The tolerance of reirradiation and hyperthermia in breast cancer patients with reconstructions

Figures & data

Table I.  Patient and tumor characteristics in relation to time period between reconstruction and HT and reRT

	Median; range	n	%
Interval between HT and reRT and reconstruction (weeks)	12; 4–282
Graft		15	41
Flap		16	43
Combined		6	16
Dose RT given previously (Gy)	50; 40–54
Number of prior surgeries
1		2	5
2		17	46
≥3		18	49
Number of prior chemotherapies
0		15	41
1		12	32
2		7	19
≥3		3	8
Number of prior hormonal therapies
0		18	49
1		15	41
≥2		4	11
Concurrent hormonal therapy		15	41
Macroscopic tumour
Single lesion		6	16
≥3		7	19
Tumour maximum diameter (mm)	53; 5–320
Maximum depth of target volume (mm)	30; 15–40
Subclinical disease		22	59
Bloom-Richardson biological grading system
Good		2	5
Moderate		5	14
Poor		22	59
Unknown		8	22

*Dose to chest wall without the boost.

Figure 1. a. Split-thickness graft, b. Latissimus dorsi flap, c. Transverse rectus abdominis muscle, d. Rhomboid flap.

Figure 2. a. Combination split-thickness skin graft and latissimus dorsi flap, b. Combination split-thickness skin graft and omentum flap.

Table II.  Treatment characteristics.

	Median; range	n	%
Total reRT dose (Gy)
60		1	3
32		36	97
Reirradiated breast reconstruction		3	8
Size of RT field (cm^2)	414; 0–1260
Size of HT field (cm^2)	600; 324–1375
Indent of HT sessions
4		29	78
5		1	3
8		7	19
Number of hyperthermia applications
1		29	78
2		7	19
4		1	3
Total duration of HT sessions (min)
240		28	76
300		1	3
480		8	22
Number of interstitial thermometry points	10; 0–19
Tmax temperature (°C)	43.3; 41.2–45.4
Tave temperature (°C)	41.0; 39.2–42.8
T90 temperature (°C)	39.5; 37.1–41.6
CEM*43T90 (min)	4.9; 0.0–18.3
Water bolus temperature (°C)	39.0; 36.0–42.0

*CEM, cumulative equivalent minutes.

Table III.  CTCAE v3 scoring of hyperthermia toxicity.

Degree
0	None
1	Minimal symptoms; intervention not indicated
2	Medical intervention; minimal debridement indicated
3	Moderate to major debridement or reconstruction indicated
4	Life-threatening consequences
5	Death

Table IV.  World Health Organization scoring of thermal burns.

Degree
0	None
01	Erythema
2	Partial thickness injury; erythema and blister, possibly white spots, very painful
3	Full thickness injury; complete dermis thickness damaged, chalk white or charred wound that is dry and anaesthetic, no capillary refill possibly including subcutaneous fat injury
4	Burn including underling muscle tissue
5	Resulting in death

Table V.  CTCAE v3 scoring of acute radiotherapy toxicity.

Degree
0	None
1	Faint erythema or dry desquamation
2	Moderate to brisk erythema; patch moist desquamation, mostly confined t skin folds and creases; moderate oedema
3	Moist desquamation other than skin folds and creases; bleeding induced by minor trauma or abrasion
4	Skin necrosis or ulceration of full thickness dermis; spontaneous bleeding from involved site
5	Death

Table VI.  Thermal parameters in relation to hyperthermia toxicity.

		p value
Tave (°C); mean ± SD* (range)	41.4 ± 0.9 (39.2–42.8)	0.108
T90 ± (°C); mean ± SD* (range)	39.7 ± 1.1 (37.1–41.6)	0.115
Tmax ± (°C); mean ± SD* (range)	43.5 ± 1.1 (41.2–45.6)	0.408
CEM43°CT90tot (min); mean ± SD* (range)	4.9 ± 6.9 (0–18.3)	0.587

Table VIb.  Patient and treatment characteristics included in the evaluation of prognostic factors for toxicity.

		p value
Prior hormonal therapy	Yes or no	0.105
Size hyperthermia field	<600 cm^2 and ≥600 cm^2	0.141
Prior chemotherapy	Yes or no	0.177
Type of tissue transfer	Graft, flap or combined	0.207
Concurrent hormonal therapy	Yes or no	0.245
Interval between RT + HT and reconstruction	Early ≥20 weeks and late >20 weeks	0.324
Number of interstitial thermometry probes	≤10 or >10	0.457
Prior surgery	1–2, or ≥3 surgical treatments	0.775
Number of hyperthermia treatment sessions	4–5 versus 8	0.814
Depth	1–4 cm	0.818
Size radiotherapy field	≤400 cm^2 and >00 cm^2	0.971

Table VII.  Maximum acute HT toxicity per patient and reconstruction.

	Graft	Flap	Combined	All
Breast reconstruction CTCAE toxicity	15	16	6
0	8 (22%)	9 (24%)	3 (8%)	20 (54%)
1	3 (8%)	4 (11%)	3 (8%)	10 (27%)
2	4 (11%)			4 (11%)
3	0	3* (8%)		3 (8%)
Burn, WHO score
0	8 (22%)	9 (2%)	3 (8%)	30 (54%)
1	0
2	5 (14%)	3 (8%)	3 (8%)	11 (30%)
3	2 (5%)	3* (8%)		5* (13%)
Subcutaneous	0	1 (3%)		1 (3%)

*Three ulcerations which required necrotomy.

Figure 3. Duration of local tumor control for 36 tissue transfers in 35 patients from the time of initiation of treatment treatment (N = number of tissue transfer, F = number of failures).

Figure 4. Overall survival for 36 tissue transfers in 35 patients from the time of initiation of treatment (N = number of tissue transfer, F = number of failures).