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The standard of care for locoregional management of early stage breast cancer became breast-conserving surgery (BCS) followed by a course of whole-breast radiotherapy (Pierce et al.,2005). In general, the majority of in-breast local recurrences occur in the region of the prior lumpectomy site and index quadrant whether the patient undergoes postoperative breast irradiation or not (Smith et al., 2000).
Many clinical trials have demonstrated that the addition of a localized dose to the tumor bed significantly reduces local recurrences and confirmed the concept of dose–response for a specific tumor volume in breast cancer (Timothy, 2005).
Although relatively short lived, radiation induced skin reactions are uncomfortable and itchy. It can be painful and are some-times dose-limiting and has been associated with decreased quality of life. Furthermore, severe radiodermatitis necessitates treatment modifications or delays, which may compromise the efficacy of radiotherapy (McQuestion, 2006).
Moist desquamation, evidenced by red, exposed dermis and serous oozing, occurs after four to five weeks of therapy as the basal cells are further depleted (Archambeau et al., 1995).The present study aimed to evaluate the ability of planned intrercuurent boost method to decrease occurrence of radiodermatitis in the breast and less treatment interruptions in comparison to the conventional method of giving the boost after finishing whole breast irradiation.
Our primary end point was to compare the planned intrercuurent boost method with the conventional WBRT method regarding the rate of radiodermatitis, treatment breaks and the average overall treatment time.Our secondary end point was to compare the planned intrercuurent boost method with the conventional WBRT method regarding the rate of ipsilateral breast local recurrence.
This open label, phase 2 trial was conducted at Clinical Oncology and Nuclear Medicine Department, Ain Shams University hospitals. 50 eligible patients were assigned in a 1: 1 ratio to receive either:
Arm 1: conventional irradiation of the whole breast consisting of WBRT of 5000 cGy followed by a boost of 1600 cGy to the tumor bed.
Arm 2: intercurrent boost method consisting of WBRT till 3600 cGy then tumor bed boost of 1600 cGy (with stopping of WBRT) then return to WBRT for 1400 cGy (total WBRT dose 5000 cGy). Regional lymph node irradiation was continued during the period of stoppage of the WBRT.No switch from either arm to the other was allowed. No chemotherapy or hormonal therapy was allowed during radiation.All patients received their boost as 1600 cGy in 8 fractions to the tumor bed +2 cm safety margin.All patients underwent a CT to the breast in the treatment position with a radio opaque mark on the surgical scar after receiving the chemotherapy (before the start of the WBRT)to make delineation of the tumor bed. Electrons or photons were used according to the depth of the tumor bed. The electron energy was selected so that the 90% isodose line covers the deepest extension of the lumpectomy bed +the appropriate margin.If the tumor bed lies at a great depth (more than 4 cm)photon therapy was used.
The most important toxicity reported and assessed in the patients was the skin toxicity (acute radiation dermatitis).It was graded according to the RTOG grading of radiotherapy induced acute skin changes.
Patients were followed and examined every 5 sessions to asses the grade of radiodermatitis.Patients were allowed to continue their radiotherapy sessions if they have grade 0, 1 or 2 dermatitis.If patient develops patchy moist desquamation or grade 3 dermatitis treatment was stopped for 3 days and a local cream (mostly topical steroid) was prescribed to the sites of dermatitis.
The grade of dermatitis reported for each patient was the highest grade of dermatitis taking place during the course of irradiation. Patients were followed for 2 years.
Grade 2 and grade 3 dermatitis were more frequent among arm 1 with statistically significant difference .No patient in botharms developed grade 4 dermatitis. Treatment breaks were more frequent in arm 1with statistically significant difference.
There was no statistically significant difference between the 2 arms regarding the length of the treatment breaks needed to relief dermatitis or as regarding treatment duration (overall treatment time). There was no statistically significant difference regarding local and systemic failure (event free survival) between the 2 arms.