Reconstructive complications and early toxicity in breast cancer patients treated with proton-based postmastectomy radiation therapy

BackgroundPostmastectomy radiation therapy (PMRT) decreases the risk of locoregional recurrence and increases overall survival rates in patients with high-risk node positive breast cancer. While the number of breast cancer patients treated with proton-based PMRT has increased in recent years, there is limited data on the use of proton therapy in the postmastectomy with reconstruction setting. In this study, we compared acute toxicities and reconstructive complications in patients treated with proton-based and photon-based PMRT.MethodsA retrospective review of our institutional database was performed to identify breast cancer patients treated with mastectomy with implant or autologous reconstruction followed by PMRT from 2015 to 2020. Baseline clinical, disease, and treatment related factors were compared between the photon-based and proton-based PMRT groups. Early toxicity outcomes and reconstructive complications following PMRT were graded by the treating physician.ResultsA total of 11 patients treated with proton-based PMRT and 26 patients treated with photon-based PMRT were included with a median follow-up of 7.4 months (range, 0.7-33 months). Six patients (55%) in the proton group had a history of breast cancer (3 ipsilateral and 3 contralateral) and received previous RT 38 months ago (median, range 7-85). There was no significant difference in mean PMRT (p = 0.064) and boost dose (p = 0.608) between the two groups. Grade 2 skin toxicity was the most common acute toxicity in both groups (55% and 73% in the proton and photon group, respectively) (p = 0.077). Three patients (27%) in the proton group developed grade 3 skin toxicity. No Grade 4 acute toxicity was reported in either group. Reconstructive complications occurred in 4 patients (36%) in the proton group and 8 patients (31%) in photon group (p = 0.946).ConclusionsAcute skin toxicity remains the most frequent adverse event in both proton- and photon-based PMRT. In our study, reconstructive complications were not significantly higher in patients treated with proton- versus photon-based PMRT. Longer follow-up is warranted to assess late toxicities

Mediastinal Tracheostomy in the Management of Recurrent Laryngeal Cancer

<p>A 61-year-old man was treated for laryngeal squamous cell cancer with radiation in 2004. He presented again in 2012, with squamous cell cancer on the floor of his mouth. He underwent a right mandibulectomy with a free forearm flap, followed by radiation. A year later, he was found to have recurrent laryngeal cancer and underwent a total laryngectomy. Unfortunately, one of the margins was positive on the final pathology. The patient presented again in 2013 with obstructive symptoms and hemoptysis, synonymous with local recurrence at the tracheostomy level. There was no evidence of distant disease, and, in view of his relative young age and good functional status, he underwent a mediastinal tracheostomy with a right myocutaneous pectoralis flap.</p><p>The patient's postoperative course was significant for moderate ischemia of the proximal posterior tracheal wall. This was managed conservatively, with the patient requiring multiple dilations and the temporary placement of a fully covered airway stent, before tolerating a permanent laryngeal tube. Pathological examination showed all the new margins to be negative, and multiple subsequent imaging studies revealed no local recurrence. However, the patient was found to have a suspicious 1 cm left upper nodule for which he underwent a thoracoscopic wedge resection 22 months after his mediastinal tracheostomy. This showed another squamous cell cancer that was less differentiated than his prior oral and laryngeal cancers. The patient is currently disease free, 36 months after his mediastinal tracheostomy.</p

Adolescent Onset of Localized Papillomatosis, Lymphedema, and Multiple Beta-Papillomavirus Infection: Epidermal Nevus, Segmental Lymphedema Praecox, or Verrucosis? A Case Report and Case Series of Epidermal Nevi

Herein, we report the case of a 12-year-old female who noted the recent onset of an oval, circumscribed, 10-cm papillomatous plaque affecting the thigh and vulva that showed histologic signs of lymphedema without evidence of secondary lymphedema. The sequencing of genes associated with a delayed onset of lymphedema or epidermal nevi (EN) - GATA2 and GJC2, and HRAS and KRAS, respectively - showed wild-type alleles. Polymerase chain reaction for human papillomavirus (HPV) DNA demonstrated infections with 15 HPV genotypes. Evidence of productive HPV infection, HPV capsid expression, and cytopathic changes was detected. At the 6-month follow-up, no evidence of recurrence was found after complete excision. The analysis of a consecutive series of 91 EN excision specimens revealed that 76% exhibited histologic evidence of lymphostasis. Notably, multiple acrochordon-like EN, which most closely resembled this case, showed similar signs of localized lymphedema. The late onset and evidence of lymphedema favors the diagnosis of congenital unisegmental lymphedema. However, the clinical findings and epidermal changes point to the diagnosis of EN. Moreover, localized verrucosis also accurately describes this patient's cutaneous findings. Based on the above evidence, we postulate that an abnormal development of lymphatics may play a primary role in the pathogenesis of some types of EN and facilitate productive HPV infection. © 2014 S. Karger AG, Base