When is radiotherapy used after mastectomy?

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Post-mastectomy radiotherapy (RT) is indicated for patients at high risk of local recurrence, such as those with a tumor larger than 5 cm, which compromise deep margins and pathologically involved axillary lymph nodes.

If the probability of post-mastectomy RT is high, this could affect the choice of type of mastectomy, choice of reconstructive approach, and optimal timing of breast reconstruction (immediate versus delayed). In these cases, we usually opt for the temporary expander and then perform the definitive reconstruction.

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What are the side effects of radiotherapy and the precautions to avoid them?

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Any side effects are local. Avoid using creams, lotions, deodorants, alcohol and talc on the area to be irradiated, before each application. After applications, specific creams can be used to minimize the effects of radiation on the site. At the end of the treatment, a moisturizing cream should be used on the treated area. The side effect is almost always hyper pigmentation of the skin. She'll look tanned and irritated, like a rash from too much sun. After two months these effects diminish and disappear. If, by chance, there is intense desquamation of the skin, in the irradiated area, the applications may even be interrupted. Some time later they will be resumed. Hydration skin care and sun protection promote the best skin care and its quick recovery.

When the armpit is also submitted to radiation, the chance of edema in the corresponding arm is greater, which is not a contraindication, but a reason to be careful.

After treatment, the skin in the region subjected to radiation must be kept under constant observation. In addition to getting a little thinner, it can cause fibrosis, microvarices or a little desquamation. You can walk in the sun, for example, for as long as the applications last, but always with the area protected by clothing. The power will not change. The area should only be exposed to direct sunlight after three months and protected with sun block. Any skin change, during or after treatment, must be reported immediately to the doctor.

Currently, there is great concern about the cardiotoxicity of radiotherapy, especially when it radiates to the left breast, which is closer to the heart.

What modern radiotherapy techniques to protect the heart?

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In recent years, new radiotherapy techniques with less exposure to radiation have been studied, without reducing the chances of curing the tumor. The three main strategies employed to reduce cardiac toxicity are: reduce radiation dose; reduce the field and volume of radiation and using the new forms of application of radiotherapy.

New techniques include intensity-modulated radiotherapy, in which three-dimensional tomographic images are used coupled with a computerized program that controls the dynamic radiotherapy system. This strategy allows radiotherapy doses to be “sculpted” in three dimensions using the exact design of areas to be treated and protected.

Another technique is image-guided radiotherapy (IGRT), which arose from the need to more accurately locate the tumor or internal organs affected by the disease at the time of treatment, so that there is a better correlation with the reference images .

The objective of IGRT is to guarantee as accurately as possible that the tumor will be within the irradiation field on every day of treatment, since they can change position between treatments, or even in the same treatment. This can occur due to respiratory movements, filling or emptying of some organs, or even small changes in positioning overnight.

IGRT involves image-guided conformal radiotherapy, such as tomography, ultrasound and X-rays, performed daily in the treatment room, before the radiotherapy procedure. The image obtained is compared with the image taken in the planning process and then the necessary adjustments are made. This allows for greater precision in the treatment, sparing adjacent normal tissues. In some cases, doctors implant small markers in the tumor, helping to visualize the movement of the tumor or organs.

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                       Radiation therapy fields showing heart protection with deep inspiration .

What is cardio-oncology?

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Cardiovascular diseases in cancer patients are increasingly frequent events, as a result of advances in cancer therapy that have resulted in both improved quality of life and increased patient survival. In recent decades, advances in cancer treatment have also resulted in greater exposure of patients to cardiovascular risk factors and chemotherapy with potential for cardiotoxicity.

Currently, there is a change in the paradigm in relation to the prognosis of cancer patients, who are now seen as having a chronic disease, which throughout its evolution can present acute decompensation, such as cardiovascular manifestations.

Cardiotoxicity is one of the most significant adverse effects of cancer treatment, responsible for considerable morbidity and mortality. Among the harmful events of chemotherapy agents/drugs in the cardiovascular system, the occurrence of heart failure with systolic ventricular dysfunction stands out, due to its higher frequency and severity. Other cardiovascular toxic effects include high blood pressure, thromboembolic disease, pericardial disease, arrhythmias, and myocardial ischemia. For several decades, cancer therapy-induced cardiomyopathy was almost exclusively associated with the use of cumulative doses of anthracyclines, which cause permanent damage at the cellular level. However, the use of new therapeutic agents, such as the monoclonal antibody trastuzumab, induces a reversible transient dysfunction of myocytes without any relation to the dose used. Currently, it is essential for cancer patients to identify cardiovascular damage early, accurately diagnose cardiotoxic events and implement adequate monitoring plans. In this context, close cooperation between cardiologists and oncologists is essential in clinical practice, in order to balance cardiotoxic risks with the benefits of antineoplastic therapy in cancer patients