Overview on cardiac, pulmonary and cutaneous toxicity in patients treated with adjuvant radiotherapy for breast cancer

Abstract

Conservative management of breast cancer represents the standard treatment for early disease. Breast conserving surgery associated with radiotherapy for stage I-II has been proven to be as equally effective as mastectomy in term of local control, distant disease, and overall survival. The growing minimal invasive surgical approach on the axillary region, and the new breast reconstructive techniques, will probably lead to a significant decrease of the rate of side-effects related to mastectomy. Therefore, the adverse events caused by adjuvant radiation still remain a challenge. Cutaneous, pulmonary and cardiac toxicity represent the main toxicities of adjuvant radiotherapy for breast cancer. Safety profile of radiation is strongly dependent on the multidisciplinary management of the single case (systemic treatment, endocrine therapy, surgery), individual characteristics (i.e., co-morbidities, age, habits), and radiation-related aspects. Radiation techniques development, and facilities implementation concerning organs-at-risk sparing systems (i.e., image-guided radiotherapy, tracking systems, respiratory gating), represent brand new tools for the clinical oncologist, that would certainly minimize toxicity profile in the next future. However, data reported from published literature will greatly help physicians, to give to the patients appropriate counseling regarding the efficacy and potential adverse events of treatments, thus optimizing the informed decision-making process.

Long-term cardiac-specific mortality among 44,292 acute myeloid leukemia patients treated with chemotherapy: a population-based analysis

“…These diverse detrimental effects are associated with polymorphisms of anthracycline metabolism enzymes, which makes tailored safety dosing possible [12,21,40,41]. Although the mechanism of cardiotoxicity in AML has not been clarified, studies in breast cancer patients whose chemotherapy regimens contain anthracycline demonstrated that the impairment of heart cells is mediated by stress protective signaling and reactive oxygen [42,43]. Notably, cardiac damage does not necessarily lead to cardiac-specific death, and thus, the mortality observed here may underestimate the cardiac damage.…”

Toxicity of Adjuvant Radiotherapy in Patients with Breast Cancer: A Review Study Toxicity of Breast Adjuvant Radiotherap

“…Several risk factors such as patient characteristics, RT techniques, environmental characteristics, and simultaneous systemic treatment must be considered in radiationinduced pulmonary sequelae (37).…”

“…Recent developments in radiotherapy such as IMRT, volumetric arc therapy (VMAT), helical tomography and image-guided radiation therapy (IGRT) have provided an improvement in the dose applied to PTV and decreased the dose of the organs at risk. The published papers on IMRT indicate more uniformity in the dose applied to PTV and less acute and delayed skin complications (37).…”

“…The EORTC esthetics rating system (47) and Harvard's NSABP/RTOG scoring system (48) are the widely used scales in the cosmetic fields. There are different factors to increase the risk of skin complications resulting from RT, including individual factors (nature, habits, associated diseases), pre and post-RT treatments (type and quality of surgery, chemotherapy, target therapy, and hormone therapy), and factors of radiation therapy (the irradiated volume, dose per fraction, total dose, and using boost and overall duration of treatment) (37).…”

Radiation dose to the left anterior descending coronary artery during interstitial pulsed-dose-rate brachytherapy used as a boost in breast cancer patients undergoing organ-sparing treatment

“…This exposure has been associated with increased risk of cardiac morbidity and mortality [3]. Darby et al .…”