Managing supraclavicular disease from breast cancer with brachial plexus-sparing techniques using helical tomotherapy.

AIMS: Managing supraclavicular fossa (SCF) disease in patients with breast cancer can be challenging, with brachial plexopathy recognised as a complication of high-dose radiotherapy to the SCF. Local control of SCF disease is an important end point. Intensity-modulated radiotherapy (IMRT) techniques provide a steep dose gradient and improve the therapeutic index, making it possible to escalate dose to planning target volumes (PTVs), while reducing the dose to organs at risk (OAR). We explored image-guided IMRT techniques using helical tomotherapy to dose escalate SCF lymph nodes with a view to restrict the dose to the brachial plexus. MATERIALS AND METHODS: Three cases with SCF nodal disease in varying clinical stages of breast cancer were planned and treated using helical tomotherapy-IMRT to assess the feasibility and safety of radiotherapy dose escalation to improve the chances of local control in SCF while restricting the dose to the brachial plexus. Consultant clinical oncologists were asked to define the PTVs and OARs as per agreed inhouse policy. The brachial plexus was outlined as a separate OAR in all three cases. In case 1 the left breast and SCF were treated with adjuvant radiotherapy (40 Gy in 15 fractions) with a sequential boost (10 Gy in five fractions) to the SCF PTV. In case 2, local recurrence was salvaged using a simultaneous integrated boost to the gross tumour plus a 3 mm margin to 63 Gy and 54 Gy to the entire SCF. Case 3 was to control nodal disease with re-irradiation of the SCF to a median dose of 44 Gy, while maintaining a low dose to the brachial plexus. Inverse planning constraints (helical tomotherapy) were applied to the PTV and OARs with the brachial plexus allowed a maximum biologically effective dose (BED) of 120 Gy. RESULTS: It was possible to treat the SCF to a higher dose using helical tomotherapy-IMRT. The treatment was successful in controlling disease in the SCF. No patients reported symptoms suggestive of brachial plexopathy. CONCLUSION: Sequential or simultaneous integrated boost to the SCF was safe and feasible. This is the first publication of dose escalation to the SCF when treating breast cancer with brachial plexus-sparing IMRT techniques. The feasibility of such techniques warrants a multicentre phase II study of dose escalation with IMRT to improve local control in isolated SCF disease.

Unilateral groin and pelvic irradiation for unilaterally node-positive women with vulval carcinoma.

It is essential that any patient with resected vulval cancer and significant nodal disease receive optimal adjuvant treatment with radiation. Adequate radiotherapy for such patients with unilateral positive groin nodes has not been defined. Whether both groins and pelvic sidewalls should be irradiated or only the affected (node positive) side remains unclear. From our registry, we identified all patients with primary, previously untreated squamous cell carcinoma of the vulva undergoing bilateral inguinofemoral lymphadenectomy (superficial and deep nodes) and having unilaterally positive groin nodes treated with unilateral groin and pelvic radiotherapy (44 Gy in 22 fractions). Clinical and pathologic records were reviewed to identify the anatomical site and timing of recurrences in these patients and determine whether unilateral groin and pelvic irradiation was sufficient for disease control on the node-negative side. From 1983 to 2002, 20 patients with unilateral positive nodes treated with unilateral groin and pelvic irradiation were identified. Nineteen patients were classed as having FIGO stage III disease and one as FIGO stage IV due to involvement of the rectal mucosa. There were nine patients with disease recurrences in this group (45%). The disease-free interval ranged from 4 to 31 months (median time to recurrence, 9 months). All nine patients had local or regional failures, the most common site being the ipsilateral groin (six of nine patients). One patient was also found to have distant metastases. There were no recurrences noted in the contralateral (nonirradiated) groin or pelvic sidewall. Recurrence was generally fatal. Eight of the nine patients subsequently died of their disease. The ninth patient died of another cause. There was a high incidence of regional failure after unilateral groin and pelvic radiotherapy, but there were no recurrences on the nonirradiated, node-negative side. Although a small series, we speculate that there is no apparent disadvantage to administering unilateral adjuvant radiotherapy for unilaterally positive groin nodes and encourage further studies in order to more confidently determine whether the tendency observed in our center holds true.

Combined radiotherapy and chemotherapy for advanced carcinoma of the cervix.

Until recently the use of cytotoxic drugs in the treatment of squamous carcinoma of the cervix has been limited to patients with local recurrence after primary therapy or with distant metastases. The effectiveness of some cytotoxic drugs, especially cisplatin, in producing tumour regression in this group of patients with a poor prognosis, has encouraged the use of chemotherapy at an earlier stage of the disease process. Since 1979 patients with FIGO IIb squamous carcinoma of the cervix extending more than half-way to the pelvic side-wall and Stages III and IV disease have been treated with a combination of cisplatin or methotrexate and radiotherapy. The complete remission rate of Stage III tumours was 89% with a local recurrence rate of only 8%. In patients with advanced Stage IIb disease only 44% achieved complete remission and three patients with Stage IV disease failed to respond. The projected 5-year survival rate is 66% for patients with Stage III disease and 49% for all patients. The results of this combined treatment are presented and discussed and the suggestion made that chemotherapy combined with radiotherapy can be safely used to advantage in patients at high risk of local relapse.

A device for interstitial therapy of low pelvic tumours--the Hammersmith perineal hedgehog.

The freehand production of accurate volume or multiplane implants for interstitial therapy is difficult. The size of tumour that may be treated in this fashion is therefore limited. A solution to this problem is to use a perspex template to guide the implant and maintain its configuration during treatment. We describe our experience using such a template (the Syed-Neblett template) in treating pelvic tumours. The device has been adapted for use with the iridium wire available in the UK. Two new templates have been designed which are more versatile for treating tumours in this area. Ten patients have been treated and with appropriate analgesia, antibiotic cover and nursing care the implant was well tolerated.