques (ABC)
Prone breast irradiation
Intensity-modulated radiation therapy
Accelerated partial breast irradiation
None however is considered superior to another and the choice of technique employed depends on multiple patient factors:
ABC has been used consistently as a method to reduce heart dose:
By increasing the distance from the chest wall to the heart
Prone breast irradiation:
Allows for the breast to fall away from the chest:
Potentially improving cardiac dose
Intensity-modulated radiation therapy:
Can create segments within the beam to limit heart dose
Accelerated partial breast irradiation:
Limits the volume treated to the area surrounding the lumpectomy cavity and thus spares the heart
References:
Eldredge-Hindy H, Lockamy V, Crawford A, et al. Active breathing coordinator reduces radiation dose to the heart and preserves local control in patients with left breast cancer: report of a prospective trial. Pract Radiat Oncol. 2015;5:4-10.
Mulliez T, Veldeman L, Speleers B, et al. Heart dose reduction by prone deep inspiration breath hold in left-sided breast irradiation. Radiother Oncol. 2015;114:79-84. Shah C, Badiyan S, Berry S, et al. Cardiac dose sparing and avoidance techniques in breast cancer radiotherapy. Radiother Oncol. 2014;112:9-16.
Yim J, Suttie C, Bromley R, Morgia M, Lamoury G. Intensity modulated radiotherapy and 3D conformal radiotherapy for whole breast irradiation: a comparative dosimetric study and introduction of a novel qualitative index for plan evaluation, the normal tissue index. J Med Radiat Sci. 2015;62:184-191.
Rodrigo Arrangoiz MS, MD, FACS, FSSO 