What is Hyperthermia for Chest Wall Recurrence?
Currently, there are several recommended treatments for local breast cancer reoccurrence, including surgery, chemotherapy, hormone therapy, radiation alone, or radiation paired with a technique known as hyperthermia. Hyperthermia, also known as thermal therapy, involves heating the body or cancerous tissue to high temperatures between 104 and 109.4 degrees Fahrenheit. When used alongside radiation, hyperthermia plays a key role in improving local control for patients with breast or chest wall reoccurrences that are resistant to chemotherapy, not suitable for surgery, and have had prior radiation. Hyperthermia helps to heighten the effects of radiation-caused DNA damage, by blocking DNA repair in cancer cells and by increasing the oxygen supply to tumors, which is required for radiation therapy to produce free radicals that damage cancer cells. One of the significant benefits of hyperthermia is that it can be used in combination with smaller doses of radiation therapy, leading to more effective results and fewer side effects. Hyperthermia is a specialized treatment available only at select centers across the United States and globally. Therefore, it’s essential for doctors to have in-depth knowledge of this therapy to help patients access it. The purpose of this article is to discuss treatment options for local breast cancer recurrences, with a particular focus on the role of hyperthermia.
The usefulness of hyperthermia in cancer treatment comes from the harmful effects of increased temperatures on cancer cells. Studies have shown that temperatures between 105.8 to 111.2 degrees Fahrenheit are non-toxic to normal cells, but harmful to cancer cells. Several cellular changes caused by high temperatures include:
1. Increased cell permeability which increases the influx of Calcium ions involved in signaling the natural cell death process and increases cell permeability to drug delivery
2. Breakdown of the cell’s structure and enlarged tumor pores, enabling easier drug delivery
3. Changes in the structures involved in cell division, protein disassembly which results in the formation of cells with multiple nuclei
Various energies used to heat tumors include microwaves, radiofrequency, ultrasound, hot water perfusion (tubes, blankets), resistive wire implants, ferromagnetic seeds, nanoparticles, and infrared radiators. Hyperthermia is more commonly delivered with electromagnetic devices, as they appear to provide better power disposition and temperature distribution. Devices such as a waveguide, spiral, and current sheet are positioned on tumor surfaces for this purpose.
What Causes Hyperthermia for Chest Wall Recurrence?
Certain factors increase the risk of cancer returning in the chest wall after treatment. These factors include the size of the original tumor, the stage of the cancer when it was first found, and whether or not the cancer had spread to lymph nodes. In one study of over a thousand patients, researchers found that if the original tumor was large (at least 4 cm) or if there were four or more lymph nodes involved, patients had more than a 20% chance of experiencing a local recurrence, which is when the cancer comes back in the same area.
A research group investigating early-stage breast cancer reported that patients who had one to three positive lymph nodes (meaning the cancer had spread to those nodes) had a just over 20% chance of the cancer returning locally within 10 years after a mastectomy (breast removal). If they had four or more positive nodes, that risk rose to just over 32%.
Other factors that raise the risk include being 40 years old or younger, having widespread disease in multiple areas, and certain genetic factors. Specific details about the cancer cells themselves also play a role. For example, if the cancer cells are found in the margins of the removed tissue, this suggests not all the cancer was removed and increases the likelihood of a recurrence. Additionally, the presence of ductal carcinoma in situ (DCIS, a type of non-invasive breast cancer), an extensive part of the tumor located inside milk ducts, a high-grade tumor, or invasion into the lymph vessels raises the risk. Properties of the cancer cells, like whether they express certain oncogenes and tumor suppressor genes (proteins that can cause cancer when they malfunction), as well as whether they respond to estrogen, also influence the risk.
One encouraging piece of information is that the use of additional treatments after surgery, like chemotherapy and radiation (called adjuvant chemoradiation therapy), has been shown to reduce the risk of the cancer returning in the chest wall.
Risk Factors and Frequency for Hyperthermia for Chest Wall Recurrence
Reoccurrence of breast cancer in the chest wall is often a sign of a poor prognosis and is typically associated with or a prelude to the disease spreading to distant parts of the body. However, treating these local and regional recurrences aggressively may enable patients to live longer without the disease. There is a wide variation in the 10-year rate of chest wall recurrence after a mastectomy, with 5% to 45% of patients, including both early and late-stage, experiencing a recurrence within the first 5 years following their treatment.
- This rate drops to about 2% to 15% for patients who received radiation therapy after their surgery.
- Aside from chest wall recurrence, 10% to 20% of patients with stage I to IIIA breast cancer will experience additional regional recurrences, including in the lymph nodes.
- Following a local or regional recurrence, the reported rates of developing distant metastases are 35% for those who did not have radiation therapy and 6% for those who did.
- Local recurrence alone can predict distant metastases.
- In a study with 6792 patients, isolated local or regional recurrence was found in 18% of them, and only a third remained free of distant metastases.
- Post recurrence, 10-year disease-free survival and overall survival rates range from 7% to 12% and 22% to 26%, respectively.
Signs and Symptoms of Hyperthermia for Chest Wall Recurrence
Chest wall recurrence after a mastectomy can be identified by a number of signs and symptoms. These can be local to the chest area or could indicate that the cancer has spread to other parts of the body (metastasis).
- A new lump or mass
- An area of thickening along the mastectomy scar
- Chest wall pain
- Skin changes such as ulceration, bleeding, or inflammation
- Symptoms like swelling, redness, or itching
- Brachial plexopathy – a condition which causes pain, numbness, or weakness in the shoulder, arm, or hand –
- Dyspnea (shortness of breath) and persistent cough, which can be signs of lung metastasis
- Bone pain
- Loss of appetite and weight loss
- Neurological symptoms that might indicate brain metastasis
If any of these symptoms are present, it is important to seek medical help promptly.
Testing for Hyperthermia for Chest Wall Recurrence
If your doctor thinks you might have a chest wall recurrence (a common complication where the cancer comes back in the chest wall after initial treatment), the first step will be to take a biopsy of the suspicious area. A biopsy is when a small piece of tissue is removed and examined under a microscope to check for cancer cells.
The ER/PR and HER2 status is also typically checked. These are types of protein receptors that cancer cells have, and knowing their status can help your doctor decide which treatments might work best for you. It’s important to note that the status of these receptors can change if the cancer comes back, for various reasons such as changes in the disease, uneven distribution of cancer cells, or differential effects of treatment. This is why it’s necessary to repeat these tests.
Next, your doctor will recommend imaging tests to check if the cancer has spread to other parts of the body. This may involve a computed tomography (CT) scan, which is a special kind of X-ray that takes detailed pictures inside your body. The CT scan may be of your chest, abdomen, and pelvis. Other possible tests include a PET/CT scan (which shows how cells in your body are working), an MRI (which uses magnets and radio waves to create images of the inside of the body), or bone scans (which can show if the cancer has spread to the bones).
Further guidelines on this type of examination can be found in the NCCN guidelines. NCCN stands for the National Comprehensive Cancer Network, which is an alliance of leading cancer centers devoted to patient care, research, and education.
Treatment Options for Hyperthermia for Chest Wall Recurrence
Before settling on a treatment strategy, your doctor will discuss your aims and expectations with you. If you are not feeling well and your cancer has spread widely, you might choose a less intense course of treatment. Our primary focus will be on patients who have chosen to undergo aggressive treatment with the aim of a possible cure. It’s also vital to remember that aggressive care can help improve the quality of life.
Management of patients who experience cancer return in the chest wall may include various treatment forms. It could be surgical removal if possible, radiation therapy, chemotherapy, hormone therapy if the cancer is responsive to hormones, and heat treatment along with radiation. Doctors should communicate with all patients to determine the best course of care. In order to obtain the best results, patients will likely require a mix of different treatments.
What else can Hyperthermia for Chest Wall Recurrence be?
- Cystinosis
- Heart stroke
- Hyperthyroidism
- Multiple organ dysfunction syndromes
- Osteogenesis imperfecta
- Pheochromocytoma
- Prader-Willi syndrome
- Rhabdomyolysis
- Wolf-Hirschhorn syndrome
Surgical Treatment of Hyperthermia for Chest Wall Recurrence
In cases where the disease can be surgically removed, removing or cutting away the chest wall has been found to have good results. A study by Toi and his colleagues reported that, after five years, about 47% of the people who had this surgery for recurrent breast cancer were still alive. Petrella and his team found similar results in their study with 40 patients, reporting that after five years, about 68.5% of the people were still alive and approximately 46% were disease-free. These researchers also mentioned that age and the presence of cancer in other parts of the body negatively affected overall survival. Several other studies have reported similar survival rates after five years, ranging between 35% and 62%. It is important to note that none of these patients received chemotherapy before surgery.
For patients whose disease cannot be initially removed by surgery, a combination of chemotherapy, radiation, or both can be used to try to reduce the size of the tumor and make it suitable for surgical removal. If surgery is still not possible, patients might have less positive outcomes. Research has shown that patients who have obvious disease at the time of radiation therapy have a lower rate of disease control (63%) and survival (34%) after five years compared to patients without any residual disease after surgery and systemic treatment (81% and 62% respectively). This emphasizes the importance of complete surgical removal or systemic treatment to shrink the tumor where possible.
