Factors affecting cosmetic outcome in breast-conserving cancer treatment--objective quantitative assessment

Radiation Boost After Adjuvant Whole Breast Radiotherapy: Does Evidence Support Practice for Close Margin and Altered Fractionation?

Adding a boost to whole breast radiation (WBI) following breast-conserving surgery (BCS) may help improve local control, but it increases the total cost of treatment and may worsen cosmetic outcomes. Therefore, it is reserved for patients whose potential benefit outweighs the risks; however, current evidence is insufficient to support comprehensive and consistent guidance on how to identify these patients, leading to a potential for significant variations in practice. The use of a boost in the setting of close margins and hypofractionated radiotherapy represents two important areas where consensus guidelines, patterns of practice, and current evidence do not seem to converge. Close margins were previously routinely re-excised, but this is no longer felt to be necessary. Because of this recent practice change, good long-term data on the local recurrence risk of close margins with or without a boost is lacking. As for hypofractionation, although there is guidance recommending that the decision to add a boost be independent from the whole-breast fractionation schedule, it appears that patterns-of-practice data may show underutilization of a boost when hypofractionation is used. The use of a boost in these two common clinical scenarios represents important areas of future study for the optimization of adjuvant breast radiation.

A cosmesis outcome substudy in a prospective, randomized trial comparing radioguided seed localization with standard wire localization for nonpalpable, invasive, and in situ breast carcinomas

BACKGROUND

The primary study objective was to compare the cosmetic result of radioguided seed localization (RSL) with wire localization (WL).

METHODS

A subgroup of patients enrolled in a multicentered, randomized trial comparing WL with RSL participated. Frontal photographs were taken 1 and 3 years postsurgery. The European Organization for Research and Treatment of Cancer Cosmetic Rating System was used to evaluate cosmesis outcomes by the patient and a panel of 5 raters.

RESULTS

The study enrolled 73 patients (WL, n = 38; RSL, n = 35). Most patients rated their overall cosmesis as "excellent" or "good" (76% WL, 80% RSL). Patient and panel ratings on all cosmetic outcomes were similar between groups. Multivariable regression for overall cosmesis found larger specimen volume and reoperation to be predictors of worse ratings.

CONCLUSIONS

All cosmetic outcomes assessed were similar after WL and RSL. The comparable outcomes may reflect similar reoperation rates and volumes of excision between groups.

Late effects of cancer treatment in breast cancer survivors

Postoperative radiation therapy (RT) and chemotherapy,both reduces the risk of local recurrence and extends overall survival in patients with breast cancer (BC). Concerns have, however, been raised about the risk of acute and chronic side effects in breast cancer survivors as the number of treated individuals is large and their expected survival is long compared to most patients with other malignant diseases. Cardiac toxicity, reproductive dysfunction, pneumonitis (RP),arm lymph edema, neuropathy, skin changes are examples of the wide range of complications that has been associated with adjuvant treatment.

Late Toxicity of Radiotherapy: A Problem or a Challenge for the Radiation Oncologist?

BACKGROUND: Large randomized clinical trials have established radiotherapy in conjunction with adjuvant systemic treatment as standard treatment in breast cancer after both mastectomy and lumpectomy. Although standard radiation therapy is well tolerated by the majority of patients, some patients might suffer from late normal tissue effects. METHODS: The literature on radiotherapy following surgery of breast cancer was reviewed with regard to late toxicity. RESULTS: Radiotherapy may, to some degree, cause persistent pain in the breast, arm and shoulder in up to 30-50% of patients after 3-5 years, lymphedema in 15-25%, and restriction of arm and shoulder movement in 35%. Awareness of cardiotoxicity is needed since anthracyclines, trastuzumab, and radiotherapy may cause damage to the heart. However, using modern radiotherapy techniques, the available evidence does not suggest a higher incidence of cardiac mortality. CONCLUSIONS: This review updates the database on toxicity from radiation in breast cancer. Advances in research of radiation-induced late effects may lead to improved treatment choices for breast cancer patients including radiotherapy and may improve quality of life after surviving breast cancer.

Boosting the tumor bed from deep-seated tumors in early-stage breast cancer: a planning study between electron, photon, and proton beams

PURPOSE

To assess the potential dosimetric advantages and drawbacks of photon beams (modulated or not), electron beams (EB), and protons as a boost for the tumor bed in deep-seated early-stage breast cancer.

MATERIAL AND METHODS

Planning CTs of 14 women with deep-seated tumors (i.e., > or =4 cm depth) were selected. The clinical target volume (CTV) was defined as the area of architectural distortion surrounded by surgical clips. The planning treatment volume (PTV) was the CTV plus 1cm margin. A dose of 16 Gy in 2 Gy fractions was prescribed. Organs at risk (OARs) were heart, lungs, breasts, and a 5-mm thick skin segment on the breast surface. Dose-volume metrics were defined to quantify the quality of concurrent treatment plans assessing target coverage and sparing of OAR. The following treatment techniques were assessed: photon beams with either static 3D-conformal, dynamic arc (DCA), static gantry intensity-modulated beams (IMRT), or RapidArc (RA); a single conformal EB; and intensity-modulated proton beams (IMPT). The goal for this planning effort was to cover 100% of the CTV with 95% of the prescribed dose and to minimize the volume inside the CTV receiving >107% of the dose.

RESULTS

All techniques but DCA and EB achieved the planning objective for the CTV with an inhomogeneity ranging from 2% to 11%. RA showed the best conformity, EB the worst. Contra-lateral breast and lung were spared by all techniques with mean doses <0.5 Gy (zero for protons). The ipsi-lateral lung received a mean dose <10% of that prescribed with photon beams and <2% with IMPT, increasing to 17% with EB. The heart, in left-sided breast tumors, received also the highest dose with EB. The skin was best protected with RA with a mean dose of 5.4 Gy and V(15Gy)=2.4%.

CONCLUSIONS

Boosting the tumor bed in early-stage breast cancer with optimized photon or proton beams may be preferred to EB especially for deep-seated targets. The marked OAR (i.e., ipsi-lateral breast, lung, heart, and skin surface) dose-sparing effect may allow for a potential long-term toxicity risk reduction and better cosmesis. DCA or RA may also be considered alternative treatment options for patients eligible for accelerated partial breast irradiation trials.

A nationwide survey of radiation oncologists' management practices of radiation-induced skin reaction (RISK)

Purpose:A questionnaire was developed to explore variations among radiation oncologists in managing early-stage breast cancer, specifically radiation-induced skin reaction (RISK).

Materials and methods:A survey was designed to target a database of 962 radiation oncologists, self-identified as ‘interested in treatment of breast cancer’. This database was obtained from the American Society of Therapeutic Radiology & Oncology (ASTRO). Participants submitted the survey online or by mail. Overall response to the survey was 282 out of 962 (29.3%). Data were handled as rates.

Results:Out of 282 respondents, 275 (97.5%) agreed on delivering 4500–5040 cGy. The most frequently employed dose was 5040/180 cGy. Three-dimensional-conformal (3DCRT) treatment was used by 55.4%, intensity-modulated radiotherapy (IMRT) by 24.5%, and conventional by 20.1%. Almost all (92.5%) agreed on using boost in ductal carcinoma in situ (DCIS). Image-guided boost placement (IGBP) was used by 87.3%. Boost dose included variations: 50.2, 7.3, and 18% used 1000, 1200, and 1400 cGy, respectively; the remaining used higher doses. In management of RISK, Aquaphor was the most popular agent (72.1%). Other agents were utilized either alone or in combination. Almost all (99%) agreed that large breast size increases RISK.

Conclusion:This survey offers a glimpse of management practices in early-stage breast cancer amongst a cross-section of radiation oncologists in the United States. Although there appears to be an overall congruence on the doses and techniques of radiation delivery, the management of RISK is varied. Additional efforts are warranted to standardize practices in order to practice evidence based medicine in a cost-effective manner.

The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery

BACKGROUND

Guidelines for breast conserving surgery (BCS) advise mastectomy if negative margins cannot be obtained after reasonable surgical attempts. This study examined the effect of multiple reexcisions on local recurrence (LR) and identified factors predictive of the need for multiple reexcisions.

METHODS

2,770 patients undergoing BCS over 25 years were analyzed; 137 patients (group A) with two or more reexcisions, 1514 patients with one reexcision (group B), and 1119 patients who had no reexcision (group C). The median follow-up was 73 months.

RESULTS

The five and ten-year actuarial LR rates for groups A, B, and C were 5.5%, 1.9%, 2.5%, and 10%, 5.7%, and 5.6%, respectively. The number of reexcisions did not predict for LR on multivariate analysis. Women <40 years underwent reexcision more frequently than other age groups. Patients with tumors detected by palpation alone made up 14% of the reexcision group versus 8% of the no reexcision group (p < 0.001). Patients with ductal carcinoma in situ and lobular carcinoma were more likely to require reexcision than those with ductal carcinoma. On multivariate analysis, younger age, detection by physical exam only, lobular histology, smaller tumor size, and the presence of extensive intraductal component (EIC) were highly significant predictors of the need for reexcision.

CONCLUSIONS

Multiple reexcisions do not impact on LR rates if negative margins are ultimately obtained. Conversion to mastectomy based solely on the number of excisions performed is not indicated. Subsets of patients more likely to require reexcision, who may be candidates for a larger initial resection, can be identified.

Obesity Alters Rat Abdominal Flap Survival

Obesity presents a risk factor for flap-related complications in autologous tissue breast reconstruction. In this study, an animal model was developed to examine this phenomenon. Abdominal flaps based on a superficial inferior epigastric pedicle were elevated in an experimental group of obese Zucker (fa/fa) rats (n = 8; mean weight, 413 g) and in their lean littermates (n = 9; mean weight, 276 g). Flap tissue was harvested from a subset of both groups for baseline characterization, including histology, and assays for ATP and oxidative phosphorylation uncoupler, UCP-2. Flaps were then evaluated for survival by planimetry at 4 and 7 days postprocedure. Flap survival 7 days postoperatively was reduced in obese (42.0% ± 8.6%) versus lean (70.3% ± 6.7%) rats ( P < 0.05). At baseline, flap tissue of obese animals had decreased ATP content relative to lean counterparts (0.12 ± 0.12 nM/μg vs 0.36 ± 0.23 nM/μg protein, P < 0.05), whereas UCP2 mRNA was higher in obese flap tissue versus lean. Reduced viability of obese flaps may be attributable to decreased baseline energy stores due to oxidative phosphorylation uncoupling by UCP-2. This study is the first to introduce a promising animal model for examining the effect of obesity on increased flap-related complications in breast reconstruction using autologous tissue.

Cosmetic outcome of breast conservative treatment for early stage breast cancer

PURPOSE

To evaluate the cosmetic outcome of breast conservative therapy and to examine the degree of agreement between the patients' and oncologists' ratings. We also analyze the influence of several factors on cosmesis.

METHODS AND MATERIALS

We retrospectively evaluated 145 patients with primary breast cancer treated by local excision and radiotherapy between January 2000 and May 2001. Cosmetic outcome was evaluated by doctors and patients and was scored as excellent, good, fair or poor.

RESULTS

73% of patients rated cosmesis as excellent or good while the percentage was 71% when rated by radiation oncologists. The degree of cosmesis concordance evaluated by oncologists and patients was low (kappa = 0.3). In our study the variables which significantly influence on the cosmetic outcome were concomitant adjuvant chemotherapy (p = 0.04) and radiation therapy boost, either by electron beam or brachytherapy (p = 0.013).

CONCLUSION

The cosmetic outcome of breast conserving therapy was good. There was a similar rating by the patient and radiation oncologist, but the level of concordance between patients and doctors was low. Factors that significantly influence the cosmesis appear to be concomitant adjuvant chemotherapy and radiation therapy boost.

Radiation therapy in the elderly

The purpose of this review is to highlight aspects of radiation oncology specifically related to aging and caring for the older patient with cancer. Particular emphasis is placed on the preclinical and clinical studies focusing on the efficacy and toxicity of RT in this population. Special techniques are also reviewed that have particular relevance to the treatment of the elderly.

Cosmetic outcome of breast conserving therapy after sentinel node biopsy versus axillary lymph node dissection

INTRODUCTION

Next to locoregional control, good cosmetic outcome is one of the main goals of breast conserving treatment (BCT) for breast cancer surgery. Factors affecting cosmetic outcome are well known. The sentinel node (SN) procedure avoids lymphedema in the breast, which might influence cosmetic outcome. The aim of this study was to evaluate the cosmetic outcome of BCT after the SN procedure compared to that after axillary lymph node dissection (ALND).

METHODS

The subjects were 20 patients who underwent ALND and 20 patients who underwent the SN procedure. After a minimum follow-up period of 43 months, we photographed each patient. Fifteen healthy women served as control subjects. We used the percentage breast retraction assessment index (pBRA=BRA/reference length x 100) to compare cosmetic outcome.

RESULTS

The median pBRAs of the ALND group and SN group (14.3 and 6.71, respectively) significantly differed ( p=0.001). The pBRA of the SN group was comparable to the pBRA (6.1) of the control group ( p=0.317).

CONCLUSION

Cosmetic outcome of BCT after the SN procedure was superior compared to the cosmetic outcome after ALND. This is an important additional reason to implement the SN procedure in routine daily practice.

A comparison in cosmetic outcome between per-operative interstitial breast implants and delayed interstitial breast implants after external beam radiotherapy

BACKGROUND AND PURPOSE

Interstitial implants for brachytherapy boost in the breast conserving therapy of breast cancer can be performed in two ways; implants during the tumor excision (per-operative implants) or after the external beam therapy (delayed interstitial implants). Differences in cosmetic outcome were investigated.

PATIENTS AND METHODS

Cosmetic results in 47 patients having a per-operative implant were compared to 123 patients having a delayed interstitial implant in a matched case-control study. Cosmesis was scored on a four-point-scale varying from 0 (excellent) to 3 (poor).

RESULTS

After mean follow-up of 63 months, three observers found no difference in cosmetic outcome between the two groups after adjustment for variables found to be related with cosmesis (difference in mean score 0.50, P=0.26). Implant volume at 100% isodose was not found to differ (P=0.084) between the per-operative group (mean 102 cm3, S.D. 34 cm3) and the delayed group (mean 93 cm3, S.D. 29 cm3).

CONCLUSIONS

Performing per-operative implants has not led to smaller implants. The method of performing brachytherapy does not result in marked differences in cosmetic outcome.

Predictive factors for skin telangiectasia following post-mastectomy electron beam irradiation

This study evaluated the predictive factors associated with skin telangiectasia following post-mastectomy electron beam irradiation of the chest wall and regional lymph nodes in patients with breast cancer. From July 1987 to December 1994, 120 women with stages II and III breast cancer received electron beam irradiation following modified radical mastectomy. Doses of 50-50.4 Gy per 25-28 fractions were given to the chest wall (with bolus), the internal mammary nodes, the supraclavicular nodes and the axillary lymph nodes using a 12 MeV or 15 MeV single portal electron beam. 19 patients received an additional 10-16 Gy boost to the surgical scar using a 9 MeV electron beam. Univariate and multivariate analyses for the development of skin telangiectasia showed 5- and 7-year actuarial rates of telangiectasia to be 59% and 72%, respectively. In univariate analysis, an additional surgical scar boost (p=0.023) as well as no treatment interruption (p=0.028) were associated with a significantly increased risk of skin telangiectasia. In multivariate analysis, the only significant independent factor for the development of skin telangiectasia was surgical scar boost (p=0.026); no treatment interruption showed a trend but did not achieve significance (p=0.051). Thus, patients given an additional boost to the surgical scar are more likely to develop skin telangiectasia. Shorter treatment courses may result in a higher probability of skin telangiectasia following electron beam irradiation.

A comparison of ink-directed and traditional whole-cavity re-excision for breast lumpectomy specimens with positive margins

BACKGROUND

Excising a breast tumor with negative margins minimizes local recurrence. With a positive margin, the standard re-excision consists of excising the whole cavity and all surrounding breast tissue. By marking the sides of the lumpectomy specimen with six different colored inks, the surgeon can limit the re-excision to the involved margin. We compared the local recurrence rate after these two re-excision methods.

METHODS

Records were reviewed of 527 women (546 breasts) treated with lumpectomy at two institutions. The log-rank test was used to compare the local recurrence-free survival.

RESULTS

Of 546 tumors, 245 (45%) had negative margins on the initial lumpectomy and were not re-excised. Fifty-five percent had a positive or close margin; 181 underwent whole-cavity re-excision, and 120 had ink-directed re-excision. The mean follow-up time was 3.4 years. There was no significant difference in local recurrence for the patients whose initial margin was negative (3.7%) compared with the 243 patients with initially positive margins who underwent a re-excision (3.3%). Eleven of 181 (6%) patients undergoing a whole-cavity re-excision developed a local recurrence, compared with none of 120 (0%) patients with an ink-directed re-excision (P = not significant). Tissue mass excised was significantly smaller in the ink-directed group (23 vs. 83 g, P < .05).

CONCLUSIONS

Ink-directed re-excision of lumpectomy specimens with positive margins minimizes the amount of breast tissue removed without increasing the incidence of local recurrence and is therefore preferable to the standard whole-cavity method.

Reduction mammoplasty improves breast conservation therapy in patients with macromastia

BACKGROUND

Macromastia has been considered a contraindication to breast conservation therapy because of difficulties with radiation therapy. This study evaluates the feasibility of bilateral reduction mammoplasty as a component of breast conservation therapy for breast cancer patients with pendulous breasts.

METHODS

Of 153 patients undergoing reduction mammoplasty at the University of Texas M. D. Anderson Cancer Center, 28 were identified as breast cancer patients with macromastia receiving breast conservation therapy. Median follow-up was 23.8 months.

RESULTS

Median patient age was 55 years. Nearly all patients were described as obese. Median weight of the reduction mammoplasty specimen on the cancerous side was 766 g. One patient (4%) required completion mastectomy for inadequate margin control. Major postoperative complications occurred in 2 patients (7%). There were no major postradiation complications. Patient survey revealed a satisfaction rate of 86%.

CONCLUSION

Bilateral reduction mammoplasty is a reasonable and safe option for breast cancer patients with macromastia who desire breast conservation therapy.

A method to improve the dose distribution of interstitial breast implants using geometrically optimized stepping source techniques and dose normalization

BACKGROUND AND PURPOSE

The standard linear source breast implant of our institution was compared with alternative linear source implant geometries and a stepping source implant, to evaluate the possibility of minimizing the treated volume. Normalization to a higher isodose than the conventional 85% of the mean central dose (MCD) was investigated for the stepping source implant to reduce the thickness of the treated volume and to increase dose uniformity. The purpose of this study was to develop an implant geometry yielding a high conformity and a more uniform dose distribution over the target volume.

MATERIALS AND METHODS

The dose distributions of four implant geometries were compared for a planning target volume (PTV) of 48 cm(3). Implants #1 (standard) and #2 had linear sources arranged in a triangular pattern of equal lengths and lengths adapted to the shape of the PTV. Implants #3 and #4 were squared pattern arranged implants with linear sources and a stepping source with geometric optimized dwell times. The active lengths were adapted to the shape of the PTV. Using implant #4 for PTVs of different volumes, the reference dose (RD) was normalized to 85 and 91% of the MCD.

RESULTS

Comparing implants #2, #3, and #4 with #1, the treated volume (V(100)) encompassed by the reference isodose was reduced by 22, 35, and 37%, respectively. The volumes receiving a dose of at least 125% (V(125)) of the reference dose was reduced by 16, 30, and 30%, respectively. The conformation number increased being 0.30, 0.39, 0.47, and 0.48 for implants #1, #2, #3, and #4, respectively. The average reduction of V(125) when the dose was normalized to 91% compared with 85% of the MCD was 18%.

CONCLUSIONS

A conformal treatment to a PTV could be best achieved with a geometrically optimized stepping source plan with needles arranged in a squared pattern. Reduction of high dose volumes within the implant was obtained by normalizing the RD to 91% instead of 85% of the MCD.

The influence of patient, tumor and treatment factors on the cosmetic results after breast-conserving therapy in the EORTC 'boost vs. no boost' trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups

PURPOSE

To analyze the influence of different patient, tumor, and treatment parameters on the cosmetic outcome after breast-conserving therapy at 3-year follow-up. A subjective and an objective cosmetic scoring method was used and the results of both methods were compared.

PATIENTS AND METHODS

In EORTC trial 22881/10882, 5569 early-stage breast cancer patients were treated with tumorectomy and axillary dissection, followed by tangential fields irradiation of the breast to a dose of 50 Gy in 5 weeks, at 2 Gy per fraction. A total of 5318 patients, having a microscopically complete tumorectomy, were randomized between no further treatment and a boost of 16 Gy to the primary tumor bed. The cosmetic result at 3-year follow-up was assessed by a panel for 731 patients, and by digitizer measurements, measuring the displacement of the nipple, for 1141 patients. Univariate and multivariate analyses were used to evaluate the correlation between various patient, tumor, and treatment factors and cosmesis.

RESULTS

The factors associated with a worsened cosmesis according to the panel evaluation were: an inferior tumor location, a large excision volume, the presence of postoperative breast complications, and the radiotherapy boost. According to the digitizer measurements, a central/superior tumor location, a large excision volume, an increased pathological tumor size, an increased radiation dose inhomogeneity, and an increased bra cup size resulted in an increased asymmetry in nipple position. It appeared that the evaluation of the nipple position (whether by panel or by digitizer) is only moderately representative of the overall cosmetic outcome.

CONCLUSION

To achieve a good cosmesis, it is necessary to excise the tumor with a limited margin, to avoid postoperative complications, to assess the need for a boost in the individual patient, and to give the radiation dose as homogeneously as possible. As far as the method of evaluation is concerned, the panel evaluation is the most appropriate method for giving an overall impression of the cosmetic result after breast-conserving therapy (BCT). The use of the digitizer is recommended for comparing the cosmetic outcome of two different approaches to BCT or for analyzing cosmetic changes over time.

Cosmetic results and complications after breast conserving therapy for early breast cancer

BACKGROUND

The cosmetic and functional results of breast conserving therapy for early breast cancer were evaluated. These are important endpoints in the assessment of breast conserving therapy in addition to tumor control and survival. The factors suspected to influence cosmesis were also analyzed.

METHODS

In 206 patients with stage I and II breast cancer treated by wide excision and axillary dissection followed by radiation therapy, the cosmetic results and complications were analyzed. The cosmetic outcome was assessed by a scoring method and breast retraction assessment (BRA). As complications, arm edema and restriction of shoulder movement and late skin reactions were analyzed.

RESULTS

Of the 206 patients 92% showed an excellent to good cosmetic score before radiation therapy. The score deteriorated, but gradually improved and stabilized after 1 year. Eighty-one percent of the patients had an excellent to good cosmetic score at 3 years. The BRA of the 206 patients was 1.8 cm on average before radiation therapy. It increased to 2.3 cm after termination of radiation therapy, and did not change thereafter. Tumor size over 2 cm (p = 0.005) and tumors in the inner quadrant (p = 0.003) were factors which negatively affected the cosmetic score at 3 years. Tumor size over 2 cm (p = 0.003), tumors in the upper quadrant (p = 0.005), or a nipple-tumor distance of more than 2 cm (p = 0.01) were also negative factors for the BRA at 3 years. Arm edema, restriction of shoulder movement, and late skin reaction were generally mild, and were observed in 12%, 0% and 34% of patients at 3 years, respectively.

CONCLUSIONS

The overall cosmetic results of breast conserving therapy are acceptable and the complication rate is low. Tumor characteristics, tumor size, location and nipple-tumor distance are factors that affect cosmesis.

The influence of the boost in breast-conserving therapy on cosmetic outcome in the EORTC "boost versus no boost" trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. European Organization for Research and Treatment of Cancer

PURPOSE

To evaluate the influence of a radiotherapy boost on the cosmetic outcome after 3 years of follow-up in patients treated with breast-conserving therapy (BCT).

METHODS AND MATERIALS

In EORTC trial 22881/10882, 5569 Stage I and II breast cancer patients were treated with tumorectomy and axillary dissection, followed by tangential irradiation of the breast to a dose of 50 Gy in 5 weeks, at 2 Gy per fraction. Patients having a microscopically complete tumor excision were randomized between no boost and a boost of 16 Gy. The cosmetic outcome was evaluated by a panel, scoring photographs of 731 patients taken soon after surgery and 3 years later, and by digitizer measurements, measuring the displacement of the nipple of 3000 patients postoperatively and of 1141 patients 3 years later.

RESULTS

There was no difference in the cosmetic outcome between the two treatment arms after surgery, before the start of radiotherapy. At 3-year follow-up, both the panel evaluation and the digitizer measurements showed that the boost had a significant adverse effect on the cosmetic result. The panel evaluation at 3 years showed that 86% of patients in the no-boost group had an excellent or good global result, compared to 71% of patients in the boost group (p = 0.0001). The digitizer measurements at 3 years showed a relative breast retraction assessment (pBRA) of 7.6 pBRA in the no-boost group, compared to 8.3 pBRA in the boost group, indicating a worse cosmetic result in the boost group at follow-up (p = 0.04).

CONCLUSIONS

These results showed that a boost dose of 16 Gy had a negative, but limited, impact on the cosmetic outcome after 3 years.

Local Management of Primary Breast Cancer

BACKGROUND: Various options are available for the local control of cancer in the breast -- mastectomy, conservation therapy, and mastectomy with reconstruction. METHODS: To evaluate the benefits and drawbacks of the available management options, the authors combine their extensive experience with a review of the literature on outcomes from these approaches. RESULTS: Conservation therapy provides survival outcomes similar to those from mastectomy. Differences in local recurrence rates can be minimized by close adherence to guidelines for patient selection, operative approach, and radiation technique. CONCLUSIONS: The role of the physician in selecting a local therapy for breast cancer has changed from one of informing the patient of the treatment to assessing the presence of medical contraindications to any of the treatments, educating the patients on each treatment approach, providing access to multidisciplinary consultation, and allowing the patient to choose an appropriate treatment approach.

Is machine energy (4-8 MV) associated with outcome for stage I-II breast cancer patients?

PURPOSE

To assess the relationship between machine energy (4-8 MV) and treatment outcome in patients treated with conservative surgery and radiation therapy.

METHODS AND MATERIALS

Between 1968 and 1985, 1624 patients were treated for clinical Stage I or II invasive breast cancer. The study population was limited to 1380 patients who underwent complete gross excision and received greater than or equal to 60 Gy to the tumor bed. Of these, 1125 were treated on a 4 MV, 153 on a 6 MV, and 102 on an 8 MV linear accelerator. Patients were selected for treatment on the 8 MV machine based on chest wall separations greater than 24 cm. Of patients treated on the 8 MV, netting was used for 42% and bolus was used for 26%. The median dose with bolus was 14 Gy in seven fractions (range: 2-34.2 Gy). Patients treated on the 8 MV accelerator were older, had a higher percentage of clinical T2 tumors, a higher percentage of pathologically positive nodes, and a lower incidence of extensive intraductal component (EIC). Median follow-up times were 130, 153, and 102 months, respectively, for survivors treated on the 4, 6, and 8 MV machines.

RESULTS

We analyzed the site and 5-year crude incidence of first failure by machine energy and found the pattern of first failure site (local, nodal, or distant) to be virtually identical for each energy group. Of the local failures, 12 were in the skin of the treated breast, and these failures were evenly distributed by machine energy. We performed a multivariate analysis to adjust for factors known to predict for treatment failure. When adjusted for these other variables, machine energy was not associated with an increased (or decreased) risk of recurrence (RR for 8 MV vs. 4 MV = 0.94, p = 0.7; RR for 6 MV vs. 4 MV = 1.0, p = 0.9). We also analyzed the nature and incidence of treatment complications (rib fracture, radiation pneumonitis, soft tissue necrosis, and brachial plexopathy) and found no significant differences among the three treatment groups when stratified by treatment technique (tangents only vs. three-field). There was also no significant difference in cosmetic outcome at 5 years among the three groups.

CONCLUSIONS

We conclude that machine energy over the range of 4 to 8 MV does not significantly affect treatment outcome. Specifically, it was feasible to treat patients with large chest wall separations using an 8 MV machine without an increase in skin recurrences and with the improved dose homogeneity afforded by 8 MV machines as compared with those of lower energies.

Comparison of the surgical procedures for breast conserving treatment of early breast cancer in seven EORTC centres

The aim of this study was to develop a standardised surgical report for breast-conserving procedures, supporting the systematic documentation of the different aspects of the surgery. The surgical procedure for tumourectomy and axillary clearance was translated into a series of steps that could be quantitatively documented. This description was submitted twice to a group of surgeons from different departments to ensure that all steps that are considered to have relevance for outcome were included and that no superfluous data were collected. After two corrective phases, a first test format was developed. Between February 1993 and May 1994, seven surgical departments, participating in EORTC trials, completed this questionnaire for a number of their patients. The data collected related to general information on the department, the tumour excision itself, the axillary dissection and, in a later phase, on pathology. 269 questionnaires (264 tumour excisions, 259 axillary dissections and 189 pathology reports) were collected and analysed. Even though the participating departments were involved in a single trial on breast-conserving surgery and had previously developed regular contacts about the practical aspects of treatment, many differences were detected. In general, variations were found in the waiting time between treatment prescription and execution, experience of the surgeon, duration of the procedure, and the use of prophylactic antibiotics. Also, in the practical execution of the procedure, major variations in the type of incision, width of tumour excision, closure of the breast tissue and skin, the use of frozen sections and the extent of the axillary dissection were found. The most relevant differences and their possible consequences are discussed. It has been proven possible and feasible to document quantitatively a surgical procedure. The fact that within a group of surgeons participating in the same clinical trials, many differences in the surgical techniques are observed, stresses the need to reach a consensus on a stricter set of guidelines for breast-conserving procedures and their documentation, especially when conducting clinical trials.

More detailed documentation of operative procedures in breast conserving treatment: what good will it do us?

When researching the literature, many differences within surgical techniques for breast conservation, tumour excision and axillary dissection are described in the smallest detail. Most authors have their own preferences but little clinical research has been done to evaluate the impact of those differences on outcome: local control, cosmesis, complications or costs. Even when prospective, randomized clinical trial protocols provide many instructions to perform the surgery, the case report forms almost never document the surgery actually performed. This is in contrast to radiotherapy and chemotherapy regimens, which have had higher standards of quality of care implemented. The development of more detailed and standardized procedural information should lead to more accurate and specific information, which can be easily transferred in a learning process, and enable more reliable clinical research. Documentation and guidelines for surgery are essential tools in implementing a process of quality audit for a type of surgery where accuracy is essential.

Factors affecting acute skin toxicity in patients having breast irradiation after conservative surgery: a prospective study of treatment practice at the Royal Marsden Hospital

The results are presented of a prospective study of acute skin toxicity in 197 patients with early stage breast cancer, who were treated by conservative surgery and postoperative radiotherapy. We have examined the factors determining the severity of the acute skin reaction with particular reference to the degree of dry or moist desquamation at the completion of treatment. One hundred and ten patients had treatment with radiotherapy alone. The remaining 87 received synchronous chemotherapy with breast irradiation, using either the 3M or the 2M regimen, consisting of mitoxantrone and methotrexate, with (3M) or without Mitomycin-C (2M). Patients were analysed according to both the severity and the site of the skin reaction, age, dose, dose variation across the central outline, treatment technique, beam energy, field separation and breast size. A univariate analysis of these results, which has been presented as an odds ratio of the likelihood of developing a moderate or severe reaction in comparison with those scored as mild, has shown that several factors are associated with an increase in the acute skin reaction. These include the use of the semi-supine technique (odds ratio (OR) = 7.3 (95% CI 3.7-14.6)), beam energy (60Co: 6-10 MV photons OR = 5.9 (95% CI 2.6-13.4)), field separation (> or = 20 cm: < 20 cm OR = 4.1 (95% CI 2.2-7.8)), dose variation across the central outline (> or = 10%: < 10% OR = 9.7 (95% CI 2.6-36.4)), inclusion of the axilla (OR = 4.6 (95% CI 2.4-8.9)), and bust size (bra cup size C and D: A and B OR = 4.6 (95% CI 2.7-11.9)). Using multivariate logistic regression, the technique of radiation delivery and bust size were shown to be independently significant variables affecting acute skin reaction. In view of the high correlation between variables (e.g. radiotherapy technique and beam energy) it is still not possible to specify with definite certainty which is the primary variable causing the skin reaction. However 20/57 (35%) of patients treated by the semisupine technique sustained a severe skin reaction, with > 10% dry or moist desquamation in the treatment field. This compares with only 6/140 (4%) patients treated by the supine method. A possible mechanism by which treatment using the semisupine technique may enhance acute toxicity is discussed. We conclude that there are both treatment and patient related factors that will increase the acute skin reaction after breast irradiation.

The influence of radiotherapy on cosmetic outcome after breast conservative surgery

PURPOSE

The influence of radiotherapy in the cosmetic outcome after conservative surgery for breast cancer was evaluated using an objective method of calculating the asymmetry between the two breasts.

METHODS AND MATERIALS

One hundred and one patients treated with the same conservative surgery were evaluated for cosmetic outcome. Sixty-one of them received external radiotherapy (50 + 10 Gy) to the residual breast; the remaining 40 underwent surgery only. The aspect of the patients' breasts was objectively assessed for symmetry by means of a computerized technique. A subjective assessment of the cosmetic outcome was performed both by physician and patient. These objective and subjective assessments were compared in the two groups treated with or without radiotherapy.

RESULTS

The results obtained did not show significant differences in terms of cosmetic outcome in the two groups. Skin telangectasia was noted in two radiotherapy patients, while hypertrophic breast scars were only noted in six nonirradiated patients.

CONCLUSIONS

We found that standard radiotherapy does not seem to influence the symmetry and the cosmetic results in breast conservative treatment when compared to a similar group of patients with the same quadrantectomy procedure and no radiotherapy.

Effect of reexcision on the success of breast-conserving surgery

BACKGROUND

The success of lumpectomy and radiotherapy is dependent on minimizing the residual tumor burden in the breast. Histologic margin status is one measure of the extent of residual tumor. This study was undertaken to determine the success rate of a single conservative lumpectomy in obtaining negative margins and to evaluate the incidence of residual tumor after biopsies with positive or unknown margins.

METHODS

This is a retrospective study covering a 5-year period (June 1988-June 1993).

RESULTS

Three hundred sixteen women had lumpectomies. In 239, lumpectomy was the initial operation after a positive fine-needle aspiration or as a diagnostic procedure. Thirteen cases had positive margins. Reexcision was performed in 90 cases. The indication for reexcision was a positive margin in 42 cases (4 with gross tumor) and unknown margin status in 48. Nineteen of the reexcisions for positive margins and 20 of the reexcisions for unknown margins contained residual tumor. Eighty-six (96%) of the 90 reexcised patients underwent breast preserving surgery. Patient age, menopausal status, histologic tumor type, tumor size, and clinical presentation were not predictive of residual tumor.

CONCLUSIONS

The need for reexcision does not preclude breast preservation. Because single-stage lumpectomy is successful in achieving negative margins in 95% of patients, diagnostic biopsy without margin evaluation should be abandoned to avoid routine reexcision.

Pathophysiology of irradiated skin and breast

The evolution, time course, and dose response of gross and histologic changes associated with the acute and late changes of the skin are noted and a composite pathophysiologic operational model given. This model focuses the selection of the observations to be "scored" to assess the tolerance and cosmetic response of the skin and breast to different dose and combined therapy studies. Skin scoring, Late effects skin, Late effects breast, Skin irradiation response, Breast radiation response, Pathophysiology of irradiated skin, Dose tolerance of skin, Dose tolerance of breast, Skin functional unit, Microvessel response to irradiation.

Factors influencing cosmetic results after conservation therapy for breast cancer

PURPOSE

Host, tumor, and treatment-related factors influencing cosmetic outcome are analyzed for patients receiving breast conservation treatment.

METHODS AND MATERIALS

Four-hundred and fifty-eight patients with evaluable records for cosmesis evaluation, a subset of 701 patients treated for invasive breast cancer with conservation technique between 1969 and 1990, were prospectively analyzed. In 243 patients, cosmetic evaluation was not adequately recorded. Cosmesis evaluation was carried out from 3.7 months to 22.3 years, median of 4.4 years. By pathologic stage, tumors were 62% T1N0, 14% T1N1, 15%, T2N0, and 9% T2N1. The majority of patients were treated with 4-6 MV photons. Cosmetic evaluation was rated by both patient and physician every 4-6 months. A logistic regression analysis was completed using a stepwise logistic regression. P-values of 0.05 or less were considered significant. Excellent cosmetic scores were used in all statistical analyses unless otherwise specified.

RESULTS

At most recent follow-up, 87% of patients and 81% of physicians scored their cosmetic outcome as excellent or good. Eighty-two percent of physician and patient evaluations agreed with excellent-good vs. fair-poor rating categories. Analysis demonstrated a lower proportion of excellent cosmetic scores when related to patient age > 60 years (p = 0.001), postmenopausal status (p = 0.02), black race (p = 0.0034), and T2 tumor size (p = 0.05). Surgical factors of importance were: volume of resection > 100 cm3 (p = 0.0001), scar orientation compliance with the National Surgical Adjuvant Breast Project (NSABP) guidelines (p = 0.0034), and > 20 cm2 skin resected (p = 0.0452). Extent of axillary surgery did not significantly affect breast cosmesis. Radiation factors affecting cosmesis included treatment volume (tangential breast fields only vs. three or more fields) (p = 0.034), whole breast dose in excess of 50 Gy (p = 0.0243), and total dose to tumor site > 65 Gy (p = 0.06), as well as optimum dose distribution with compensating filters (p = 0.002). Daily fraction size of 1.8 Gy vs. 2.0 Gy, boost vs. no boost, type of boost (brachytherapy vs. electrons), total radiation dose, and use of bolus were not significant factors. Use of concomitant chemotherapy with irradiation impaired excellent cosmetic outcome (p = 0.02). Use of sequential chemotherapy or adjuvant tamoxifen did not appear to diminish excellent cosmetic outcomes (p = 0.31). Logistic regression for excellent cosmetic outcome analysis was completed for age, tumor size, menopausal status, race, type of surgery, volume of breast tissue resected, scar orientations, whole breast radiation dose, total radiation dose, number of radiation fields treated, and use of adjuvant chemotherapy. Significant independent factors for excellent cosmetic outcome were: volume of tissue resected (p = 0.0001), type of surgery (p = 0.0001), breast radiation dose (p = 0.005), race (p = 0.002), and age (p = 0.007).

CONCLUSIONS

Satisfactory cosmesis was recorded in 81% of patients. Impaired cosmetic results are more likely with improper orientation of tylectomy and axillary incisions, larger volume of breast resection, radiation dose to the entire breast in excess of 50.0 Gy, and concurrent administration of chemotherapy. Careful selection of treatment procedures for specific patients/tumors and refinement in surgical/irradiation techniques will enhance the cosmetic results in breast conservation therapy.

Dose and volume effects on fibrosis after breast conservation therapy

PURPOSE

To analyze factors involved in the development of fibrosis in the boost area after breast conservation therapy (BCT) in patients treated with continuous low dose rate iridium implants following 50 Gy whole breast irradiation.

METHODS AND MATERIALS

Fibrosis was estimated by palpation in 404 patients by four physicians. The median follow-up (FUP) duration was 70 months (range 30-133 months). Original implant data were used for reconstruction and dose-volume calculations. The total dose of the external whole breast irradiation and iridium implants was expressed in Normalized Total Dose (NTD): the total dose given in fractions of 2 Gy, which is biologically equivalent to the actual dose given according to the linear-quadratic model, using an alpha/beta value of 2 Gy, and 1.5 h for the recovery half-life of sublethal damage repair. To identify predictors of fibrosis we used a proportional odds model in a polychotomous logistic regression analysis.

RESULTS

Seven independent factors were identified that were related to the severity of fibrosis: age, duration of FUP, clinical T-size, photon beam energy, NTD level, implant volume, and adjuvant chemotherapy. From the proportional odds model, a volume exponent could be estimated (0.16 +/- 0.04) that enabled us to determine dose-effect relations for different volumes. A 10-fold higher risk of fibrosis was seen when the total dose was above 79 Gy as compared with doses lower than 70 Gy. A fourfold increase in risk of fibrosis was seen for each 100 cm3 increase in irradiated boost volume. The use of adjuvant chemotherapy resulted in a twofold increase in the risk of fibrosis (dose modifying factor approximately 1.08). The application of Co-60 beams had a similar effect. The relative odds for the other factors were smaller (1.4 for each 10 years of older age, and 1.2 for clinical T-size over 20 mm). The FUP-period had a nonlinear effect: relative odds 2.2 at 6 years, 3.6 at 7-8 years, and 2.8 at 9-11 years. The dose rate (mean 0.57, range 0.26-0.89 Gy/h) had no influence on the development of fibrosis and there was no correlation between dose rate and irradiated volume.

CONCLUSIONS

To optimize cosmetic results after BCT, both the total dose and the irradiated volume should be kept as low as possible. Minimum effective dose levels still have to be established. The boost volume can be minimized by more conformal brachytherapy techniques and optimal localization. It may be worthwhile to take adjuvant chemotherapy into account in decisions on boost dose levels.

Breast conservation therapy: local tumor control in patients with pathologically clear margins who receive 5000 cGy breast irradiation without local boost

A retrospective study was performed to determine the value of pathological evaluation of inked primary tumor specimen margins in the local control of patients with stage I and II breast cancer. In 150 patients with 153 invasive breast cancers, treatment involved surgical resection of the primary tumor, pathological determination of tumor-free inked specimen margins, and 5000 cGy whole breast radiation therapy (RT) without tumor bed RT local boost. This approach yielded an actuarial five-year local control rate of 95%. The local control rate was 96% for T-1 cases and 93% for T-2 cases. The local control rate was 96% for patients with clear margins achieved at initial resection and 94% for patients with clear margins achieved at re-excision. Among patients with clear margins at re-excision, the local control rate was 97% for those with no residual cancer and 88% for those with residual cancer. Patients with surgical margins clear by 3 mm or less had a local control rate of 92% at five years. Local control rates appear to be comparable to other breast conservation approaches which routinely employ local RT boosts. In omitting the local RT boost in patients with clear margins, the overall RT course will be briefer and the cosmetic changes associated with high-dose, large volume local RT boosts can be avoided.