- Email: [email protected]
Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction
Volume 93 Number 3S Supplement 2015 PTV was modified accordingly. Cosmesis was scored according to the Harvard scale at the 3 month follow up visit. Results: Since February 2014, ten patients were enrolled on this prospective registry. Median age was 57.4 (range: 42 e 77). Mean PTV volume was 76.4 cc (range: 131 e 54.6 cc), representing a 64% reduction in volume when compared to a conventional PTV margin. Mean time in treatment room was 36 min, of which 15 min was spent on patient set up and MR imaging. 100 online volumetric MR images were available for evaluation. The mean 90% and 95% prescription dose covered 99.7% (range: 99.1-100%) and 97.6% (range: 90.5 e 99.9%) of PTV respectively. Mean inter-fraction standard deviation in 90% and 95% prescription coverage was less than 1% of PTV (90% prescription coverage: 0.26% PTV, and 95% prescription coverage: 0.63% PTV). Evaluation of cine MR during treatment did not demonstrate significant intra-fractional motion. Maximum skin dose was less than prescription in all cases. Nine of the ten patients had 3 month cosmetic data collected per the Harvard scale for breast cosmesis. All nine patients had excellent (7/9) or good (2/9) cosmetic results. Conclusion: Delivery of MR-guided APBI with reduced margins achieved appropriate target coverage based on assessment of actual delivered dose with favorable short term cosmesis. To our knowledge, this is the first series of APBI patients to be treated using MR-IGRT with minimal margins, thereby sparing a greater proportion of normal breast. Efforts to collect local control and long term cosmetic data are currently underway. Author Disclosure: S. Acharya: None. B.W. Fischer-Valuck: None. M.C. Roach: None. R. Kashani: None. L.L. Ochoa: None. M. Yang: None. S. Mutic: Honoraria; Philips Healthcare. Consultant; ViewRay. Travel Expenses; American Association of Medical Dosimetrists, American Association of Physicists in Medicine, American Society for Therapeutic Radiation Oncology. Stock; TreatSafely, Radialogica. I. Zoberi: None. M.A. Thomas: None.
2026 Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction J.S. Wong,1,2 Y.H. Chen,1 L.T. Truong,2 J.R. Bellon,1,2 R.S. Punglia,1,2 J.M. Moreau,2 Y.S. Chun,2 and C.A. Hergrueter2; 1Dana-Farber Cancer Institute, Boston, MA, 2Brigham and Women’s Hospital, Boston, MA Purpose/Objective(s): Postmastectomy radiation therapy (PMRT) delivered to an immediate reconstruction (often a tissue expander [TE]) increases the risk of complications. Acellular dermal matrix (ADM) has been used with a TE to improve cosmetic outcome and minimize capsular contracture. We hypothesized that ADM used with a TE in a PMRT setting would lessen complications and improve cosmetic outcome. We conducted a prospective trial to assess the success of this approach. Materials/Methods: From 2009 - 2012, we prospectively evaluated patients with stage I-III breast cancer who underwent mastectomy, immediate TE-ADM reconstruction, and PMRT. T4 tumors were excluded. Type of final reconstruction (implant, autologous flap) was at the plastic surgeon’s discretion. Patients were followed at 6-month intervals after PMRT for a minimum of 2 years. Data on final reconstruction, treatment, major complications (infection requiring hospitalization, major revision, pain requiring implant removal) and cosmetic outcome were collected. The prescribed chest wall dose was 50-50.4 Gy via photons in 25-28 fractions, with 0.5-cm bolus to the scar every other day. No boost was given. Success was defined as 90% of patients attaining all of the following: 1) final reconstruction, 2) no major complications, and 3) physician-rated excellent or good cosmetic outcome. Results: Thirty-two patients were enrolled. Four were unevaluable at 2 years: 1 left the country, 2 developed metastases and 1 withdrew consent. Median follow up from end of RT was 24 months. Median age was 41.5 (range, 24-63). Median BMI was 23.8 (range, 19-41.4). Nine percent had stage I disease, 72% had stage II and 19% had stage III disease; 88% received chemotherapy. Fifty-three percent underwent bilateral reconstruction. There were no local recurrences. At 2 years, the success rate
Poster Viewing Session
E11
among evaluable patients was 71% (20/28; 19 implants and 1 flap; 90% confidence interval, 54-85%). Of the 8 failures, 2 implants failed solely due to cosmetic scores, 2 had infections, 1 had significant capsular contracture (eventually revised to flap), 1 implant was revised to a flap, 1 flap required major revision, and 1 TE was removed due to pain and had no final reconstruction. Therefore, 96% (27/28) ultimately had an implant (23) or a flap (4) reconstruction. Conclusion: At two years, 71% met our strict criteria for success in this small prospective series of patients receiving PMRT to a TE-ADM reconstruction. The great majority ultimately achieved a final reconstruction. The results with longer follow up will be of interest. Further details including TE/implant volumes and dosimetry will be reported. Additional study of how to optimize reconstruction with PMRT is warranted. Author Disclosure: J.S. Wong: None. Y. Chen: None. L.T. Truong: None. J.R. Bellon: None. R.S. Punglia: None. J.M. Moreau: None. Y.S. Chun: None. C.A. Hergrueter: None.
2027 Prospective Assessment of Deep Inspiration Breath Hold to Prevent Radiation Associated Cardiac Perfusion Defects in Patients With Left-Sided Breast Cancer T.M. Zagar,1 X. Tang,2 E.L. Jones,1 J. Matney,3 S. Das,4 R. Green,1 A. Sheikh,5 A. Khandani,1 W. McCartney,5 T. Wong,1 and L.B. Marks6; 1 University of North Carolina, Chapel Hill, NC, 2Memorial Sloan Kettering, West Harrison, NY, 3The University of North Carolina, Chapel Hill, NC, 4Departments of Radiation Oncology, Medicine and Radiology, University of North Carolina, Chapel Hill, NC, 5Department of RadiologyNuclear Medicine, University of North Carolina, Chapel Hill, NC, 6 University of North Carolina Hospitals, Chapel Hill, NC Purpose/Objective(s): Radiation therapy (RT) for left-sided breast cancer can cause regional cardiac perfusion abnormalities in nearly half of patients at 6 months post-RT. While the significance of these perfusion abnormalities remains unclear, RT is a well-accepted risk factor for heart disease. We herein report the results of a single-arm prospective clinical study to assess deep inspiratory breath hold (DIBH; using AlignRTÔ) as a means to prevent the development of perfusion abnormalities in patients with left-sided breast cancer. Materials/Methods: Patients about to receive left-sided tangential RT had a pre-RT cardiocentric single photon emission computed tomography with CT based attenuation correction (IQÒ SPECT-CT) rest-cardiac gated perfusion scan (to assure a normal baseline). DIBH and conformal blocking was used to assure that the heart was excluded from the primary RT beam. Doses to the heart were computed. At 6-months post-RT, the SPECT-CT was repeated. The perfusion and motion images were assessed quantitatively using a 17-segment model evaluating a summed rest score (SRS) and wall motion score (WMS); scores of 0 indicate no perfusion defects or wall motion abnormalities, respectively. Results: Eighteen (of 20 targeted) patients have been enrolled. Two were not evaluable (e.g. due to an abnormal pre-RT SPECT scan). All patients received tangential radiation to the breast/chest wall (typical doses 200 cGy x 25 or 267 cGy x 16); five also received regional nodal RT as well; and 17/18 received a tumor bed boost. The mean heart dose ranged from 42-160 cGy for all 18 patients (mean of the means Z 78 cGy). Of the 16 evaluable patients, post-RT SPECTs have been obtained in eight. All eight have a normal post-RT SPECT scan; i.e. SRS score Z 0. Conclusion: In patients receiving tangential RT for left-sided breast cancer, cardiac avoidance with DIBH (e.g. with AlignRT) and conformal field shaping, appears to be able to prevent the development of RT-associated cardiac perfusion abnormalities. The mean dosages to the heart are quite low. Updated information on the remaining patients will be presented. Funded in part by VisionRT. Author Disclosure: T.M. Zagar: Research Grant; VisionRT. X. Tang: None. E.L. Jones: None. J. Matney: None. S. Das: None. R. Green: None. A. Sheikh: None. A. Khandani: None. W. McCartney: None. T. Wong: None. L.B. Marks: Research Grant; VisionRT.
2026 Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction J.S. Wong,1,2 Y.H. Chen,1 L.T. Truong,2 J.R. Bellon,1,2 R.S. Punglia,1,2 J.M. Moreau,2 Y.S. Chun,2 and C.A. Hergrueter2; 1Dana-Farber Cancer Institute, Boston, MA, 2Brigham and Women’s Hospital, Boston, MA Purpose/Objective(s): Postmastectomy radiation therapy (PMRT) delivered to an immediate reconstruction (often a tissue expander [TE]) increases the risk of complications. Acellular dermal matrix (ADM) has been used with a TE to improve cosmetic outcome and minimize capsular contracture. We hypothesized that ADM used with a TE in a PMRT setting would lessen complications and improve cosmetic outcome. We conducted a prospective trial to assess the success of this approach. Materials/Methods: From 2009 - 2012, we prospectively evaluated patients with stage I-III breast cancer who underwent mastectomy, immediate TE-ADM reconstruction, and PMRT. T4 tumors were excluded. Type of final reconstruction (implant, autologous flap) was at the plastic surgeon’s discretion. Patients were followed at 6-month intervals after PMRT for a minimum of 2 years. Data on final reconstruction, treatment, major complications (infection requiring hospitalization, major revision, pain requiring implant removal) and cosmetic outcome were collected. The prescribed chest wall dose was 50-50.4 Gy via photons in 25-28 fractions, with 0.5-cm bolus to the scar every other day. No boost was given. Success was defined as 90% of patients attaining all of the following: 1) final reconstruction, 2) no major complications, and 3) physician-rated excellent or good cosmetic outcome. Results: Thirty-two patients were enrolled. Four were unevaluable at 2 years: 1 left the country, 2 developed metastases and 1 withdrew consent. Median follow up from end of RT was 24 months. Median age was 41.5 (range, 24-63). Median BMI was 23.8 (range, 19-41.4). Nine percent had stage I disease, 72% had stage II and 19% had stage III disease; 88% received chemotherapy. Fifty-three percent underwent bilateral reconstruction. There were no local recurrences. At 2 years, the success rate
Poster Viewing Session
E11
among evaluable patients was 71% (20/28; 19 implants and 1 flap; 90% confidence interval, 54-85%). Of the 8 failures, 2 implants failed solely due to cosmetic scores, 2 had infections, 1 had significant capsular contracture (eventually revised to flap), 1 implant was revised to a flap, 1 flap required major revision, and 1 TE was removed due to pain and had no final reconstruction. Therefore, 96% (27/28) ultimately had an implant (23) or a flap (4) reconstruction. Conclusion: At two years, 71% met our strict criteria for success in this small prospective series of patients receiving PMRT to a TE-ADM reconstruction. The great majority ultimately achieved a final reconstruction. The results with longer follow up will be of interest. Further details including TE/implant volumes and dosimetry will be reported. Additional study of how to optimize reconstruction with PMRT is warranted. Author Disclosure: J.S. Wong: None. Y. Chen: None. L.T. Truong: None. J.R. Bellon: None. R.S. Punglia: None. J.M. Moreau: None. Y.S. Chun: None. C.A. Hergrueter: None.
2027 Prospective Assessment of Deep Inspiration Breath Hold to Prevent Radiation Associated Cardiac Perfusion Defects in Patients With Left-Sided Breast Cancer T.M. Zagar,1 X. Tang,2 E.L. Jones,1 J. Matney,3 S. Das,4 R. Green,1 A. Sheikh,5 A. Khandani,1 W. McCartney,5 T. Wong,1 and L.B. Marks6; 1 University of North Carolina, Chapel Hill, NC, 2Memorial Sloan Kettering, West Harrison, NY, 3The University of North Carolina, Chapel Hill, NC, 4Departments of Radiation Oncology, Medicine and Radiology, University of North Carolina, Chapel Hill, NC, 5Department of RadiologyNuclear Medicine, University of North Carolina, Chapel Hill, NC, 6 University of North Carolina Hospitals, Chapel Hill, NC Purpose/Objective(s): Radiation therapy (RT) for left-sided breast cancer can cause regional cardiac perfusion abnormalities in nearly half of patients at 6 months post-RT. While the significance of these perfusion abnormalities remains unclear, RT is a well-accepted risk factor for heart disease. We herein report the results of a single-arm prospective clinical study to assess deep inspiratory breath hold (DIBH; using AlignRTÔ) as a means to prevent the development of perfusion abnormalities in patients with left-sided breast cancer. Materials/Methods: Patients about to receive left-sided tangential RT had a pre-RT cardiocentric single photon emission computed tomography with CT based attenuation correction (IQÒ SPECT-CT) rest-cardiac gated perfusion scan (to assure a normal baseline). DIBH and conformal blocking was used to assure that the heart was excluded from the primary RT beam. Doses to the heart were computed. At 6-months post-RT, the SPECT-CT was repeated. The perfusion and motion images were assessed quantitatively using a 17-segment model evaluating a summed rest score (SRS) and wall motion score (WMS); scores of 0 indicate no perfusion defects or wall motion abnormalities, respectively. Results: Eighteen (of 20 targeted) patients have been enrolled. Two were not evaluable (e.g. due to an abnormal pre-RT SPECT scan). All patients received tangential radiation to the breast/chest wall (typical doses 200 cGy x 25 or 267 cGy x 16); five also received regional nodal RT as well; and 17/18 received a tumor bed boost. The mean heart dose ranged from 42-160 cGy for all 18 patients (mean of the means Z 78 cGy). Of the 16 evaluable patients, post-RT SPECTs have been obtained in eight. All eight have a normal post-RT SPECT scan; i.e. SRS score Z 0. Conclusion: In patients receiving tangential RT for left-sided breast cancer, cardiac avoidance with DIBH (e.g. with AlignRT) and conformal field shaping, appears to be able to prevent the development of RT-associated cardiac perfusion abnormalities. The mean dosages to the heart are quite low. Updated information on the remaining patients will be presented. Funded in part by VisionRT. Author Disclosure: T.M. Zagar: Research Grant; VisionRT. X. Tang: None. E.L. Jones: None. J. Matney: None. S. Das: None. R. Green: None. A. Sheikh: None. A. Khandani: None. W. McCartney: None. T. Wong: None. L.B. Marks: Research Grant; VisionRT.