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ABSTRACT & COMMENTARY
Synopsis: The activity of photodynamic therapy in the treatment of recurrent chest wall disease in patients with adenocarcinoma of the breast has been well documented.1 However, there is reluctance to use this modality in patients who have been extensively treated with surgery, chemotherapy, and full-dose radiation for fear of inducing nonhealing ulcers and necrosis. Subsequent studies have suggested that a lower dose of PDT can achieve control of chest wall disease with less toxicity. This study reports PDT treatment of 102 chest wall sites in 9 patients with lesions ranging in size from .57 to 9 cm. Systemic therapy continued without modification during PDT. Complete response was noted in 89% of the lesions, reduction without regrowth occurred in 8%, and there was no response in 3% of the lesions. All lesions except 1 healed within 3 months and all of the lesions healed without additional scarring. This study suggests that lower doses of PDT can effectively control chest wall disease, even if it has been highly refractory to prior treatments. Repeat applications, if necessary, can be done without additional toxicity.
Source: Allison R, et al. Cancer. 2001;91:1-8.
Despite major advances in the treatment of breast cancer, the development of persistent and progressive chest wall disease despite optimal surgery, maximum doses of radiation, and chemo-hormonal therapy is still not an uncommon occurrence. Photodynamic therapy (PDT) has been recognized for many years as a potential treatment for cutaneous malignancies and can result in an excellent clinical and cosmetic response. However, it appears that high doses of the photosensitizer and/or too high a light dose do not improve response rates and can increase morbidity, manifested as treatment related pain, fibrosis, scarring, hyperpigmentation and, at times, local necrosis.
In this study the photosensitizer Photofrin was administered in a dose of 0.8 mg/kg followed by laser therapy approximately 48 hours later using a KTP:YAG laser using a 630 nm wavelength with dose ranges from 135-170 Joules/cm2 (mean, 150 J/cm2). Nine patients with persistent and progressive chest wall disease despite standard surgery, radiation, and chemotherapy with or without Tamoxifen were treated. A total of 102 lesions were treated with a range of 4-26 lesions per patient. At 6 months of follow-up all patients were still alive. At that time, 89% of tumors had been eliminated completely. A 50% or greater reduction occurred in 8% and no response occurred in 3%. Only 1 treated lesion grew through therapy. At the 6-month follow-up period no fibrosis was noted in any treatment regions, and no treatment region was painful. None of the 9 patients needed pain medication for chest wall discomfort. Two patients underwent a second course of treatment after the 6-month evaluation. Similar results were noted with no increased morbidity.
COMMENT BY MICHAEL J. HAWKINS, MD
None of the patients who were treated required modification of their systemic chemotherapy. Successful treatment of chest wall disease can have a positive psychological effect for the patient and often represents the most disturbing aspect of a patient’s recurrent disease. This study emphasizes that it is possible to obtain meaningful palliation of chest wall disease while continuing systemic treatment. Because of their markedly different mechanisms of action, PDT and chemohormonal therapy may be given simultaneously without an increase in the toxicity of either modality. The ability to administer PDT concurrently with existing treatments is often overlooked. Many patients with progressive chest wall disease can be significantly palliated without interrupting systemic therapy.
1. Schuh M, et al. J Clin Oncol. 1987;5:1766-1770.