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Long-Term Side Effects and Cosmetic Outcome in a Pool of Breast Cancer Patients Treated with Intraoperative Radiotherapy with Electrons as Sole Treatment. TUMORI JOURNAL 2018; 98:324-30. [DOI: 10.1177/030089161209800308] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims To evaluate late toxicity and cosmetic outcome after intraoperative radiotherapy using electrons (ELIOT) as sole treatment modality in early breast cancer patients. Methods A total of 119 patients selected randomly among 1200 cases was analyzed. Late toxicities were documented using the LENT-SOMA scoring system, cosmesis was evaluated with the Harvard scale, and a numeric rating scale was used to assess symptoms. Results After a median follow-up of 71 months, grade II fibrosis was observed in 38 patients (31.9%) and grade III fibrosis in 7 patients (5.9%). Postoperative complications (12.6%) did not correlate with late toxicity. Physicians and patients scored cosmesis as excellent or good in 84% and 77.3% of the cases, respectively. Patient satisfaction was higher than 90%. Conclusions In the study, ELIOT gives low and acceptable long-term toxicity. A longer follow-up and a larger number of patients are needed to confirm these promising results.
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Immink JM, Putter H, Bartelink H, Cardoso JS, Cardoso MJ, van der Hulst-Vijgen MHV, Noordijk EM, Poortmans PM, Rodenhuis CC, Struikmans H. Long-term cosmetic changes after breast-conserving treatment of patients with stage I-II breast cancer and included in the EORTC 'boost versus no boost' trial. Ann Oncol 2012; 23:2591-2598. [PMID: 22499858 DOI: 10.1093/annonc/mds066] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In breast cancer treated with breast-conserving radiotherapy, the influence of the boost dose on cosmetic outcome after long-term follow-up is unknown. PATIENTS AND METHODS We included 348 patients participating in the EORTC 'boost versus no boost' mega trial with a minimum follow-up of 6 years. Digitalised pictures were analysed using specific software, enabling quantification of seven relative asymmetry features associated with different aspects of fibrosis. RESULTS After 3 years, we noted a statistically significantly poorer outcome for the boost patients for six features compared with those of the no boost patients. Up to 9 years of follow-up, results continued to worsen in the same magnitude for the both patient groups. We noted the following determinants for poorer outcome: (i) boost treatment, (ii) larger excision volumes, (iii) younger age, (iv) tumours located in the central lower quadrants of the breast and (v) a boost dose administered with photons. CONCLUSIONS A boost dose worsens the change in breast appearance in the first 3 years. Moreover, the development of fibrosis associated with whole-breast irradiation, as estimated with the relative asymmetry features, is an ongoing process until (at least) 9 years after irradiation.
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Affiliation(s)
- J M Immink
- Department of Radiotherapy, Medical Center, Reinier de Graaf Groep, Delft.
| | - H Putter
- Department of Statistics, Leiden University Medical Center, Leiden
| | - H Bartelink
- Department of Radiotherapy, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - J S Cardoso
- Electrical and Computer Engineering INESC Porto, Faculty of Engineering, University of Porto, Porto
| | - M J Cardoso
- Department of Surgery, Champalimaud Cancer Center, Lisbon, Portugal
| | | | - E M Noordijk
- Department of Radiotherapy, Leiden University Medical Center, Leiden
| | - P M Poortmans
- Department of Radiation Oncology, Institute Verbeeten, Tilburg
| | - C C Rodenhuis
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht
| | - H Struikmans
- Department of Radiotherapy, Leiden University Medical Center, Leiden; Department of Radiotherapy, Radiotherapy Centre West, The Hague, The Netherlands
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Immediate breast reconstruction using autologous free dermal fat grafts provides better cosmetic results for patients with upper inner cancerous lesions. Surg Today 2011; 41:477-89. [DOI: 10.1007/s00595-010-4307-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 03/09/2010] [Indexed: 10/18/2022]
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Johansen J, Overgaard J, Overgaard M. Effect of adjuvant systemic treatment on cosmetic outcome and late normal-tissue reactions after breast conservation. Acta Oncol 2009; 46:525-33. [PMID: 17497320 DOI: 10.1080/02841860701291698] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To investigate whether adjuvant treatment with CMF or tamoxifen predisposes to an unfavorable cosmetic outcome or increased breast morbidity after radiotherapy in breast conservation. Data from 266 patients who entered a randomized breast conservation trial (DBCG-82TM protocol) was analyzed. The patients were treated with lumpectomy and axillary dissection followed by external beam radiotherapy to the residual breast. High-risk patients (n = 94), as well as 31 low-risk patients, received additional radiation to the regional lymph nodes. Adjuvant systemic treatment was given to all high-risk patients: premenopausal patients (n = 67) received eight cycles of CMF intravenously (600/40/600 mg per m2) every fourth week; postmenopausal patients (n = 27) received 30 mg of tamoxifen daily for one year. Clinical assessments included cosmetic outcome, breast fibrosis, skin telangiectasia, and dyspigmentation which were scored on a 4-point categorical scale after median 6.6 years. The observations were analyzed in multivariate logistic regression analysis which included potential risk factors on outcome related to systemic treatment, surgery, radiation technique, tumor, and patient characteristics. In premenopausal patients, systemic treatment with CMF independently predicted a fair/poor cosmetic outcome, RR = 2.2 (95% CI 1.2-4.2), as well as increased skin telangiectasia, RR = 3.3 (1.4-8.2). There was no impact of tamoxifen treatment on cosmetic outcome in postmenopausal patients (p = 0.32). However, univariate analysis showed that tamoxifen was significantly associated with breast fibrosis (p < 0.004), as was radiation to the regional lymph nodes (p < 0.0001). A strong interaction between axillary irradiation and tamoxifen treatment occurred since 26 of 27 high-risk postmenopausal patients had received both tamoxifen and axillary irradiation. In multivariate regression analysis, axillary irradiation independently predicted moderate/severe breast fibrosis with a relative risk of 5.0 (2.0-12.5) and 9.6 (3.3-27.7) in premenopausal and postmenopausal patients, respectively. To circumvent the strong interaction between tamoxifen treatment and axillary irradiation, a subsequent analysis omitting axillary treatment from the multivariate regression showed a significant effect of both tamoxifen and CMF on the occurrence of breast fibrosis with relative risks of 5.3 (CI 1.8-15.8) and 4.4 (1.8-10.3), respectively. Adjuvant systemic treatment with CMF given sequentially to radiotherapy independently predicted an adverse cosmetic outcome as well as increased skin telangiectasia after breast conserving treatment. Due to a strong interaction between tamoxifen administration and radiation to the regional lymph nodes, the effect of tamoxifen on the development of fibrosis could not be fully discerned in this study. Axillary irradiation increased the incidence of moderate to severe breast fibrosis in both premenopausal and postmenopausal patients.
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Affiliation(s)
- Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark.
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Arenas M, Sabater S, Hernández V, Henríquez I, Ameijide A, Anglada L, Mur E, Artigues M, Lafuerza A, Borras J. Cosmetic outcome of breast conservative treatment for early stage breast cancer. Clin Transl Oncol 2006; 8:334-8. [PMID: 16760008 DOI: 10.1007/s12094-006-0179-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- M Arenas
- Oncology Department, Hospital Universitari Sant Joan de Reus, Catalonia, Spain.
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Bowden SJ, Fernando IN, Burton A. Delaying Radiotherapy for the Delivery of Adjuvant Chemotherapy in the Combined Modality Treatment of Early Breast Cancer: Is It Disadvantageous and Could Combined Treatment be the Answer? Clin Oncol (R Coll Radiol) 2006; 18:247-56. [PMID: 16605056 DOI: 10.1016/j.clon.2005.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Women with early stage breast cancer are increasingly being treated with both adjuvant chemotherapy and radiotherapy. The optimal sequence of these two treatment modalities is yet to be defined. It remains controversial whether delaying radiotherapy in order to deliver chemotherapy compromises local disease control and survival. Consequently, clinical practice in the UK is divided, with a number of different combination schedules being used in an effort to bring forward the start of radiotherapy. In practice, however, any benefit in local control must be balanced against a potential increase in toxicity. A review of the current literature on the effect of radiotherapy delay is presented, together with data on the toxicity of combined chemo-radiotherapy schedules and recent data from clinical trials designed to determine the optimal sequencing of chemotherapy and radiotherapy.
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Affiliation(s)
- S J Bowden
- CR UK Clinical Trials Unit, Institute for Cancer Studies, The University of Birmingham, Edgbaston, Birmingham, UK.
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Coles CE, Moody AM, Wilson CB, Burnet NG. Reduction of radiotherapy-induced late complications in early breast cancer: the role of intensity-modulated radiation therapy and partial breast irradiation. Clin Oncol (R Coll Radiol) 2005; 17:16-24. [PMID: 15714924 DOI: 10.1016/j.clon.2004.08.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Radiotherapy after conservation surgery has been proven to decrease local relapse and death from breast cancer, and is now firmly established in the management of early breast carcinoma. Currently, the challenge is to minimise the morbidity caused by this treatment without losing its efficacy. This review will be divided into two parts, with Part I focusing on the radiation factors contributing to late normal tissue complications after radiotherapy for early breast cancer. Three major normal tissue side-effects will be discussed: cosmetic outcome, cardiac complications and pulmonary side-effects.
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Affiliation(s)
- C E Coles
- Oncology Centre, Box 193, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK.
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Bellon JR, Shulman LN, Come SE, Li X, Gelman RS, Silver BJ, Harris JR, Recht A. A prospective study of concurrent cyclophosphamide/methotrexate/5-fluorouracil and reduced-dose radiotherapy in patients with early-stage breast carcinoma. Cancer 2004; 100:1358-64. [PMID: 15042668 DOI: 10.1002/cncr.20136] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Concurrent administration of chemotherapy and radiotherapy has the potential advantage of delaying neither treatment and providing radiation sensitization. However, the optimal approach to concurrent treatment in women with early-stage breast carcinoma remains undefined. We present updated results of a prospective protocol of concurrent cyclophosphamide/methotrexate/5-fluorouracil (CMF) and reduced-dose radiotherapy, focusing on tumor control and patient tolerance. METHODS One hundred twelve women with AJCC Stage I or Stage II breast carcinoma with 0-3 positive axillary lymph nodes were enrolled in a prospective single-arm study of concurrent CMF and reduced-dose radiotherapy (39.6 gray [Gy] to the whole breast, 16-Gy boost). A high proportion of women had risk factors associated with an increased risk of local disease recurrence, including age <40 (32%), close or positive margins (37%), or lymphatic/vascular invasion (51%). The median follow-up period was 94 months. RESULTS The 5-year overall survival rate was 94%. By 60 months, 5 patients (4%) experienced local disease recurrence and 19 patients (17%) experienced distant metastasis. There were no isolated regional lymph node recurrences. Local disease recurrence occurred in 1 of 25 patients (4%), 1 of 16 patients (6%), and 3 of 70 patients (4%) with positive, close (<1 mm), and negative margins, respectively. One patient developed acute myelogenous leukemia. An additional patient developed Grade 2 pneumonitis. Cosmetic results were not recorded uniformly for all patients and therefore could not be reliably analyzed. CONCLUSIONS Concurrent CMF and reduced-dose radiotherapy resulted in a low level of late toxicity and excellent local tumor control, despite the large proportion of patients with substantial risk factors for local disease recurrence. Future studies of concurrent regimens, particularly in patients at high risk of local disease recurrence, are warranted.
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Affiliation(s)
- Jennifer R Bellon
- Department of Radiation Oncology, Brigham and Women's Hospital and the Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts 02115, USA.
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Recht A. Integration of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. Clin Breast Cancer 2003; 4:104-13. [PMID: 12864938 DOI: 10.3816/cbc.2003.n.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
There is no consensus on the optimal combination of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. This article reviews prospective and retrospective studies that shed light on this topic. Patients with positive, close, or unknown microscopic margins appear to benefit from relatively early initiation of radiation therapy, whereas those with wider tumor-free margin widths do not. For patients at high risk of distant failure (such as those with = 4 positive axillary nodes), chemotherapy may be more effective when it begins before radiation therapy rather than after. Regimens of concurrent radiation therapy and chemotherapy tend to have higher acute and subacute complication rates than sequential regimens, but the actual rates vary substantially with the exact details of the overall treatment program. There are no data on the impact of the timing of tamoxifen administration on the effectiveness of radiation therapy. Tamoxifen does not appear to increase complication rates relative to the use of radiation therapy alone. Thus, the best way of giving combined-modality therapy is uncertain. Further retrospective and prospective studies to investigate the issues discussed herein should be performed.
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Affiliation(s)
- Abram Recht
- Department of Radiation Oncology, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA,USA.
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Berberich W, Schnabel K, Berg D, Lamprecht E. Boost irradiation of breast carcinoma: teletherapy vs. brachytherapy. Eur J Obstet Gynecol Reprod Biol 2001; 94:276-82. [PMID: 11165739 DOI: 10.1016/s0301-2115(00)00354-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND The results of adjuvant radiotherapy including a boost dose after breast-conserving surgery of mamma carcinoma were retrospectively analysed to relate local tumor control, survival, and cosmetic results to the boost technique. MATERIAL AND METHODS The study included 229 female patients who were treated in the period 1986--1997. Group A consisted of patients where the primary irradiation was hyperfractionated (two fractions per day) and the boost was applied by reduced portals, also at two fractions per day. In group B the 'boost' was applied interstitially intraoperatively and the 'primary' irradiation followed at one fraction per day. The cosmetic results and the late changes to the mamma were the subjects of follow-up examinations and were assessed using the EORTC score. RESULTS 129 patients formed group A, median follow-up 4.2 years, and 100 patients with median follow-up of 9.4 years formed group B. 59% of group A and 60% of group B were in stage pT1, 38% and 39% were in pT2, and 25% and 39% were in stage N1 or N2 (no significant differences). Tumors were mostly poorly to moderately differentiated. The upper outer quadrant was most afflicted. Local recurrence occurred in two and five cases, lymph-node recurrence in two cases each, while there were ten and 12 cases of distant metastases. There were no deaths in group A and in group B six with obvious distant metastases and eight with other causes of death. The cosmetic results and late side-effects (induration, teleangiectasis, ulcers) were significantly worse in the interstitial group B. Multivariate analysis revealed that only the total applied dose significantly affected the severity of late radiation side-effects. The cosmetic results worsened with time, the tendency for lymph edemas in the irradiated side increased. Induration decreased continuously after pure teletherapy but increased continuously after interstitial therapy. These trends did not change in either group. CONCLUSIONS Both therapy schemes resulted in successful local tumor control with good cosmetic results and few side effects, but the interstitial boost therapy was clearly less favourable. Longer-term follow-up is required to compare the late side-effects even further.
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MESH Headings
- Adult
- Aged
- Brachytherapy/adverse effects
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/radiotherapy
- Carcinoma, Lobular/surgery
- Cosmetic Techniques
- Female
- Follow-Up Studies
- Humans
- Hyperpigmentation/etiology
- Lymphedema/etiology
- Middle Aged
- Neoplasm Metastasis
- Neoplasm Recurrence, Local
- Radiotherapy, Adjuvant/adverse effects
- Radiotherapy, Adjuvant/methods
- Survival Rate
- Telangiectasis/etiology
- Time Factors
- Ulcer/etiology
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Affiliation(s)
- W Berberich
- Institute for Radiotherapy, St. Mary's Hospital, D-92224 Amberg, Germany
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