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Background: Skeletal metastases below elbow and knee are uncommon, those to tibia are even rarer. Diagnosis may be delayed, and often confused with primary bone tumors (in solitary metastases) or with osteomyelitis or arthritis. Management depends on extent of disease and severity of symptoms. In most cases, treatment is essentially directed towards symptom relief. Method: We describe a case of metastases to the tibia and foot in a case of breast cancer after a long disease-free period. Results: Roentgenogram appearance mimicked osteomyelitis, which was ruled out by absence of fever, sterile cultures and no response to antibiotics. Diagnosis was established by a bone biopsy, with immunohistochemistry demonstrating a carcinoma with estrogen and progesterone receptor positivity. The patient was managed with multiagent chemotherapy, hormone therapy, bisphosphonates and palliative radiotherapy. She remained stable for 1 year after which her disease progressed with cutaneous metastases, and she was given symptomatic treatment only. Conclusion: Management of acrometastases from breast cancer involves a multimodality approach. Both systemic therapy and local therapy (in the form of surgery or radiation therapy) may help. Treatment needs to be individualized depending on prognosis and extent of disease. [Copyright &y& Elsevier]

Aims: Radiotherapy forms an integral part of breast-conserving treatment in early-stage breast cancer. Subcutaneous fibrosis of the treated breast is an important late effect in whole-breast irradiation. The aim of this study was to compare the normal tissue complication probability (NTCP) for radiation-induced fibrosis in treated breast using accelerated partial-breast irradiation (APBI) vs conventional treatment. Materials and Methods: Ten postoperative early-stage breast cancer patients (T1N0M0) were included in this dosimetric analysis. APBI treatment was planned using conformal radiotherapy technique and conventional treatment plans included two tangential portals. All the APBI treatment plans were made with five non-coplanar beams with 6 MV photons. The prescription dose was 38 Gy in 10 fractions for the APBI treatments and 50 Gy in 25 fractions, followed by a boost dose of 16 Gy in 8 fractions, for the conventional treatments. We used Lyman's relative-seriality model and the breast fibrosis NTCP model fitting parameters for the study. Results: The equivalent uniform dose (EUD) was 30.09 Gy and 50.79 Gy in APBI and conventional treatment, respectively. The mean NTCP values for ipsilateral breast fibrosis in APBI and conventional treatment were 0.51 and 25.66%, respectively. Using the paired t-test, a statistically significant difference was seen in the breast fibrosis NTCP values for APBI vs conventional treatment (P<0.001). Conclusions: APBI reduces the ipsilateral breast fibrosis compared to conventional whole-breast treatment in early-stage breast cancer. [ABSTRACT FROM AUTHOR]

This study examined the pathological complete response (pCR) rate and safety of sequential gemcitabine-based combinations in breast cancer. We also examined gene expression profiles from tumour biopsies to identify biomarkers predictive of response. Indian women with large or locally advanced breast cancer received 4 cycles of gemcitabine 1200 mg m(-2) plus doxorubicin 60 mg m(-2) (Gem+Dox), then 4 cycles of gemcitabine 1000 mg m(-2) plus cisplatin 70 mg m(-2) (Gem+Cis), and surgery. Three alternate dosing sequences were used during cycle 1 to examine dynamic changes in molecular profiles. Of 65 women treated, 13 (24.5% of 53 patients with surgery) had a pCR and 22 (33.8%) had a complete clinical response. Patients administered Gem d1, 8 and Dox d2 in cycle 1 (20 of 65) reported more toxicities, with G3/4 neutropenic infection/febrile neutropenia (7 of 20) as the most common cycle-1 event. Four drug-related deaths occurred. In 46 of 65 patients, 10-fold cross validated supervised analyses identified gene expression patterns that predicted with >or=73% accuracy (1) clinical complete response after eight cycles, (2) overall clinical complete response, and (3) pCR. This regimen shows strong activity. Patients receiving Gem d1, 8 and Dox d2 experienced unacceptable toxicity, whereas patients on other sequences had manageable safety profiles. Gene expression patterns may predict benefit from gemcitabine-containing neoadjuvant therapy. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the breast dose heterogeneity in CT-based radiotherapy treatment planning and to correlate with breast parameters. Also, the number of slices required for treatment planning in breast cancer by tangential field technique has been assessed by comparing the treatment plans according to International Commission on Radiation Units and Measurement (ICRU) 50 guidelines (1993) for single-slice, three-slice, and multi-slice (3D) planning. Sixty women who underwent isocentric tangential field breast radiotherapy were included in this study. The plans were optimized and analyzed with dose volume histograms. Sixty-three percent of the single-slice plans and 26.7% of the three-slice plans showed poor dose homogeneity as compared to the 3D plans. Dose inhomogeneity correlated better with breast volume (r² = 0.43) than the chest wall separation (r² = 0.37) and breast area product (r² = 0.36). Similarly, breast volume correlated better with breast area product (r² = 0.80) than with chest wall separation (r² = 0.56). Breast volume can be approximated to breast area product from the relation, breast volume = [(breast area product x 8.85) - 120.05]. The results of this study showed that most of the cases require 3D planning for breast cancer. It also showed that patients with large breast are prone to have more dose inhomogeneity with standard tangential field radiotherapy. In centers where 3D planning is not possible due to lack of facilities or workload, three slices-based planning can be performed to approximate the dosimetric advantage of 3D planning. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the local control of hepatic metastasis with radiofrequency ablation treatment. Materials and Methods: We did a retrospective analysis in 40 patients treated with radiofrequency ablation for hepatic metastasis. The tumors ablated included up to two metastatic liver lesions, with primaries in breast, gastrointestinal tract, cervix, etc. Radiofrequency ablation was performed under general anesthesia in all cases, using ultrasound guidance. Radionics Cool-Tip RF System was used to deliver the treatment. Results: The median age of patients treated was 49 years. There were 13 female and 27 male patients. The median tumor size ablated was 1.5 cm (0.75-4.0 cm). A total of 52 radiofrequency ablation cycles were delivered. Successful ablation was achieved in all patients with hepatic metastasis less than 3 cm in size. Pain was the most common complication seen (75%). One patients developed skin burns. At 2-year follow-up 7.5% of patients had locally recurrent disease. Conclusions: Radiofrequency ablation is a minimally invasive treatment modality. It can be useful in a select group of patients with solitary liver metastasis of less than 3 cm size. [ABSTRACT FROM AUTHOR]

Summary: Background: Treatment verification and reproducibility plays a major role in radiotherapy to achieve better tumour control. Small uncertainties in daily repositioning of the patients and internal organ motion can lead to discrepancies between the planned and delivered radiation treatments. A factor that influences dose homogeneity and treatment volume is the accuracy of treatment setup. Small deviations in positioning the patient with regard to the beam setup could have a relatively significant impact on the treatment volume and it is imperative to control the setup error during radiotherapy. This study focuses on the importance of inter- and intra-fraction error in tangential breast radiotherapy with an electronic portal imaging device. Aim: To study the variation in treatment setup due to intra-fraction and inter-fraction during tangential field breast irradiation. Materials/Methods: Twelve patients of carcinoma breast were selected for this study and CT based planning was performed with simple tangential fields. The patients were treated on a 6MV linear accelerator equipped with an electronic portal imaging device (EPID). Portal images were acquired for both medial and lateral tangential fields for 10 fractions and intra- and inter-fraction studies were performed for all the patients. Parameters such as central lung distance (CLD), central beam edge to skin distance (CBESD), central irradiated width (CIW) and cranio-caudal distances (CCD) were measured on the acquired portal image. Results: The average systematic differences observed for CLD, CBESD, CCD and CIW were 1.2mm, 2.8mm, 2.07mm and 3.30mm. For intra-fraction motion, the observed standard deviations for CLD, CBESD and CCD were 0.7mm, 0.73mm, and 1.36mm. Similarly the CLD, CBESD, CIW and CCD were analyzed for inter-fraction variation. Conclusions: The online portal imaging device is an important tool for ensuring the proper delivery of planned dose. Our results suggest that intra-fraction motion of the breast has less impact on the treatment volume. Regular treatment verification between treatment fractions will help in reducing the normal tissue toxicity and ensures proper dose delivery to the tumour volume. [Copyright &y& Elsevier]

Breast cancer with multiple parenchymal brain metastases carries an extremely poor outcome. Cranial radiotherapy improves survival by only a few months and the role of systemic therapy is marginal and largely unexplored. We report a patient with recurrent carcinoma of breast presenting with multiple bilateral cervical nodes and brain metastases manifesting as a right hemiparesis and facial nerve palsy, who was treated with palliative whole brain irradiation and letrozole. At the follow up at 20 months, neurological function had fully recovered, and both cerebral and extracerebral lesions had completely resolved, with calcification of the cerebral lesions. This report suggests that letrozole has beneficial effects both in extracranial and intracranial disease in hormone responsive metastatic breast cancer. [ABSTRACT FROM AUTHOR]