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1–45 A Cosmetic Evaluation of Breast Cancer Treatment: A Randomized Study of Radiotherapy Boost Technique
However, proton therapy may well have an important role in accelerated partial breast irradiation (APBI), and this topic is the subject of intense clinical research at this time. At Massachusetts General Hospital, the treatments last only 1 week (but are given twice a day), which reduces the costs considerably. Moreover, the doses received by the heart, lung, and nontargeted breast tissue are significantly lower than if other techniques are used.4 The noninvasive nature of this treatment also makes it more attractive to patients and physicians than more invasive techniques (eg, use of MammoSite or other brachytherapy devices). Therefore, al-
though more studies are needed, proton therapy is likely to play an important and significant role in APBI in the near future.
1–45
months after RT. The evaluations were done using a panel of global and specific subjective scores, a digitized scoring system using the breast retraction assessment (BRA) measurement, and a patient’s selfassessment evaluation. As cosmetic results were graded according to severity, the comparison of boost techniques was done using the ordinal logistic regression model. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) are presented. Results.—At 36 months of followup, there was no significant difference between the two groups with respect to the global subjective cosmetic outcome (OR = 1.40; 95% CI = 0.69-2.85, p = 0.35). Good to excellent scores were observed in 65% of implant patients and 62% of photon/electron patients. At 24 months and beyond, telangiectasia was more severe in the implant group with an OR of 9.64 (95% CI = 4.05-22.92, p < 0.0001) at 36 months. The only variable associated with a worse global cosmetic outcome was the presence of concomitant chemotherapy (OR = 3.87; 95% CI = 1.74-8.62). The BRA value once adjusted for age, con-
A Cosmetic Evaluation of Breast Cancer Treatment: A Randomized Study of Radiotherapy Boost Technique Vass S, Bairati I (Complexe Hospitalier de la Sagamie, Chicoutimi, Quebec; Laval Univ, Quebec City) Int J Radiat Oncol Biol Phys 62:1274-1282, 2005
Purpose.—To compare cosmetic results of two different radiotherapy (RT) boost techniques used in the treatment of breast cancer after whole breast radiotherapy and to identify factors affecting cosmetic outcomes. Methods and Materials.—Between 1996 and 1998, 142 patients with Stage I and II breast cancer were treated with breast conservative surgery and adjuvant RT. Patients were then randomly assigned to receive a boost dose of 15 Gy delivered to the tumor bed either by iridium 192, or a combination of photons and electrons. Cosmetic evaluations were done on a 6month basis, with a final evaluation at 36
88 88
®
A. Taghian, MD, PhD
References 1. Darby S, McGale P, Peto R, et al: Mortality from cardiovascular disease more than 10 years after radiotherapy for breast cancer: Nationwide cohort study of 90,000 Swedish women. Br Med J 326:256-257, 2003. 2. Particle Therapy Co-operative Group: Particles: A newsletter for those interested in proton, light ion and heavy
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
charged particle radiotherapy (35; January 2005). Available at: http://ptcog.mgh.harvard.edu. Accessed November 16, 2005. 3. Patt DA, Goodwin JS, Kuo Y-F, et al: Cardiac morbidity of adjuvant radiotherapy for breast cancer. J Clin Oncol 23:7475-7482, 2005. 4. Taghian A, Kozak KR, Adams J, et al: Accelerated partial-breast irradiation (APBI) using protons for patients with early-stage breast cancer: A comparison with 3D conformal photon/electron based treatment (abstract). Int J Radiat Oncol Biol Phys 63(Suppl 1):S8-S9, 2005.
comitant chemotherapy, and boost volume showed a positive association with the boost technique. The BRA value was significantly greater in the implant group (p = 0.03). There was no difference in the patient’s final self-assessment score between the two groups. Three variables were statistically associated with an adverse self-evaluation: an inferior quarant tumor localization, postoperative hematoma, and concomitant chemotherapy. Conclusions.—Although this trial showed that at 36 months of follow-up, there were no significant differences in the overall global cosmetic scores between the implant boost group and the photon/electron boost group, telangiectasia was more severe and the BRA value was greater in the implant group. This small randomized trial evaluated several factors important for optimal breast cosmetic outcome in conservation management. The data presented support previously documented findings. The method of analysis was interesting in that it combined
objective as well as subjective physician and patient assessments. An important factor in late tissue effects is that of the radiation dose per fraction. The intended external-beam boost dose per fraction in this study was reportedly 3 Gy, and it was this technique that was compared to the low-dose-rate brachytherapy treatment. Another significant contributor to cosmetic complications is the need for reoperation owing to fat necrosis. Reoperation can further impair cosmesis through additional loss of tissue volume and symmetry. The authors did not report any
cases of reoperation due to fat necrosis in this series. At the Mallinckrodt Institute, reoperation for fat necrosis has been more common after boost brachytherapy than after externalbeam boost irradiation for such patients.1 The results of this study confirm those of previous comparisons of wholebreast irradiation with brachytherapy confined to the boost volume and dose. Additional insight into the long-term cosmetic effects of brachytherapy given as partial breast irradiation (ie, to larger volumes, at higher doses, and at high
dose rates) will evolve from the National Surgical Adjuvant Breast and Bowel Project B-39 study already in progress.
1–46
my site were documented every 6 to 12 months posttreatment using a standardized physician-rated cosmesis questionnaire. The relationships between TLD dose and acute skin reaction, pigmentation, or telangiectasia at 5 years were analyzed using the GEE algorithm and the GENMOD procedure in the SAS statistical package. Fisher’s exact test was used to determine whether there were any significant associations between acute skin reaction and late pigmentation or telangiectasia or between the volumes encompassed by various isodoses and fibrosis or fat necrosis. Results.—The median TLD dose per fraction (185 dose points) multiplied by 10 was 9.2 Gy. In all 37 patients, acute skin reaction Grade 1 or higher was observed at 5.9% (6 of 102) of dose points receiving 10 Gy or less vs. 44.6% (37 of 83) of dose points receiving more than 10 Gy (p < 0.0001). In 25 patients at 60 months, 1.5% telangiectasia was seen at dose points receiving 10 Gy or less (1 of 69) vs. 18% (10 of 56) telangiectasia at dose points receiving more than 10 Gy (p = 0.004). Grade 1 or more pigmentation developed at 1.5% (1 of 69) of dose points
receiving less than 10 Gy vs. 25% (14 of 56) of dose points receiving more than 10 Gy (p < 0.001). A Grade 1 or more acute skin reaction was also significantly associated with development of Grade 1 or more pigmentation or telangiectasia at 60 months. This association was most significant for acute reaction and telangiectasia directly over the lumpectomy site (p < 0.001). Grade 1 or more fibrosis, in 25 patients with a 60-month follow-up, occurred in 47.4% (9 of 19) of patients with a volume of 45 cm3 or less covered by the 100% isodose vs. 83.3% (5 of 6) of patients with a larger volume (p = 0.180). Asymptomatic and biopsy-proven fat necrosis occurred in 5 patients. No significant differences in fat necrosis rates according to volume were detected. Conclusions.—For high-dose-rate brachytherapy to the lumpectomy site, TLD skin dose was significantly related to acute skin reaction and to pigmentation and telangiectasia at 60 months. An acute skin reaction was also significantly associated with the development of telangiectasia at 60 months. TLD skin dose measurement may allow modification of the brachytherapy implant geometry (dwell
TLD Skin Dose Measurements and Acute and Late Effects After Lumpectomy and HighDose-Rate Brachytherapy Only for Early Breast Cancer Perera F, Chisela F, Stitt L, et al (London Health Sciences Centre, Ont, Canada; Columbia St Mary’s Hosp, Milwaukee, Wis; Univ of Western Ontario, London, Canada) Int J Radiat Oncol Biol Phys 62:1283-1290, 2005
Purpose.—This report examines the relationships between measured skin doses and the acute and late skin and soft tissue changes in a pilot study of lumpectomy and high-dose-rate brachytherapy only for breast cancer. Methods and Materials.—Thirtyseven of 39 women enrolled in this pilot study of high-dose-rate brachytherapy (37.2 Gy in 10 fractions b.i.d.) each had thermoluminescent dosimetry (TLD) at 5 points on the skin of the breast overlying the implant volume. Skin changes at TLD dose points and fibrosis at the lumpecto-
M. E. Taylor, MD
Reference 1. Perez CA, Taylor ME, Halverson K, et al: Brachytherapy or electron beam boost in conservative therapy of carcinoma of the breast. A nonrandomized comparison. Int J Radiat Oncol Biol Phys 34:995-1007, 1996.
®
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
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though more studies are needed, proton therapy is likely to play an important and significant role in APBI in the near future.
1–45
months after RT. The evaluations were done using a panel of global and specific subjective scores, a digitized scoring system using the breast retraction assessment (BRA) measurement, and a patient’s selfassessment evaluation. As cosmetic results were graded according to severity, the comparison of boost techniques was done using the ordinal logistic regression model. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) are presented. Results.—At 36 months of followup, there was no significant difference between the two groups with respect to the global subjective cosmetic outcome (OR = 1.40; 95% CI = 0.69-2.85, p = 0.35). Good to excellent scores were observed in 65% of implant patients and 62% of photon/electron patients. At 24 months and beyond, telangiectasia was more severe in the implant group with an OR of 9.64 (95% CI = 4.05-22.92, p < 0.0001) at 36 months. The only variable associated with a worse global cosmetic outcome was the presence of concomitant chemotherapy (OR = 3.87; 95% CI = 1.74-8.62). The BRA value once adjusted for age, con-
A Cosmetic Evaluation of Breast Cancer Treatment: A Randomized Study of Radiotherapy Boost Technique Vass S, Bairati I (Complexe Hospitalier de la Sagamie, Chicoutimi, Quebec; Laval Univ, Quebec City) Int J Radiat Oncol Biol Phys 62:1274-1282, 2005
Purpose.—To compare cosmetic results of two different radiotherapy (RT) boost techniques used in the treatment of breast cancer after whole breast radiotherapy and to identify factors affecting cosmetic outcomes. Methods and Materials.—Between 1996 and 1998, 142 patients with Stage I and II breast cancer were treated with breast conservative surgery and adjuvant RT. Patients were then randomly assigned to receive a boost dose of 15 Gy delivered to the tumor bed either by iridium 192, or a combination of photons and electrons. Cosmetic evaluations were done on a 6month basis, with a final evaluation at 36
88 88
®
A. Taghian, MD, PhD
References 1. Darby S, McGale P, Peto R, et al: Mortality from cardiovascular disease more than 10 years after radiotherapy for breast cancer: Nationwide cohort study of 90,000 Swedish women. Br Med J 326:256-257, 2003. 2. Particle Therapy Co-operative Group: Particles: A newsletter for those interested in proton, light ion and heavy
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
charged particle radiotherapy (35; January 2005). Available at: http://ptcog.mgh.harvard.edu. Accessed November 16, 2005. 3. Patt DA, Goodwin JS, Kuo Y-F, et al: Cardiac morbidity of adjuvant radiotherapy for breast cancer. J Clin Oncol 23:7475-7482, 2005. 4. Taghian A, Kozak KR, Adams J, et al: Accelerated partial-breast irradiation (APBI) using protons for patients with early-stage breast cancer: A comparison with 3D conformal photon/electron based treatment (abstract). Int J Radiat Oncol Biol Phys 63(Suppl 1):S8-S9, 2005.
comitant chemotherapy, and boost volume showed a positive association with the boost technique. The BRA value was significantly greater in the implant group (p = 0.03). There was no difference in the patient’s final self-assessment score between the two groups. Three variables were statistically associated with an adverse self-evaluation: an inferior quarant tumor localization, postoperative hematoma, and concomitant chemotherapy. Conclusions.—Although this trial showed that at 36 months of follow-up, there were no significant differences in the overall global cosmetic scores between the implant boost group and the photon/electron boost group, telangiectasia was more severe and the BRA value was greater in the implant group. This small randomized trial evaluated several factors important for optimal breast cosmetic outcome in conservation management. The data presented support previously documented findings. The method of analysis was interesting in that it combined
objective as well as subjective physician and patient assessments. An important factor in late tissue effects is that of the radiation dose per fraction. The intended external-beam boost dose per fraction in this study was reportedly 3 Gy, and it was this technique that was compared to the low-dose-rate brachytherapy treatment. Another significant contributor to cosmetic complications is the need for reoperation owing to fat necrosis. Reoperation can further impair cosmesis through additional loss of tissue volume and symmetry. The authors did not report any
cases of reoperation due to fat necrosis in this series. At the Mallinckrodt Institute, reoperation for fat necrosis has been more common after boost brachytherapy than after externalbeam boost irradiation for such patients.1 The results of this study confirm those of previous comparisons of wholebreast irradiation with brachytherapy confined to the boost volume and dose. Additional insight into the long-term cosmetic effects of brachytherapy given as partial breast irradiation (ie, to larger volumes, at higher doses, and at high
dose rates) will evolve from the National Surgical Adjuvant Breast and Bowel Project B-39 study already in progress.
1–46
my site were documented every 6 to 12 months posttreatment using a standardized physician-rated cosmesis questionnaire. The relationships between TLD dose and acute skin reaction, pigmentation, or telangiectasia at 5 years were analyzed using the GEE algorithm and the GENMOD procedure in the SAS statistical package. Fisher’s exact test was used to determine whether there were any significant associations between acute skin reaction and late pigmentation or telangiectasia or between the volumes encompassed by various isodoses and fibrosis or fat necrosis. Results.—The median TLD dose per fraction (185 dose points) multiplied by 10 was 9.2 Gy. In all 37 patients, acute skin reaction Grade 1 or higher was observed at 5.9% (6 of 102) of dose points receiving 10 Gy or less vs. 44.6% (37 of 83) of dose points receiving more than 10 Gy (p < 0.0001). In 25 patients at 60 months, 1.5% telangiectasia was seen at dose points receiving 10 Gy or less (1 of 69) vs. 18% (10 of 56) telangiectasia at dose points receiving more than 10 Gy (p = 0.004). Grade 1 or more pigmentation developed at 1.5% (1 of 69) of dose points
receiving less than 10 Gy vs. 25% (14 of 56) of dose points receiving more than 10 Gy (p < 0.001). A Grade 1 or more acute skin reaction was also significantly associated with development of Grade 1 or more pigmentation or telangiectasia at 60 months. This association was most significant for acute reaction and telangiectasia directly over the lumpectomy site (p < 0.001). Grade 1 or more fibrosis, in 25 patients with a 60-month follow-up, occurred in 47.4% (9 of 19) of patients with a volume of 45 cm3 or less covered by the 100% isodose vs. 83.3% (5 of 6) of patients with a larger volume (p = 0.180). Asymptomatic and biopsy-proven fat necrosis occurred in 5 patients. No significant differences in fat necrosis rates according to volume were detected. Conclusions.—For high-dose-rate brachytherapy to the lumpectomy site, TLD skin dose was significantly related to acute skin reaction and to pigmentation and telangiectasia at 60 months. An acute skin reaction was also significantly associated with the development of telangiectasia at 60 months. TLD skin dose measurement may allow modification of the brachytherapy implant geometry (dwell
TLD Skin Dose Measurements and Acute and Late Effects After Lumpectomy and HighDose-Rate Brachytherapy Only for Early Breast Cancer Perera F, Chisela F, Stitt L, et al (London Health Sciences Centre, Ont, Canada; Columbia St Mary’s Hosp, Milwaukee, Wis; Univ of Western Ontario, London, Canada) Int J Radiat Oncol Biol Phys 62:1283-1290, 2005
Purpose.—This report examines the relationships between measured skin doses and the acute and late skin and soft tissue changes in a pilot study of lumpectomy and high-dose-rate brachytherapy only for breast cancer. Methods and Materials.—Thirtyseven of 39 women enrolled in this pilot study of high-dose-rate brachytherapy (37.2 Gy in 10 fractions b.i.d.) each had thermoluminescent dosimetry (TLD) at 5 points on the skin of the breast overlying the implant volume. Skin changes at TLD dose points and fibrosis at the lumpecto-
M. E. Taylor, MD
Reference 1. Perez CA, Taylor ME, Halverson K, et al: Brachytherapy or electron beam boost in conservative therapy of carcinoma of the breast. A nonrandomized comparison. Int J Radiat Oncol Biol Phys 34:995-1007, 1996.
®
Breast Diseases: A Year Book Quarterly Vol 17 No 1 2006
89 89