- Email: [email protected]
2020
S220
I. J. Radiation Oncology
● Biology ● Physics
Volume 66, Number 3, Supplement, 2006
grade 3/4 acute radiation toxicity was identified in 10% (6/58) of patients who had IORT. Severe subcutaneous tissue induration was noted in 5 patients and 1 of the 5 patients also had marked skin atrophy. Excellent/good cosmetic outcome was reported in 60% of patients. There has been no recurrence or death. Conclusions: The findings of the present study in relation to the feasibility rate and acute toxicity suggest that IORT could be considered suitable for further development. Longer follow up is required for the evaluation of late radiation toxicity, cosmetic outcome and local control rate. Author Disclosure: B.H. Chua, None; M. Henderson, None; R. Das, None; A. Milner, None.
2019
Is Local Recurrence Increased With the Use of a Heart Block in Radiation Therapy for Breast Cancer?
J. R. Bellon, M. T. Gover, A. Keshaviah, J. S. Wong, J. R. Harris Dana-Farber Cancer Institute/Brigham and Women’s Hospital, Boston, MA Purpose/Objective(s): Cardiac irradiation has long been implicated in the development of coronary artery disease. In order to limit the volume of heart in the irradiated field, we have routinely designed a custom-shaped cerrobend block to shield the cardiac silhouette when irradiating the left breast. This study examines the impact of this technique on in-breast (local) recurrence. Materials/Methods: A retrospective cohort study was performed based on medical chart review. The local recurrence rate among breast cancer patients with left-sided lesions whose radiation treatment planning included a heart block was compared to right-sided patients (treated without a heart block). Left-sided patients were treated following-breast conserving surgery with CT-based treatment planning to allow for delineation of the heart and lumpectomy site. Care was taken to place the block away from the lumpectomy site. Patients with a heart block were matched 2:1 to right-sided patients based on the date of breast cancer diagnosis in order to ensure comparable follow-up time between the two cohorts. Results: Data were collected on 199 patients treated at the Dana-Farber Cancer Institute between 1997 and 2001 (67 left-sided patients treated with a heart block, 132 patients with right-sided tumors). Tumor and treatment characteristics were generally similar between the cohorts. Median follow-up was 5.0 years. Isolated local recurrence as a first site of failure occurred in 1 (1.5%) left-sided patient, and 2 (1.5%) right-sided patients. Other events, including distant metastasis, regional nodal recurrences, contralateral breast cancers, second primary cancer or death from other causes occurred 10.4% and 11.4% of patients, respectively. Fisher’s exact test for the comparison of local recurrence vs other events vs no events was not significant The sole left-sided patient with a local recurrence developed inflammatory disease 39 months after diagnosis. Conclusions: The use of a heart block did not result in a higher rate of tumor recurrence in the breast. These data support the use of a heart block (away from the area of the primary tumor) as a safe practice. A large randomized trial would be necessary to determine whether the use of a heart block decreases non-breast cancer mortality. Author Disclosure: J.R. Bellon, None; M.T. Gover, None; A. Keshaviah, None; J.S. Wong, None; J.R. Harris, None.
2020
Phase I/II Trial of Herceptin Plus Radiotherapy for Chemotherapy-Refractory Locally Advanced or Recurrent Breast Cancer
J. K. Horton1, R. F. Sherron1, D. T. Moore1, D. W. Ollila1, L. A. Carey1, E. C. Dees1, M. Graham2, J. S. Halle1, C. I. Sartor1 1 University of North Carolina, Chapel Hill, NC, 2Wake Med, Raleigh, NC Purpose/Objective(s): Inoperable locally advanced or recurrent breast cancer is poorly controlled with standard therapy. Herceptin, an effective therapy for HER2 over-expressing breast cancer, has been shown to be an effective radiosensitizer in preclinical studies. We implemented a Phase I/II trial to investigate the tolerability and efficacy of concurrent Herceptin plus radiotherapy in patients with HER2 over-expressing breast cancer who were candidates for neoadjuvant or primary radiotherapy (RT). Materials/Methods: Patients with locally advanced or recurrent, chemotherapy-refractory, HER2 over-expressing breast cancer who were candidates for neoadjuvant or primary radiotherapy were eligible. After enrollment, additional protocolrequired tests included cardiac evaluation (multiple gated acquisition (MUGA) scan) and biopsy. Patients with inadequate cardiac function or non-HER2 over-expressing disease received radiotherapy alone. Treatment consisted of weekly Herceptin (2mg/kg) concurrent with 50 Gray (Gy) to the breast and regional lymph nodes over 5 weeks. Planned mastectomy or resection followed radiotherapy. Doses up to 70 Gy were delivered for patients receiving primary RT. Acute toxicity was monitored weekly during treatment. Wound complications were monitored prospectively. Subacute and chronic toxicity were monitored by MUGA and physical examination every six months. Efficacy was defined by pathologic response (pathologic complete response (pCR) and minimal residual disease (pTmic) vs. residual disease) and time to local progression. Adjuvant systemic therapy was delivered to all patients at the discretion of the treating medical oncologist. The accrual goal was 65 patients to see a 20% absolute improvement in pathologic response rate from 10 to 30%. Results: The trial was stopped early due to slow accrual. Nineteen patients were enrolled. Seven patients were subsequently deemed ineligible to receive concurrent Herceptin primarily as a result of pre-treatment biopsy (3) or cardiac evaluation (3). Median potential follow-up for surviving patients is 26 months. Acute toxicities (grade 3) included 2 skin, and 1 lymphopenia. One patient had delayed wound healing. Interestingly, all 4 toxicities occurred in 2 patients. Only one patient had a ⬎10% asymptomatic decline in cardiac function; no patients developed symptomatic cardiotoxicity. Of the seven patients proceeding to planned mastectomy, 43% had pCR or pTmic. Median time to symptomatic local progression was 30 months and median overall survival was 35 months in patients treated with mastectomy and 29 months in patients treated with primary radiotherapy without surgery (p⫽NS). Conclusions: To our knowledge, this is the only prospective trial of concurrent Herceptin and radiotherapy where radiationrelated toxicity and efficacy were specifically evaluated. Concurrent Herceptin with radiotherapy did not result in increased
Proceedings of the 48th Annual ASTRO Meeting
acute toxicity in this series, but a planned CALGB study will better define acute toxicity. While the efficacy endpoints were not met with confidence due to low patient numbers, Herceptin and RT demonstrated promising control and pathologic response rates. Author Disclosure: J.K. Horton, None; R.F. Sherron, None; D.T. Moore, None; D.W. Ollila, None; L.A. Carey, Genentech, Inc., B. Research Grant; Genentech, Inc., D. Speakers Bureau/Honoraria; Genentech, Inc., F. Consultant/Advisory Board; E.C. Dees, Genentech Advisory Board, 12/2005., F. Consultant/Advisory Board; M. Graham, None; J.S. Halle, None; C.I. Sartor, Genentech, Inc., B. Research Grant.
2021
Long Term Outcome for Early Breast Carcinoma: The University of Chicago Multi-Center Experience
M. A. Nichols, L. K. Mell, D. MacDermed, M. E. Witt, R. R. Weichselbaum, S. J. Chmura University of Chicago Hospitals, Chicago, IL Purpose/Objective(s): To examine the outcomes in women undergoing breast conservation therapy at the University of Chicago in regard to local control, patterns of failure and overall survival. Materials/Methods: We retrospectively reviewed the outcomes of 1094 women with unilateral Stage I, II, and III invasive breast carcinoma. All women were treated at three University of Chicago affiliated institutions between 1986 and 2004. The median follow up was 88 months in surviving patients (84.5 all patients). Median age was 58.0 years. 39.0% of women received chemotherapy with (74.0% receiving anthracycline based). Median radiation dose to the whole breast was 46 gray (Gy). 98.8% of women received a supplemental boost with a median dose of 14Gy. Median dose to the tumor bed was 60Gy. By stage, 63% were stage I, 35% stage II and 2% stage III. Mammographically detected tumors comprised 42.1% of patients while the remaining women were detected clinically. Results: The crude 10-year local control rate (LC) was 91.7% in women ⬍⫽40 years old, 96.1% in women 41–55 years old, and 96.8% in women over the age of 55. The actuarial 10 year local progression free survival (LPFS) was 76.7% (95% CI: 72.4 – 80.4) for stage I and 65.6% (95% CI: 59.4 –71.1) for stage II. There was a greater 10 year LPFS in women under the age of 41 relative to women older than 55, 73.8%(95% CI: 62.2– 82.3) and 64.9%(95% CI: 59.8 – 69.5), respectively. On multivariate analysis (MVA), only the number of positive lymph nodes was a significant prognostic indicator for time to local failure with a hazard ratio (HR) of 1.07 per lymph node (p⫽.001). Overall survival (OS) at 10 years by age was 76.6% (95% CI: 71.2–77.7) in women ⬍⫽40 years old, 85.4% (95% CI: 80.5– 89.2) in women age 41–55 and 67.5%(95% CI: 62.4 –72.0) in women ⬎55yo. Women who were pathologic stage I did better than those with stage II disease with 10 year OS of 78.7% (95% CI: 74.5– 82.3) versus 68.4% (95% CI: 62.1–73.8), respectively. On MVA, age (HR 1.04, p⬍.05), number of positive lymph nodes (HR 1.14, p⫽.053) and mammographically detected cancers (HR 0.633, 95% CI 0.47– 0.85, p⫽.002) were statistically significant prognostic indicators of OS. Women with mammographically detected tumors had better 10 year OS, 80.7% (95% CI: 75.4 – 84.9) versus 70.9% (95% CI: 66.1–75.2) respectively. The 10 year LPFS was 78.1% (95% CI: 72.7– 82.5) for women with mammographically detected tumors and 68.6% (95% CI: 63.9 –73.1) for women with clinically detected tumors. On MVA for LPFS, controlling for clinical and pathologic characteristics, mammographically detected tumors were associated with a better outcome with HR 0.687 (95% CI: 0.518 – 0.913, p⫽.01). On preliminary analysis of point-offailure, 59% (13/22) failed in quadrant and 41% (9/22) failed out of quadrant. Conclusions: 46Gy to the whole breast and a 14Gy boost to the lumpectomy cavity is associated with excellent local control at our institution with high rates of breast conservation. Women with mammographically detected tumors had significantly longer survival and local progression free survival than those with clinically detected tumors. Author Disclosure: M.A. Nichols, None; L.K. Mell, None; D. MacDermed, None; M.E. Witt, None; R.R. Weichselbaum, None; S.J. Chmura, None.
2022
Lymphedema Measures: Do They Help
T. A. Dufan, R. Koul, A. L. Cooke, C. Russell, W. Guenther Cancer Care Manitoba, Winnipeg, MB, Canada Purpose/Objective(s): One of the complications of breast cancer treatment is lymphedema of the ipslateral arm. No consensus exists as to what constitutes definitive treatment for lymphedema. The management of lymphedema in breast cancer patients is based on results from case studies, clinical experience and anecdotal information, and only a few randomized trials. Several therapeutic interventions exist to treat this potentially distressing and disabling condition but no consensus exists as to what constitutes optimum or definitive treatment for lymphedema. The aim of this study was to evaluate the results of the first two years of a program for patients with breast cancer related lymphedema, who have completed a minimum of 1 year follow up. Materials/Methods: Breast Health Center and medical records were reviewed for 250 patients referred for lymphedema secondary to breast cancer treatment. Pre-treatment and Post treatment volumes were compared. Severity was correlated to various variables. Spearman coefficient and Wilcoxan two sample tests were applied. Results: 138 patients were included in the final data analysis. The mean age at presentation was 54.3 years, mean BMI was 29.1 kg/m2. 44% of the patients were treated with radical mastectomy, 43% received lumpectomy and axillary nodal dissection and 13% of the patients received simple mastectomy or excision of tumor alone. 66% received radiation and 49% received chemotherapy. 55% of the patients were treated with Combined Decongestive Therapy and 32% received Manual Lymphatic Drainage®. The mean pre-treatment volume of the affected arm was 2929 ml and normal arm was 2531 ml. At the end of 1 year the post treatment volume of affected arm was 2741 ml. The absolute volume of the affected arm was reduced by a mean of 188 ml p⬍.0001. Type of surgery p⫽0.0142, age p⫽0.0354 and BMI p⬍0.0001 were related to the severity of lymphedema. The severity of lymphedema was not related to number of axillary lymph nodes removed, chemotherapy and whether patient had received loco regional radiation. Conclusions: Our program offers some or all components of Combined Decongestive Therapy to patients suffering from lymphedema and is associated with a 47% relative reduction in the lymphedema volume at 1 year. Because the treatment was
S221
I. J. Radiation Oncology
● Biology ● Physics
Volume 66, Number 3, Supplement, 2006
grade 3/4 acute radiation toxicity was identified in 10% (6/58) of patients who had IORT. Severe subcutaneous tissue induration was noted in 5 patients and 1 of the 5 patients also had marked skin atrophy. Excellent/good cosmetic outcome was reported in 60% of patients. There has been no recurrence or death. Conclusions: The findings of the present study in relation to the feasibility rate and acute toxicity suggest that IORT could be considered suitable for further development. Longer follow up is required for the evaluation of late radiation toxicity, cosmetic outcome and local control rate. Author Disclosure: B.H. Chua, None; M. Henderson, None; R. Das, None; A. Milner, None.
2019
Is Local Recurrence Increased With the Use of a Heart Block in Radiation Therapy for Breast Cancer?
J. R. Bellon, M. T. Gover, A. Keshaviah, J. S. Wong, J. R. Harris Dana-Farber Cancer Institute/Brigham and Women’s Hospital, Boston, MA Purpose/Objective(s): Cardiac irradiation has long been implicated in the development of coronary artery disease. In order to limit the volume of heart in the irradiated field, we have routinely designed a custom-shaped cerrobend block to shield the cardiac silhouette when irradiating the left breast. This study examines the impact of this technique on in-breast (local) recurrence. Materials/Methods: A retrospective cohort study was performed based on medical chart review. The local recurrence rate among breast cancer patients with left-sided lesions whose radiation treatment planning included a heart block was compared to right-sided patients (treated without a heart block). Left-sided patients were treated following-breast conserving surgery with CT-based treatment planning to allow for delineation of the heart and lumpectomy site. Care was taken to place the block away from the lumpectomy site. Patients with a heart block were matched 2:1 to right-sided patients based on the date of breast cancer diagnosis in order to ensure comparable follow-up time between the two cohorts. Results: Data were collected on 199 patients treated at the Dana-Farber Cancer Institute between 1997 and 2001 (67 left-sided patients treated with a heart block, 132 patients with right-sided tumors). Tumor and treatment characteristics were generally similar between the cohorts. Median follow-up was 5.0 years. Isolated local recurrence as a first site of failure occurred in 1 (1.5%) left-sided patient, and 2 (1.5%) right-sided patients. Other events, including distant metastasis, regional nodal recurrences, contralateral breast cancers, second primary cancer or death from other causes occurred 10.4% and 11.4% of patients, respectively. Fisher’s exact test for the comparison of local recurrence vs other events vs no events was not significant The sole left-sided patient with a local recurrence developed inflammatory disease 39 months after diagnosis. Conclusions: The use of a heart block did not result in a higher rate of tumor recurrence in the breast. These data support the use of a heart block (away from the area of the primary tumor) as a safe practice. A large randomized trial would be necessary to determine whether the use of a heart block decreases non-breast cancer mortality. Author Disclosure: J.R. Bellon, None; M.T. Gover, None; A. Keshaviah, None; J.S. Wong, None; J.R. Harris, None.
2020
Phase I/II Trial of Herceptin Plus Radiotherapy for Chemotherapy-Refractory Locally Advanced or Recurrent Breast Cancer
J. K. Horton1, R. F. Sherron1, D. T. Moore1, D. W. Ollila1, L. A. Carey1, E. C. Dees1, M. Graham2, J. S. Halle1, C. I. Sartor1 1 University of North Carolina, Chapel Hill, NC, 2Wake Med, Raleigh, NC Purpose/Objective(s): Inoperable locally advanced or recurrent breast cancer is poorly controlled with standard therapy. Herceptin, an effective therapy for HER2 over-expressing breast cancer, has been shown to be an effective radiosensitizer in preclinical studies. We implemented a Phase I/II trial to investigate the tolerability and efficacy of concurrent Herceptin plus radiotherapy in patients with HER2 over-expressing breast cancer who were candidates for neoadjuvant or primary radiotherapy (RT). Materials/Methods: Patients with locally advanced or recurrent, chemotherapy-refractory, HER2 over-expressing breast cancer who were candidates for neoadjuvant or primary radiotherapy were eligible. After enrollment, additional protocolrequired tests included cardiac evaluation (multiple gated acquisition (MUGA) scan) and biopsy. Patients with inadequate cardiac function or non-HER2 over-expressing disease received radiotherapy alone. Treatment consisted of weekly Herceptin (2mg/kg) concurrent with 50 Gray (Gy) to the breast and regional lymph nodes over 5 weeks. Planned mastectomy or resection followed radiotherapy. Doses up to 70 Gy were delivered for patients receiving primary RT. Acute toxicity was monitored weekly during treatment. Wound complications were monitored prospectively. Subacute and chronic toxicity were monitored by MUGA and physical examination every six months. Efficacy was defined by pathologic response (pathologic complete response (pCR) and minimal residual disease (pTmic) vs. residual disease) and time to local progression. Adjuvant systemic therapy was delivered to all patients at the discretion of the treating medical oncologist. The accrual goal was 65 patients to see a 20% absolute improvement in pathologic response rate from 10 to 30%. Results: The trial was stopped early due to slow accrual. Nineteen patients were enrolled. Seven patients were subsequently deemed ineligible to receive concurrent Herceptin primarily as a result of pre-treatment biopsy (3) or cardiac evaluation (3). Median potential follow-up for surviving patients is 26 months. Acute toxicities (grade 3) included 2 skin, and 1 lymphopenia. One patient had delayed wound healing. Interestingly, all 4 toxicities occurred in 2 patients. Only one patient had a ⬎10% asymptomatic decline in cardiac function; no patients developed symptomatic cardiotoxicity. Of the seven patients proceeding to planned mastectomy, 43% had pCR or pTmic. Median time to symptomatic local progression was 30 months and median overall survival was 35 months in patients treated with mastectomy and 29 months in patients treated with primary radiotherapy without surgery (p⫽NS). Conclusions: To our knowledge, this is the only prospective trial of concurrent Herceptin and radiotherapy where radiationrelated toxicity and efficacy were specifically evaluated. Concurrent Herceptin with radiotherapy did not result in increased
Proceedings of the 48th Annual ASTRO Meeting
acute toxicity in this series, but a planned CALGB study will better define acute toxicity. While the efficacy endpoints were not met with confidence due to low patient numbers, Herceptin and RT demonstrated promising control and pathologic response rates. Author Disclosure: J.K. Horton, None; R.F. Sherron, None; D.T. Moore, None; D.W. Ollila, None; L.A. Carey, Genentech, Inc., B. Research Grant; Genentech, Inc., D. Speakers Bureau/Honoraria; Genentech, Inc., F. Consultant/Advisory Board; E.C. Dees, Genentech Advisory Board, 12/2005., F. Consultant/Advisory Board; M. Graham, None; J.S. Halle, None; C.I. Sartor, Genentech, Inc., B. Research Grant.
2021
Long Term Outcome for Early Breast Carcinoma: The University of Chicago Multi-Center Experience
M. A. Nichols, L. K. Mell, D. MacDermed, M. E. Witt, R. R. Weichselbaum, S. J. Chmura University of Chicago Hospitals, Chicago, IL Purpose/Objective(s): To examine the outcomes in women undergoing breast conservation therapy at the University of Chicago in regard to local control, patterns of failure and overall survival. Materials/Methods: We retrospectively reviewed the outcomes of 1094 women with unilateral Stage I, II, and III invasive breast carcinoma. All women were treated at three University of Chicago affiliated institutions between 1986 and 2004. The median follow up was 88 months in surviving patients (84.5 all patients). Median age was 58.0 years. 39.0% of women received chemotherapy with (74.0% receiving anthracycline based). Median radiation dose to the whole breast was 46 gray (Gy). 98.8% of women received a supplemental boost with a median dose of 14Gy. Median dose to the tumor bed was 60Gy. By stage, 63% were stage I, 35% stage II and 2% stage III. Mammographically detected tumors comprised 42.1% of patients while the remaining women were detected clinically. Results: The crude 10-year local control rate (LC) was 91.7% in women ⬍⫽40 years old, 96.1% in women 41–55 years old, and 96.8% in women over the age of 55. The actuarial 10 year local progression free survival (LPFS) was 76.7% (95% CI: 72.4 – 80.4) for stage I and 65.6% (95% CI: 59.4 –71.1) for stage II. There was a greater 10 year LPFS in women under the age of 41 relative to women older than 55, 73.8%(95% CI: 62.2– 82.3) and 64.9%(95% CI: 59.8 – 69.5), respectively. On multivariate analysis (MVA), only the number of positive lymph nodes was a significant prognostic indicator for time to local failure with a hazard ratio (HR) of 1.07 per lymph node (p⫽.001). Overall survival (OS) at 10 years by age was 76.6% (95% CI: 71.2–77.7) in women ⬍⫽40 years old, 85.4% (95% CI: 80.5– 89.2) in women age 41–55 and 67.5%(95% CI: 62.4 –72.0) in women ⬎55yo. Women who were pathologic stage I did better than those with stage II disease with 10 year OS of 78.7% (95% CI: 74.5– 82.3) versus 68.4% (95% CI: 62.1–73.8), respectively. On MVA, age (HR 1.04, p⬍.05), number of positive lymph nodes (HR 1.14, p⫽.053) and mammographically detected cancers (HR 0.633, 95% CI 0.47– 0.85, p⫽.002) were statistically significant prognostic indicators of OS. Women with mammographically detected tumors had better 10 year OS, 80.7% (95% CI: 75.4 – 84.9) versus 70.9% (95% CI: 66.1–75.2) respectively. The 10 year LPFS was 78.1% (95% CI: 72.7– 82.5) for women with mammographically detected tumors and 68.6% (95% CI: 63.9 –73.1) for women with clinically detected tumors. On MVA for LPFS, controlling for clinical and pathologic characteristics, mammographically detected tumors were associated with a better outcome with HR 0.687 (95% CI: 0.518 – 0.913, p⫽.01). On preliminary analysis of point-offailure, 59% (13/22) failed in quadrant and 41% (9/22) failed out of quadrant. Conclusions: 46Gy to the whole breast and a 14Gy boost to the lumpectomy cavity is associated with excellent local control at our institution with high rates of breast conservation. Women with mammographically detected tumors had significantly longer survival and local progression free survival than those with clinically detected tumors. Author Disclosure: M.A. Nichols, None; L.K. Mell, None; D. MacDermed, None; M.E. Witt, None; R.R. Weichselbaum, None; S.J. Chmura, None.
2022
Lymphedema Measures: Do They Help
T. A. Dufan, R. Koul, A. L. Cooke, C. Russell, W. Guenther Cancer Care Manitoba, Winnipeg, MB, Canada Purpose/Objective(s): One of the complications of breast cancer treatment is lymphedema of the ipslateral arm. No consensus exists as to what constitutes definitive treatment for lymphedema. The management of lymphedema in breast cancer patients is based on results from case studies, clinical experience and anecdotal information, and only a few randomized trials. Several therapeutic interventions exist to treat this potentially distressing and disabling condition but no consensus exists as to what constitutes optimum or definitive treatment for lymphedema. The aim of this study was to evaluate the results of the first two years of a program for patients with breast cancer related lymphedema, who have completed a minimum of 1 year follow up. Materials/Methods: Breast Health Center and medical records were reviewed for 250 patients referred for lymphedema secondary to breast cancer treatment. Pre-treatment and Post treatment volumes were compared. Severity was correlated to various variables. Spearman coefficient and Wilcoxan two sample tests were applied. Results: 138 patients were included in the final data analysis. The mean age at presentation was 54.3 years, mean BMI was 29.1 kg/m2. 44% of the patients were treated with radical mastectomy, 43% received lumpectomy and axillary nodal dissection and 13% of the patients received simple mastectomy or excision of tumor alone. 66% received radiation and 49% received chemotherapy. 55% of the patients were treated with Combined Decongestive Therapy and 32% received Manual Lymphatic Drainage®. The mean pre-treatment volume of the affected arm was 2929 ml and normal arm was 2531 ml. At the end of 1 year the post treatment volume of affected arm was 2741 ml. The absolute volume of the affected arm was reduced by a mean of 188 ml p⬍.0001. Type of surgery p⫽0.0142, age p⫽0.0354 and BMI p⬍0.0001 were related to the severity of lymphedema. The severity of lymphedema was not related to number of axillary lymph nodes removed, chemotherapy and whether patient had received loco regional radiation. Conclusions: Our program offers some or all components of Combined Decongestive Therapy to patients suffering from lymphedema and is associated with a 47% relative reduction in the lymphedema volume at 1 year. Because the treatment was
S221