Multidisciplinary and mixed modality radiotherapy solutions for complex cutaneous recurrent breast cancer - a case study.

Abstract

Aim: The vast majority of cutaneous metastases in women come from a breast primary (69%), however distal recurrence is less common (14%), and can have variable clinical appearances1. Its management poses numerous challenges such as achieving skin dose through concave surfaces over multiple distal and local areas. This poster will present a patient with widely metastatic dermal disease from invasive ductal carcinoma of the breast post bilateral mastectomy and axillary clearance. The aim is to describe the challenging and complex planning and treatment approaches adopted to achieve local control of their extensive dermal disease whilst conferring acceptable toxicity. Methods and materials: A 69 year old lady, •May 2008: Bilateral mastectomy, with adjuvant chemo-radiotherapy (initial diagnosis of T4N2M0 infiltrating ductal carinoma of the Left (LT) breast, BRE Grade III, ER/PR/HER2-) •Previous treatment (at a different centre) includes: - Oct 2008: Lt chest wall (CW), SCF and Axilla, 50Gy in 25Fx at 5Fx per week, with Lt CW scar boosted concurrently with electrons, for 36Gy in 12Fx at 5Fx a week; and -Nov 2010: Rt CW (Ph1+2), 50Gy in 25Fx at 5fx per week. Results: COURSE I - JULY 2013 LT + RT ANTERIOR CHEST WALL •Patient setup supine, with both arms up in personal Vacfix®. •Treating Radiation Oncologist (RO) was present in CT to outline treatment areas. •The marked area was then wired, and a CT scan was taken. •9MeV electron, prescribed to 95% was used to treat all three areas, at extended 110cm Source to SKin Distance (SSD) at field centre, and 1.0cm bolus. Conclusion: •The issues of late toxicity from overlap from the initial treatment as well as junctions from the current courses were carefully considered. This was balanced against the consequences of uncontrolled loco-regional progression. •The patient has attained complete response to the series of treatments and was rendered local disease free clinically, despite her very advanced presentation. •Overall, this patient’s clinical course illustrates how mixed modality pathway of localised radiotherapy in conjunction with chemotherapy has been particularly effective in controlling severe progressive metastatic breast cancer. •The co-ordination of teams in radiotherapy, physics, radiation oncology, chemotherapy and supportive care has highlighted the importance of the multidisciplinary approach in achieving significant improvement to the patient’s quality of life.