Martell Kevin, Long Karen, Solis Alexa, Olivotto Ivo A
Oncology, University of Calgary, Calgary, CAN.
Oncology, Tom Baker Cancer Centre, Calgary, CAN.
Cureus. 2018 Nov 13;10(11):e3584. doi: 10.7759/cureus.3584.
A 41-year-old woman presented with pT4dN1aM0, right-sided, inflammatory breast cancer. She had a co-morbid diagnosis of systemic lupus erythematosus (SLE) at the age of 20 and was found to have significant kidney involvement (lupus-associated nephritis) at the age of 28. She went on to receive six cycles of neoadjuvant chemotherapy consisting of fluorouracil, epirubicin, cyclophosphamide, and docetaxcel (FEC-D) after which she had radiographically stable disease. She then had definitive treatment with bilateral mastectomy. Pathology showed a 4-cm residual invasive ductal carcinoma in the right breast and three residual metastatic lymph nodes in the right axilla. After extensive discussions with the patient, which included counseling on the potential increased risk of radiation-induced side effects, she received 50.4 Gy in 28 fractions of adjuvant radiotherapy (RT) to the chest wall and regional lymphatics including the internal mammary chains (IMCs). To minimize the risk of pulmonary toxicity, RT field arrangement consisted of a field-in-field modulated supraclavicular anterior/posterior parallel pair matched to shallow, photon tangent pair with 0.5 cm bolus to the lateral aspect of the chest wall and two matched direct anterior electron fields of 9 MeV with 1 cm bolus and 12 MeV with 0.5 cm bolus medially to cover the remaining residual chest wall and IMCs. This was immediately followed by a boost of 7.5 Gy in three fractions delivered via a photon tangent pair with 1 cm bolus to an area 6 cm superior and inferior to the surgical scar. Total treatment time was 50 days. The patient tolerated the therapy well but she developed grade three acute dermatitis. There were no pulmonary, shoulder joint movement, or brachial plexus side effects. This case is unusual in that SLE is generally considered a contraindication for elective RT. However, given her high risk for breast cancer recurrence, RT was offered with additional caution to minimize lung dose. Having completed the treatment, the side effects experienced were no greater than what would be expected in someone who did not have a diagnosis of SLE.
一名41岁女性被诊断为pT4dN1aM0期右侧炎性乳腺癌。她20岁时被诊断患有系统性红斑狼疮（SLE），28岁时发现有严重的肾脏受累（狼疮相关性肾炎）。她接受了六个周期的新辅助化疗，化疗方案为氟尿嘧啶、表柔比星、环磷酰胺和多西他赛（FEC-D），化疗后影像学检查显示疾病稳定。随后她接受了双侧乳房切除术进行确定性治疗。病理检查显示右乳有一个4厘米的残余浸润性导管癌，右腋窝有三个残余转移淋巴结。在与患者进行广泛讨论后，包括就辐射诱导副作用的潜在风险增加进行咨询，她接受了50.4 Gy的辅助放疗（RT），分28次照射胸壁和区域淋巴结，包括内乳链（IMC）。为了将肺部毒性风险降至最低，放疗野的布置包括一个野中野调制的锁骨上前/后平行对，与浅的光子切线对匹配，在胸壁外侧加0.5厘米的填充物，以及两个匹配的直接前侧电子野，内侧一个为9 MeV加1厘米填充物，另一个为12 MeV加0.5厘米填充物，以覆盖剩余的残余胸壁和IMC。紧接着，通过一个加1厘米填充物的光子切线对，对手术疤痕上下6厘米的区域进行三次分割、每次7.5 Gy的追加放疗。总治疗时间为50天。患者对治疗耐受性良好，但出现了三级急性皮炎。没有肺部、肩关节活动或臂丛神经方面的副作用。这个病例不同寻常之处在于，SLE通常被认为是选择性放疗的禁忌症。然而，鉴于她乳腺癌复发风险高，放疗时格外谨慎，以尽量减少肺部剂量。完成治疗后，所经历的副作用并不比未诊断为SLE的患者预期的更严重。
