Radiotherapy

Radiation

High energy x-rays are used to penetrate the tissue and destroy any cancer cells that may remain in the surrounding tissue. Radiotherapy is also used for the local management of breast cancers. This is effective in the local control of breast cancer. Its use decreases the incidence of local recurrence. Radiotherapy may improve overall survival in certain patients. Radiotherapy will prevent local recurrence after breast conserving surgery (it is standard treatment to give DXT to the remaining breast tissue after lumpectomy in Stage I disease). Remember that in medial tumours (inner half of the breast), where there is a chance of internal mammary node involvement (glands under the ribs), the radiotherapist does not only irradiate the remaining breast tissue; he or she may also add an additional blast to the internal mammary nodes. This must be done with caution, as the DXT rays must not hit the heart and lungs.

The following patients must get radiation therapy:

	Any person who has had breast conserving surgery.
	Any person who has had a mastectomy and has close margins i.e. margins less than 10mm from the tumour.
	All cancers bigger than 5 cm (surgery and chemotherapy for a locally advanced breast cancer).
	More than four axillary lymph nodes positive (cancer in 3 or 4 or more) requires the patient to get radiation to the chest wall and axilla.
	Isolated bony secondaries may require radiation to that area.

 

This is effective in the local control of breast cancer. Its use decreases the incidence of local recurrence. Radiotherapy will:

	Control the large, fungating mass which has a foul odour (with or without toilet mastectomy).
	Prevent local recurrence after breast conserving surgery (it is standard treatment to give DXT to the remaining breast tissue after breast conserving surgery.

 


Remember that in medial tumours, where there is a chance of internal mammary node involvement, the radiotherapist does not only irradiate the remaining breast tissue; he or she may also add an additional portal to blast the internal mammary nodes. This must be done with caution, as the DXT rays must not hit the heart and lungs. This danger is higher on the left side, as the heart lies under the sternum and to the left side. DXT to the heart may be cardiotoxic to the myocardium (heart muscle) and may result in heart failure and death.
                               


Another point about DXT is that it is targeted at the residual breast after lumpectomy, and not at the axilla, which will have been cleared surgically by axillary dissection.

 

The axilla should never be treated by both surgical clearance and DXT. This combination is very likely to cause swelling of the ipsilateral upper limb (brawny oedema of the arm).

 

Finally DXT is invaluable treatment of Stage IV breast cancer with bony metastases.

 

Dissemination to bone warrants treatment with DXT in the following situations:

 

	Spinal secondary deposits or metastases with impending paraplegia and the associated bladder and bowel problems (incontinence of urine and / or faeces), due to spinal cord compression.
	Painful bone metastases.
	Pathological bone fracture (in addition to the DXT, the bone needs fixation internally, using a metal rod or a plate and screws, fitted by an orthopaedic surgeon under anaesthesia).

 

This will allow the patient to mobilise early and get around relatively easily. The quality of life is dramatically improved. It is important to realise that DXT is time consuming and in some patients where travel every second day, and lying in a machine when they have back problems may make DXT difficult for them and these patients might do better with a mastectomy due to lifestyle and environmental factors.

 

Locally Advanced Breast Cancers (5cm and bigger)
Primary or induction chemotherapy is the initial treatment of choice and will reduce the size of the tumour so significantly, that a mastectomy or breast conserving surgery may become a possibility (this is also called neo adjuvant chemotherapy).

 

The clinical features of locally advanced (Stage III) breast cancer can be summarised as follows:

 

Clinical features of locally advanced breast cancer:


	Skin ulceration
	Dermal infiltration
	Erythema (redness) over tumour (inflammatory cancer)
	Puckering
	Satellite nodules
	Peau d’orange
	Tethering
	Chest Wall
	Tumour fixation to:
		Ribs
		Serratus anterior or pectoralis major
		Intercostals muscles
	Axillary Nodes
	Nodes fixed to one another or to other structures
	Apical node involvement.




The mainstay of treatment of Stage III is chemotherapy and radiation therapy Occasionally surgery is also required to remove a cancer that is not responding to chemotherapy and radiation therapy. This is called a “toilet mastectomy”. It is important that this procedure is done inconjunction with a plastic surgeon, as it is better to have clear tumour margins. Skin grafts are not advisable as one can not give radiation treatment to a skin graft.