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Lymphedema Risk Following Regional Nodal Irradiation in Breast Cancer: Implications for Field Arrangement and Treatment Volume
Volume 99 Number 2S Supplement 2017 M. Elebrashi,1 S.I. Goldberg,1 B. Lavajo Vieira,3,4 and A.G. Taghian1,5; 1 Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 2Memorial Sloan Kettering Cancer Center, New York, NY, 3 Hoˆpitaux Universitaires de Gene`ve, Geneva, Switzerland, 4(AROME) Association of Radiotherapy and Oncology of the Mediterranean Area, Paris, France, 5Harvard Medical School, Boston, MA Purpose/Objective(s): To identify which type of implant based reconstruction has the most favorable outcome in the setting of post mastectomy radiation (PMRT). Materials/Methods: We conducted a retrospective cohort study of 1179 breast cancer patients who underwent a total of 1729 mastectomies of which 76% (1329) underwent implant based reconstruction; 56% (739) involved tissue expander/implant (TE/I) exchange and 44% (590) were single-stage permanent implants (PI); 23% (400) had autologous tissue reconstruction (ATR), all treated at one institution from 1997-2014. Of the total breasts undergoing mastectomy, 29% (507) received PMRT and 71% (1222) did not. Median prescribed PMRT dose to the chest wall was 50 Gy (range 45-50.4 Gy); of which 61% (311) received a chest wall boost (1016 Gy). Forty percent (495) of mastectomies were performed prophylactically in an uninvolved breast. Primary outcome was defined as implant removal (IR) due to complications requiring surgical intervention, with or without re-reconstruction. The association of clinical and pathologic parameters with IR was evaluated using logistic regression models, and the cumulative incidence of outcome was estimated using the Kaplan-Meier method. Results: The median follow-up was 64 months. In patients who received PMRT, the 5 -year risk of IR was 33.8% vs 16.4% for TE/I and PI; respectively (P Z 0.0007). Similarly, patients with TE/I had a higher risk for IR with failed implant replacement compared to patients with PI (18.6% vs 9.3%; respectively; P Z 0.0098); as well as a higher 5 yr predicted IR with successful re-reconstruction (18.7%, vs 7.8%; respectively; P Z 0.025). In the absence of PMRT, 5-year predicted incidence of IR did not differ between TE/I and PI (13.9% vs 8.4%; respectively; P Z 0.074). Neither did the 5-yr IR with failed implant replacement (3.9% vs 2.3% respectively; P Z 0.31); nor 5-yr IR with successful re-reconstruction (10.4% vs 6.3%; respectively; P Z 0.14). The 5-yr complication rate among patients with ATR was not significantly different with and without PMRT (18.2% vs 16.6%; respectively; P Z 0.97). The 5- yr complication rate was not significantly different between irradiated ATR and irradiated single stage (PI) (18.2% vs 16.4%; respectively; P Z 0.99); while this was significantly lower compared to irradiated TE/I (18.2% vs 33.8%; respectively; P Z 0.015). In multivariate analysis, PMRT, tissue expander/implant (TE/I) reconstruction and active smoking were significant predictors for implant removal (Odds Ratio [OR] Z 7.2, P < 0.001; OR Z 5.8, P Z 0.001 and OR Z 3.5, P Z 0.02; respectively). Neoadjuvant chemotherapy, surgery related parameters as reconstruction timing, and implant size were not predictive of IR. Conclusion: These data suggest that in the setting of PMRT, two stage tissue expander/implant (TE/I) has significantly higher rate of implant removal compared to Single Stage PI and ATR. PI could be considered a preferable alternative to TE/I when PMRT is indicated. Author Disclosure: L.W. Salama: None. L.Z. Braunstein: None. A. Mina: None. M.L. Abouegylah: None. M.S. Asdourian: None. M.N. Swaroop: None. M.P. Tighe: None. N.R. Taghian: None. M. Elebrashi: None. S.I. Goldberg: None. B. Lavajo Vieira: None. A.G. Taghian: Research Grant; Impedimed. Honoraria; UpToDate. Consultant; VisionRT.
9 Postmastectomy Radiation Therapy for NodeNegative Breast Cancer with Tumor Size of Five Centimeter or More: A Meta-analysis M.P. Shaikh Jr,1 F. Alite Jr,2 M.J. Wu,3 T. Altoos,4 and G.M. Jacobson1; 1 West Virginia University, Morgantown, WV, 2Geisinger Medical Center, Danville, WV, 3Loyola University Chicago, Chicago, IL, 4Countryside Cancer Center, Clearwater, FL
Oral Scientific Sessions
S5
Purpose/Objective(s): We aim to conduct a meta-analysis of prospective and case-control studies to investigate the loco-regional recurrence (i.e., recurrence in chest wall and/or regional nodes, LRR) benefit of postmastectomy radiotherapy (PMRT) in node negative breast cancer with tumor size Z 5.0 cm or pT3 (tumor size >5.0 cm). Controversy exists as to the benefits of PMRT in this setting. Materials/Methods: A comprehensive Medline and conference abstracts search to identify prospective and retrospective case-control studies with the following criteria was done. Similar to the EBCTCG meta-analysis, patients were defined to have undergone axillary dissection (AD) if the protocol required removal of axillary lymph nodes in at least level I & II, had removal of >Z 10 lymph nodes or were in a study that had a median of >Z 10 lymph nodes removed. Otherwise, they were considered to have undergone axillary sampling (AS). Studies were included in which patients had surgery as the first treatment with AS or AD and the pathologic staging showed no tumor in the lymph nodes (pN0). Patient with pathologic tumor size > 5cm (T3) or tumor size Z 5 cm were included. This was done to allow inclusion of studies that provided data on tumors >Z 5cm and not just pT3 alone. Studies where patients had neo-adjuvant chemotherapy prior to surgery were excluded. Due to rarity of the events, Peto odds ratio (Peto OR) was used as the effect-size estimator of choice. Results: A total of 6 studies were identified and meta-analyzed. These included: the EBCTCG individual-patient data meta-analysis of randomized clinical studies (RCTs) that provided counts of patients with T3N0 who were randomized to PMRT vs observation, an RCT (Klefstrom), and four retrospective case-control studies (Goulart, Helinto, Aksu, Frandsen) with a total of 445 patients (PMRT: n Z 276, control: n Z 169). In all patients (undergoing either AS or AD) there were 9 out of 276 (3.3%) patients recorded with LRR in the PMRT group compared to 21 out of 169 (12.4%) patients that did not receive PMRT. Pooled analysis showed a significant LRR benefit in patients who received PMRT compared to patient who did not (Peto OR Z 0.16, 95% CI 0.07 e 0.38, P<0.0001). In the subgroup of patients who had only AS, there were 5 LRR out of 148 (3.4%) patients who received PMRT compared to 13 out of 107 (12.1%) patient who did not receive PMRT and the improvement was significant (Peto OR Z 0.15, 95% CI 0.05 e 0.44, P Z 0.0005). In the subgroup of patients who had AD, there were 4 out of 127 (3.1%) LRR in patients undergoing PMRT versus 8 out of 56 (14.3%) patients who did not receive PMRT and the difference was significant (Peto OR Z 0.18, 95% CI 0.05 e 0.68, P Z 0.01). Conclusion: LRR is significantly improved with PMRT in node-negative patients with tumor size >Z 5 cm. This benefit was evident in both the subgroups that underwent Axillary Sampling as well as Axillary Dissection. Author Disclosure: M.P. Shaikh: None. F. Alite: None. M. Wu: None. T. Altoos: None. G.M. Jacobson: Overseas oncology programs; HVO health Volunteers Overseas.
10 Lymphedema Risk Following Regional Nodal Irradiation in Breast Cancer: Implications for Field Arrangement and Treatment Volume J. Gross,1 S. Sachdev,2 D. Lipps,3 E.D. Donnelly,4 J.P. Hayes,5 and J.B. Strauss4; 1Northwestern University, Chicago, IL, 2Northwestern University Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, 3 University of Michigan, Ann Arbor, MI, 4Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, 5Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL Purpose/Objective(s): Upper extremity lymphedema (LE) is an important complication with long-term quality-of-life impact for breast cancer survivors. Rates of LE following regional nodal irradiation (RNI) range from 9% to 65% based on known risk factors such as BMI and extent of nodal dissection. The effect of other factors such as beam arrangement and axillary volume encompassed in the radiotherapy (RT) field has not been well characterized. This study sought to identify factors associated with the development of LE, including detailed information on RT beam arrangement and treatment volume.
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International Journal of Radiation Oncology Biology Physics
Materials/Methods: Between 1999 and 2015, 492 women received RNI for breast cancer treatment at our institution following surgery. Arm circumferences were prospectively measured prior to the initiation of RT and during follow-up. RT fields were defined as follows: Field 1 Z exclusion of the dissected axilla, defined as anterior beam encompassing < 1/3 of the humeral head at the lateral field edge, +/- a supplementary posterior axillary (PA) field. Field 2 Z anterior beam encompassing 1/3 of the humeral head, +/-a supplementary PA field. Field 3 Z parallel-opposed beams encompassing the full axilla. LE was defined as arm circumference on the treated side 2.5cm or 2cm on 2 visits either 10cm above or 15cm below the olecranon process compared to the opposite arm, or LE documented after evaluation by a LE specialist. Cox proportional hazards models were used to analyze risk factors for LE development. Results: Median post-operative follow-up was 66 months (range, 7-204 months). The overall 2-year and 5-year cumulative incidence (CI) of LE was 18.5% and 24.8% respectively. The proportion of patients receiving fields 1, 2 and 3 were 20.5% (n Z 101), 41.1% (n Z 202) and 38.4% (n Z 189) respectively. On univariate analysis, Field 1 was associated with lower 5-year CI of LE (6.93%) compared to field 2 (28.2%; P<0.0001) and field 3 (30.7%; P<0.0001). There were no significant differences in year of treatment, pre-treatment BMI, handedness, age, type of breast surgery, type of axillary surgery, number of LN removed or use of chemotherapy between groups. On multivariate analysis, pre-treatment BMI (hazard ratio [HR]: 1.02, P Z 0.0002), number of LN dissected (HR: 1.03, P Z 0.002), field 2 (HR: 4.73, P<0.001) and field 3 (HR: 3.37, P Z 0.002) were associated with LE risk. Overall rate of regional recurrences (RR) was 1.62%. Despite equal proportion of locally advanced disease, field 1 was not associated with higher rate of RR (P Z 0.43). Conclusion: In addition to other risk factors, the volume of irradiated axilla was the most important risk factor for LE following RNI. Restricting the volume of axilla being treated to undissected axilla following axillary dissection conveys a lower risk of lymphedema without increased risk for RR. By contrast, the beam arrangement was not associated with LE risk. Adherence to expert guidelines regarding omission of the dissected axilla appears to be integral to minimizing the rate of LE after breast radiotherapy. Author Disclosure: J. Gross: None. S. Sachdev: None. D. Lipps: None. E.D. Donnelly: None. J. Hayes: None. J.B. Strauss: Employee; Advocate Medical Group. Independent Contractor; American Imaging Management. Honoraria; Lynn Sage Cancer Foundation. Organize radiation oncology lectures for Chicago residents; Chicago Radiological Society.
(range 14-208 months) after BCT. Median age at local recurrence (LR) was 56 years. Sixty-two percent of the recurrences were 1 cm or less and 92% were ductal infiltrative carcinoma. With a median follow-up after the second conservative treatment of 126 months, the local control rate at 5 and 10 years were 85% and 72%, respectively. Breast conservation rates were 80% and 72% at 5 and 10 years respectively. Freedom from distant metastasis was 82%. The disease-free survival (DFS), the overall survival (OS) and the disease-specific survival (DSS) were respectively 72%, 92%, and 95% at 5 years and 70%, 80%, and 88% at 10 years. Multivariate analysis showed two factors to be associated with a better local control, a recurrence size of 1cm or less (P Z 0.005) and an interval between primary breast cancer and LR of 24 months or more (P Z 0.03). Factors associated with better DFS or DSS were no initial involvement of the axilla (P Z 0.001) and a recurrence size of 1cm or less (P Z 0.01). The most common late toxicities consisted of skin fibrosis, ipsilateral breast size reduction, and telangiectasia in 25% of the patients. Intermittent grade 1 pain was seen in 35% of the patients. Cosmetic results were good in 75% and 70% of patients at 5 and 10 years. Conclusion: Local tumor excision combined with HDR brachytherapy for small local-regional tumor recurrences after primary BCT is feasible and well-tolerated. Cosmetic outcome is good to excellent. Author Disclosure: M. Jolicoeur: None. S. David: None. P. Rousseau: None. M. Mondat: None.
11 Long-Term Follow-up for High-Dose-Rate Interstitial Brachytherapy and Lumpectomy as a Second Conservative Treatment for Local Recurrences of Breast Cancer M. Jolicoeur,1 S. David,2 P. Rousseau,3 and M. Mondat1; 1Hopital Charles-LeMoyne, Longueuil, QC, Canada, 2CHUM-Hopital Notre-Dame, Montreal, QC, Canada, 3Universite de Montreal, Montreal, QC, Canada Purpose/Objective(s): To evaluate prospectively the effectiveness, toxicity and cosmetic outcomes of local excision followed by HDR brachytherapy as a second conservative treatment for isolated local recurrence (LR) after breast conservative treatment (BCT). Materials/Methods: Patients were eligible if they were initially treated with a breast conserving surgery followed by a full course of radiotherapy, and developed an in-breast local recurrence. Enrolled Patients had no sign of metastatic disease. The treatment of the recurrent disease consisted of surgical excision with negative margins followed by HDR interstitial multi-catheter brachytherapy. Target volume was defined as the surgical cavity plus a 2 cm margin. Ultrasound and/or MRI were used to assist in the localization of the surgical bed. A CT-scan based dosimetry was performed and an Iridium-192 afterloader was used to deliver a dose of 31.2 Gy in 2.6 Gy/fraction/5 days a week to the target volume. Patients had to sign a consent form and complete the OCOG cosmetic scale. Results: Between January 1998 and November 2005, 75 patients were included in this study. Recurrences occurred at a median time of 65 months
12 Palliative Breast RadiationdEffectiveness, Fractionation, and Toxicity G. Jacobson,1 S.L. Galper,2 I. Dromi Shahadi,3 Z. Symon,4 T. Rabin,5 and M.A. Ben-David6; 1Sheba Medical Center, Ramat Gan, Israel, 2VA Boston Healthcare System, Jamaica Plain, MA, 3Sheba Medical Center, Ramat Gan, Israel, 4Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel, 5Sheba Medical Center, Ramat Gan, Israel, 6Sheba Medical Center, Ramat Gan, Israel Purpose/Objective(s): Patients with advanced breast cancer may experience pain, discomfort, bleeding, discharge, and ulceration of the tumor, which have been shown to severely affect a patient’s quality of life. The effectiveness, fractionation, and toxicity of palliative radiation therapy to the breast were evaluated in this study. Materials/Methods: Following institutional review board approval, we analyzed all patients in our prospectively collected database that underwent palliative breast RT at our institution between 2006 and 2016. A total of 68 patients were identified, and we herein report the clinical outcomes, demographics, and treatment characteristics for all patients who had minimal follow-up of 2 months (52 patients). Results: The mean age was 59 years. All patients had stage IV disease when they were evaluated for RT, thirty one (58%) were metastatic at time of diagnosis. Mean time from diagnosis to palliative RT (PRT) was 53 months. Median FU duration was 12 months (range 2-94 months). Nine (16%) received prior, adjuvant, RT in the past. The indications for PRT were: pain (55%), bleeding (25%), discharge (11%) and discomfort (3%) or combination. Seven patients received single fraction of 8 Gy. In this group, the mean age was 78y/o, with poor PS (3-4). The indications for PRT were massive bleeding (63%) or severe pain (37%). Four (57%) patients needed re-irradiation, and received another single fraction of 8 Gy. Six (85%) reported excellent clinical benefit. Forty four patients (84%) received CT simulation based, 3DC radiation of different fractionated regiments: 15 fractions of 3 Gy/fx, 25 fractions of 2 Gy/fx, and 13 fractions of 3 Gy/fx. This group was younger (P Z 0.007), with mean age of 61 years, with better PS (0-2). The indications were: pain (46%), bleeding (27%), discharge (20%), or combination. Following conversion to EDQ2, mean total dose was 42 Gy (range 2670). All patients (100%) reported clinical benefit: decrease in pain level, tumor size, and discharge. None reported recurrent bleeding. Six (15%) needed re-irradiation for pain. The common side effect noted was grade 1-2 dermatitis; however, one patient developed grade 3 toxicity (radiation recall phenomena). Radiation was effective even for formerly irradiated breasts, with no extra side effects noted. There was no difference between regiments in terms of side effects or effectiveness, even for second radiation.
9 Postmastectomy Radiation Therapy for NodeNegative Breast Cancer with Tumor Size of Five Centimeter or More: A Meta-analysis M.P. Shaikh Jr,1 F. Alite Jr,2 M.J. Wu,3 T. Altoos,4 and G.M. Jacobson1; 1 West Virginia University, Morgantown, WV, 2Geisinger Medical Center, Danville, WV, 3Loyola University Chicago, Chicago, IL, 4Countryside Cancer Center, Clearwater, FL
Oral Scientific Sessions
S5
Purpose/Objective(s): We aim to conduct a meta-analysis of prospective and case-control studies to investigate the loco-regional recurrence (i.e., recurrence in chest wall and/or regional nodes, LRR) benefit of postmastectomy radiotherapy (PMRT) in node negative breast cancer with tumor size Z 5.0 cm or pT3 (tumor size >5.0 cm). Controversy exists as to the benefits of PMRT in this setting. Materials/Methods: A comprehensive Medline and conference abstracts search to identify prospective and retrospective case-control studies with the following criteria was done. Similar to the EBCTCG meta-analysis, patients were defined to have undergone axillary dissection (AD) if the protocol required removal of axillary lymph nodes in at least level I & II, had removal of >Z 10 lymph nodes or were in a study that had a median of >Z 10 lymph nodes removed. Otherwise, they were considered to have undergone axillary sampling (AS). Studies were included in which patients had surgery as the first treatment with AS or AD and the pathologic staging showed no tumor in the lymph nodes (pN0). Patient with pathologic tumor size > 5cm (T3) or tumor size Z 5 cm were included. This was done to allow inclusion of studies that provided data on tumors >Z 5cm and not just pT3 alone. Studies where patients had neo-adjuvant chemotherapy prior to surgery were excluded. Due to rarity of the events, Peto odds ratio (Peto OR) was used as the effect-size estimator of choice. Results: A total of 6 studies were identified and meta-analyzed. These included: the EBCTCG individual-patient data meta-analysis of randomized clinical studies (RCTs) that provided counts of patients with T3N0 who were randomized to PMRT vs observation, an RCT (Klefstrom), and four retrospective case-control studies (Goulart, Helinto, Aksu, Frandsen) with a total of 445 patients (PMRT: n Z 276, control: n Z 169). In all patients (undergoing either AS or AD) there were 9 out of 276 (3.3%) patients recorded with LRR in the PMRT group compared to 21 out of 169 (12.4%) patients that did not receive PMRT. Pooled analysis showed a significant LRR benefit in patients who received PMRT compared to patient who did not (Peto OR Z 0.16, 95% CI 0.07 e 0.38, P<0.0001). In the subgroup of patients who had only AS, there were 5 LRR out of 148 (3.4%) patients who received PMRT compared to 13 out of 107 (12.1%) patient who did not receive PMRT and the improvement was significant (Peto OR Z 0.15, 95% CI 0.05 e 0.44, P Z 0.0005). In the subgroup of patients who had AD, there were 4 out of 127 (3.1%) LRR in patients undergoing PMRT versus 8 out of 56 (14.3%) patients who did not receive PMRT and the difference was significant (Peto OR Z 0.18, 95% CI 0.05 e 0.68, P Z 0.01). Conclusion: LRR is significantly improved with PMRT in node-negative patients with tumor size >Z 5 cm. This benefit was evident in both the subgroups that underwent Axillary Sampling as well as Axillary Dissection. Author Disclosure: M.P. Shaikh: None. F. Alite: None. M. Wu: None. T. Altoos: None. G.M. Jacobson: Overseas oncology programs; HVO health Volunteers Overseas.
10 Lymphedema Risk Following Regional Nodal Irradiation in Breast Cancer: Implications for Field Arrangement and Treatment Volume J. Gross,1 S. Sachdev,2 D. Lipps,3 E.D. Donnelly,4 J.P. Hayes,5 and J.B. Strauss4; 1Northwestern University, Chicago, IL, 2Northwestern University Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, 3 University of Michigan, Ann Arbor, MI, 4Department of Radiation Oncology, The Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, 5Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL Purpose/Objective(s): Upper extremity lymphedema (LE) is an important complication with long-term quality-of-life impact for breast cancer survivors. Rates of LE following regional nodal irradiation (RNI) range from 9% to 65% based on known risk factors such as BMI and extent of nodal dissection. The effect of other factors such as beam arrangement and axillary volume encompassed in the radiotherapy (RT) field has not been well characterized. This study sought to identify factors associated with the development of LE, including detailed information on RT beam arrangement and treatment volume.
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International Journal of Radiation Oncology Biology Physics
Materials/Methods: Between 1999 and 2015, 492 women received RNI for breast cancer treatment at our institution following surgery. Arm circumferences were prospectively measured prior to the initiation of RT and during follow-up. RT fields were defined as follows: Field 1 Z exclusion of the dissected axilla, defined as anterior beam encompassing < 1/3 of the humeral head at the lateral field edge, +/- a supplementary posterior axillary (PA) field. Field 2 Z anterior beam encompassing 1/3 of the humeral head, +/-a supplementary PA field. Field 3 Z parallel-opposed beams encompassing the full axilla. LE was defined as arm circumference on the treated side 2.5cm or 2cm on 2 visits either 10cm above or 15cm below the olecranon process compared to the opposite arm, or LE documented after evaluation by a LE specialist. Cox proportional hazards models were used to analyze risk factors for LE development. Results: Median post-operative follow-up was 66 months (range, 7-204 months). The overall 2-year and 5-year cumulative incidence (CI) of LE was 18.5% and 24.8% respectively. The proportion of patients receiving fields 1, 2 and 3 were 20.5% (n Z 101), 41.1% (n Z 202) and 38.4% (n Z 189) respectively. On univariate analysis, Field 1 was associated with lower 5-year CI of LE (6.93%) compared to field 2 (28.2%; P<0.0001) and field 3 (30.7%; P<0.0001). There were no significant differences in year of treatment, pre-treatment BMI, handedness, age, type of breast surgery, type of axillary surgery, number of LN removed or use of chemotherapy between groups. On multivariate analysis, pre-treatment BMI (hazard ratio [HR]: 1.02, P Z 0.0002), number of LN dissected (HR: 1.03, P Z 0.002), field 2 (HR: 4.73, P<0.001) and field 3 (HR: 3.37, P Z 0.002) were associated with LE risk. Overall rate of regional recurrences (RR) was 1.62%. Despite equal proportion of locally advanced disease, field 1 was not associated with higher rate of RR (P Z 0.43). Conclusion: In addition to other risk factors, the volume of irradiated axilla was the most important risk factor for LE following RNI. Restricting the volume of axilla being treated to undissected axilla following axillary dissection conveys a lower risk of lymphedema without increased risk for RR. By contrast, the beam arrangement was not associated with LE risk. Adherence to expert guidelines regarding omission of the dissected axilla appears to be integral to minimizing the rate of LE after breast radiotherapy. Author Disclosure: J. Gross: None. S. Sachdev: None. D. Lipps: None. E.D. Donnelly: None. J. Hayes: None. J.B. Strauss: Employee; Advocate Medical Group. Independent Contractor; American Imaging Management. Honoraria; Lynn Sage Cancer Foundation. Organize radiation oncology lectures for Chicago residents; Chicago Radiological Society.
(range 14-208 months) after BCT. Median age at local recurrence (LR) was 56 years. Sixty-two percent of the recurrences were 1 cm or less and 92% were ductal infiltrative carcinoma. With a median follow-up after the second conservative treatment of 126 months, the local control rate at 5 and 10 years were 85% and 72%, respectively. Breast conservation rates were 80% and 72% at 5 and 10 years respectively. Freedom from distant metastasis was 82%. The disease-free survival (DFS), the overall survival (OS) and the disease-specific survival (DSS) were respectively 72%, 92%, and 95% at 5 years and 70%, 80%, and 88% at 10 years. Multivariate analysis showed two factors to be associated with a better local control, a recurrence size of 1cm or less (P Z 0.005) and an interval between primary breast cancer and LR of 24 months or more (P Z 0.03). Factors associated with better DFS or DSS were no initial involvement of the axilla (P Z 0.001) and a recurrence size of 1cm or less (P Z 0.01). The most common late toxicities consisted of skin fibrosis, ipsilateral breast size reduction, and telangiectasia in 25% of the patients. Intermittent grade 1 pain was seen in 35% of the patients. Cosmetic results were good in 75% and 70% of patients at 5 and 10 years. Conclusion: Local tumor excision combined with HDR brachytherapy for small local-regional tumor recurrences after primary BCT is feasible and well-tolerated. Cosmetic outcome is good to excellent. Author Disclosure: M. Jolicoeur: None. S. David: None. P. Rousseau: None. M. Mondat: None.
11 Long-Term Follow-up for High-Dose-Rate Interstitial Brachytherapy and Lumpectomy as a Second Conservative Treatment for Local Recurrences of Breast Cancer M. Jolicoeur,1 S. David,2 P. Rousseau,3 and M. Mondat1; 1Hopital Charles-LeMoyne, Longueuil, QC, Canada, 2CHUM-Hopital Notre-Dame, Montreal, QC, Canada, 3Universite de Montreal, Montreal, QC, Canada Purpose/Objective(s): To evaluate prospectively the effectiveness, toxicity and cosmetic outcomes of local excision followed by HDR brachytherapy as a second conservative treatment for isolated local recurrence (LR) after breast conservative treatment (BCT). Materials/Methods: Patients were eligible if they were initially treated with a breast conserving surgery followed by a full course of radiotherapy, and developed an in-breast local recurrence. Enrolled Patients had no sign of metastatic disease. The treatment of the recurrent disease consisted of surgical excision with negative margins followed by HDR interstitial multi-catheter brachytherapy. Target volume was defined as the surgical cavity plus a 2 cm margin. Ultrasound and/or MRI were used to assist in the localization of the surgical bed. A CT-scan based dosimetry was performed and an Iridium-192 afterloader was used to deliver a dose of 31.2 Gy in 2.6 Gy/fraction/5 days a week to the target volume. Patients had to sign a consent form and complete the OCOG cosmetic scale. Results: Between January 1998 and November 2005, 75 patients were included in this study. Recurrences occurred at a median time of 65 months
12 Palliative Breast RadiationdEffectiveness, Fractionation, and Toxicity G. Jacobson,1 S.L. Galper,2 I. Dromi Shahadi,3 Z. Symon,4 T. Rabin,5 and M.A. Ben-David6; 1Sheba Medical Center, Ramat Gan, Israel, 2VA Boston Healthcare System, Jamaica Plain, MA, 3Sheba Medical Center, Ramat Gan, Israel, 4Radiation Oncology, Sheba Medical Center, Tel Hashomer, Israel, 5Sheba Medical Center, Ramat Gan, Israel, 6Sheba Medical Center, Ramat Gan, Israel Purpose/Objective(s): Patients with advanced breast cancer may experience pain, discomfort, bleeding, discharge, and ulceration of the tumor, which have been shown to severely affect a patient’s quality of life. The effectiveness, fractionation, and toxicity of palliative radiation therapy to the breast were evaluated in this study. Materials/Methods: Following institutional review board approval, we analyzed all patients in our prospectively collected database that underwent palliative breast RT at our institution between 2006 and 2016. A total of 68 patients were identified, and we herein report the clinical outcomes, demographics, and treatment characteristics for all patients who had minimal follow-up of 2 months (52 patients). Results: The mean age was 59 years. All patients had stage IV disease when they were evaluated for RT, thirty one (58%) were metastatic at time of diagnosis. Mean time from diagnosis to palliative RT (PRT) was 53 months. Median FU duration was 12 months (range 2-94 months). Nine (16%) received prior, adjuvant, RT in the past. The indications for PRT were: pain (55%), bleeding (25%), discharge (11%) and discomfort (3%) or combination. Seven patients received single fraction of 8 Gy. In this group, the mean age was 78y/o, with poor PS (3-4). The indications for PRT were massive bleeding (63%) or severe pain (37%). Four (57%) patients needed re-irradiation, and received another single fraction of 8 Gy. Six (85%) reported excellent clinical benefit. Forty four patients (84%) received CT simulation based, 3DC radiation of different fractionated regiments: 15 fractions of 3 Gy/fx, 25 fractions of 2 Gy/fx, and 13 fractions of 3 Gy/fx. This group was younger (P Z 0.007), with mean age of 61 years, with better PS (0-2). The indications were: pain (46%), bleeding (27%), discharge (20%), or combination. Following conversion to EDQ2, mean total dose was 42 Gy (range 2670). All patients (100%) reported clinical benefit: decrease in pain level, tumor size, and discharge. None reported recurrent bleeding. Six (15%) needed re-irradiation for pain. The common side effect noted was grade 1-2 dermatitis; however, one patient developed grade 3 toxicity (radiation recall phenomena). Radiation was effective even for formerly irradiated breasts, with no extra side effects noted. There was no difference between regiments in terms of side effects or effectiveness, even for second radiation.