Angiosarcoma of the breast following lumpectomy, axillary lymph node dissection, and radiotherapy for primary breast cancer: three case reports and a review of the literature.

INTRODUCTION: One of the risks of therapeutic irradiation is the development of secondary malignant tumors. In this paper three cases are reported of angiosarcoma of the breast following breast-conserving surgery and irradiation for primary breast cancer, and the literature is reviewed. METHODS AND MATERIALS: Until now, 13 other cases of postirradiation angiosarcoma of the breast have been reported. The mean interval between treatment of primary breast cancer and the development of angiosarcoma in these 16 patients is 76 months. The clinical aspect is typical with multiple bluish or purple nodules of the skin, purple discolorations, erythematous maculas or areas, sometimes combined with ulceration, edema, or a palpable mass. Mammography does not necessarily raise suspicion and the interpretation of fine-needle aspiration or biopsy may be difficult. RESULTS: In all patients mastectomy was performed, Follow-up data are available for 12 cases. Two patients died of extensive local recurrences and one of distant metastases. CONCLUSION: Angiosarcoma of the previously irradiated breast is an extremely rare tumor and diagnosis may be difficult. The number of patients with long-term follow-up after breast-conserving therapy is growing fast. Therefore, the authors advise to pay special attention to uncommon skin changes of the treated breast, since clinical suspicion is the main clue to the diagnosis of postirradiation angiosarcoma. The primary therapy is (simple) mastectomy if wide tumor-free margins can be achieved. There is no indication for standard adjuvant chemotherapy or irradiation.

Risk of tumour growth along thermometry catheter trace: a case report.

A patient with recurrent rectal cancer was treated with the combination of radiotherapy plus hyperthermia. Intratumoral thermometry probes were introduced within closed-tip catheters, inserted through the buttocks under computed tomography (CT) control. Catheters were fixed to the skin to stay in place during the whole treatment series. At the end of the radiotherapy series, tumour progression was apparent. Seven months following treatment, tumour growth was visible at the insertion site of one of the catheters. This finding indicates that catheters should not be placed outside the treatment volume involved in any locally curative treatment.

Treatment perspectives in locally advanced unresectable pancreatic cancer.

Locally advanced unresectable pancreatic cancer is sometimes encountered without manifest distant metastases. Twenty patients with histologically proven unresectable pancreatic cancer without distant metastases were treated with radiotherapy and 5-fluorouracil (5-FU). Radiotherapy consisted of 50 Gy external upper abdomen radiation in two courses, concomitant with intravenous 5-FU 375 mg/m2 given as a bolus injection 4-6h before radiation on the first 4 days of each treatment course. The treatment protocol was completed in 18 patients without complications. The median survival time was 10 months which compares favourably with a 3-5 months median survival time when treatment is withheld. Nine patients (45 per cent) were alive at 1 year, two patients at 2, 3 and 4 years. A second-look operation was performed in four patients 6, 11, 12 and 22 months after completion of radiotherapy. In two patients the tumour could be resected. It appears that treatment with radiotherapy and 5-FU may benefit patients with locally advanced unresectable pancreatic cancer.

Postoperative radiation therapy for rectal cancer. An interim analysis of a prospective, randomized multicenter trial in The Netherlands.

The authors assessed the potential benefit of postoperative radiation therapy for rectal cancer in a two-arm, prospective multicenter trial. One hundred seventy-two patients who had undergone surgical resection for rectal adenocarcinoma were randomly assigned to either treatment consisting of external irradiation to a dose of 5000 cGy in 5 weeks or a control group (no adjuvant therapy). It was assumed that the number of cells remaining after radical surgery would be low and that the dose of 5000 cGy would be adequate in eradicating the majority of those cells. The number of local recurrences was lower in the treated group of patients, but the difference was not statistically significant. It was assumed that if a significant reduction in the number of local recurrences could be obtained, improved (disease-free) survival would result. No influence on disease-free or overall survival could be detected. These results were in agreement with those reported in Europe and the US, and it was concluded that postoperative radiation therapy alone cannot be justified as a routine procedure in the primary management of resectable rectal cancer.

Localized unresectable pancreatic cancer.

Treatment results are presented for 40 patients with unresectable localized pancreatic cancer. The treatment protocol consisted of a split-course external radiation therapy to a dose of 50 Gy combined with intravenous 5-fluorouracil on the first 4 days of each course in a dose of 375 mg/m2/day. There was no treatment mortality and morbidity was moderate. Median survival was 9 months. The 3-year survival of six patients and the 5-year survival of three patients are considered significant enough to advise this combined treatment modality as a standard and to use it in comparison with newer treatment schemes in Phase III studies.

Adjuvant postoperative radiotherapy for gastric carcinoma with poor prognostic signs.

Fifty-seven patients with poor prognostic factors following resection with curative intent for gastric adenocarcinoma (T3 or T4, positive lymph nodes, positive resection line) received adjuvant radiotherapy. A dose of 30.0-50.0 Gy was given in 10-25 fractions in one course or with a split of 2 weeks after 15 fractions. This was combined with 5-fluorouracil (5-FU) (375 mg/m2) given i.v. as a bolus during the first 4 days of radiation (n = 49). The 5-year survival was 26%; this rate is higher than the figures mentioned in the literature after surgery alone. The only way to prove the role of adjuvant radiotherapy for gastric carcinoma is a prospective randomized trial.

Low dose reirradiation in combination with hyperthermia: a palliative treatment for patients with breast cancer recurring in previously irradiated areas.

Ninety-seven patients with breast cancer recurring in a previously irradiated area (mean dose 44 Gy) were reirradiated in combination with hyperthermia and had evaluable tumor responses. In the reirradiation series, radiotherapy was given twice weekly in most patients, with a fraction size varying from 200 to 400 cGy, the total dose varying from 8 to 32 Gy. Hyperthermia was given following the radiotherapy fractions. The combined treatment resulted in 35% complete and 55% partial responses. Duration of response was median 4 months for partial response and 26 months for complete response, respectively. The median survival time for all patients was 12 months. Acute skin reaction was mild, with more than moderate erythema in only 14/97 patients. Thermal burns occurred in 44/97 patients, generally at sites where pain sensation was decreased, and therefore they did not cause much inconvenience. In the 19 patients who survived more than 2 years, no late radiation damage was observed. When patients who received a "high dose" (greater than 29 Gy and hyperthermia) were compared with those who received a "low dose" (less than 29 Gy and hyperthermia), a higher complete response rate was observed in the high dose group (58% vs. 24%), whereas no difference in acute toxicity was found. We conclude that reirradiation with 8 x 4 Gy in combination with hyperthermia twice weekly is a safe, effective and well tolerated method for palliative treatment of patients with breast cancer recurring in previously irradiated areas.

Levamisole as adjuvant immunotherapy in breast cancer.

Results are reported of a double-blind randomized study on 198 patients with resectable node positive mammary cancer, evaluating the effect of the immune modulating drug levamisole in an adjuvant setting. Drug treatment was started after completion of postoperative radiotherapy. In a two-arm trial 97 patients used levamisole and 101 patients used a placebo. No difference was noted in overall survival and disease-free survival between the two groups. Toxicity was reason for discontinuation of the drug in 30 of 97 of the patients in the levamisole group and 8/101 in the placebo group.

Adjuvant post-operative radiotherapy in operable node positive mammary cancer: a comparison of three treatment protocols.

A retrospective analysis of the results of post-operative radiotherapy in 501 operable node positive patients with mammary cancer was performed on all patients treated in 1965-1967 and in 1976, thus enabling us to judge the impact of the different dose levels used in the protocols valid at that time. Low doses were used from 1965 to 1969 and moderately high doses were used in 1976. No influence of the different treatment schedules was observed on survival or disease-free survival at 5 years. Higher T category, lower grade of differentiation, capsular invasion, and top level axillary involvement all contributed to higher risk of locoregional recurrence. High dose post-operative radiotherapy significantly reduced the rate of axillary recurrences and supraclavicular recurrences. A dose effect relationship was evident. Parasternal node metastasis was observed only once, thus influence of radiotherapy on parasternal node metastases could not be evaluated. Scar area recurrences in high risk patients were insufficiently prevented by these post-operative radiotherapy schedules. Indications for post-operative radiotherapy to axillary and supraclavicular areas in mammary cancer should be limited to high risk patients with the aim of preventing locoregional recurrence.

The correlation between liver scintigraphy and serum CEA levels in the detection of liver metastases from rectum carcinoma. A retrospective study.

Radiocolloid liver scintigraphy for the detection of liver metastases is widely used. Because of the known limitations of this technique we investigated the correlation between liver scintigraphy and serum CEA levels in patients with a confirmed diagnosis of primary rectum carcinoma. The serum CEA level is not suitable as a screening test for cancer, but it can be helpful as an extra parameter for the detection of liver metastases. The correlation between liver scintigraphy, the serum CEA level and the clinical findings has also been studied. A good correlation between liver scintigraphy and the serum CEA level was found. Serum CEA levels can be helpful in facilitating the evaluation of liver scintigraphy in patients with carcinoma of the rectum.