Literature review suggests surface mould has been tried and appears feasible with minimal complications, but its efficacy remains controversial with case series and reports.
However there is no long term follow up nor any metion of late radiation sequaela. There is more experience of re-irradiation by external beam but that is essentially is a palliative setting with mean doses of 20 to 30 Gy.
In a more radical scenario,the largest series i could find in the post mastectomy irradiated chest wall setting was:
1. http://www.ncbi.nlm.nih.gov/pubmed/17869019
The median follow-up from the second RT course was too short (just 1 year) Four patients developed late Grade 3 or 4 toxicity out of 81. However, 25 patients had follow-up >20 months, and no late Grade 3 or 4 toxicities were noted. Interesting,but its difficult to get the actual incidence of late damage from this publication.
The incidence of late damage will of course be proportional to the dose of radiotherapy making its use beyond 50 Gy probably unfeasible for a normally cautious oncologist, even if a localised volume to the chest wall is re-irradiated. But to be very honest for Andrew it could be SKY IS the LIMIT. What have you got to lose … rib fractures, soft tissue necrosis …. are these really serious to give you nightmares
And its upto a radiation oncologist to believe in his magic treatment, whether would 50 Gy do the job and give this lady a 50% or 80% chance of being free from local relapse. I m sure nobody other than Andrew himself will understand this equation of higher the dose, higher the chance of local control but equally distressing would be the chance of soft tisse necrosis and late damage.
I have to see Andrew sitting with this patient, going through a graph and telling the patient, look lady what do you want.
You want 40 % chance of local control with 30 % chance of late damage
or 60% chance of local control with 50% chance of late damage
or a 80% chance of local control with 70% chance of late damage.
Common lady, its your choice at the end of the day.
Sorry, Andrew just pulling your leg, those figures are just arbitrary and not real, so others please dont take these for granted since they are just from me.
This earlier publication , http://www.ncbi.nlm.nih.gov/pubmed/9342443?dopt=Abstract
makes me believe that evetually this patient would have a systemic relapse if she is fortunate to have had a good local control.
But we are always optimistic, hence 10 y OS = 30% is the best realistic estimate you could have for this patient with isolated local relapse.
Such a fuss about this positive margin , microscopic disease which we cant even see, but can be a matter of life or death for this 52 y old lady.
