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The Incidence of Fat Necrosis in Balloon-Based Breast Brachytherapy
S208
International Journal of Radiation Oncology Biology Physics
to conventional technique is worthy to be investigated. We herein conduct a case-control study comparing acute toxicities in patients undergoing PMRT using a linac IMRT technique vs conventional technique. Materials/Methods: Between June 2009 and December 2010, 116 prospectively selected patients with positive axillary lymph nodes were treated with a linac IMRT technique. A total dose of 50 Gy in 25 fractions was delivered to the whole PTV including chest wall and supra/infraclavicular region +/- internal mammary nodes. During the same period, 170 patients, who had indications for PMRT but were treated with conventional technique (chest wall tangents, and separate anterior fields for supra/ infraclavicular region +/- internal mammary nodes), were selected as controls. Of these, 52 patients received IMN irradiation in the IMRT group, and 82 in the control group. All patients were followed up regularly for up to 6 months. Acute toxicities were assessed using the common terminology of criteria for adverse effects (CTCAE v4.0) issued by the National Cancer Institutes. Differences in acute toxicities between groups were compared using chi-square test or Fisher exact test. The p values of 0.05 were considered statistically significant. Results: The rate of Grade 2 or worse radiation dermatitis was 42.2% (49/ 116) in the IMRT group and 52.9% (90/170) in the control group (chisquare Z 3.16; p Z 0.636). The corresponding rates of Grade 3 radiation dermatitis was 12.9% and 32.3% (15 vs 55; chi-square Z 74.53; p < 0.001). The site of Grade 3 dermatitis (i.e., moist desquamation other than anterior axillary skin folds) was most frequently occurred in the surgical scars (9/15) in the IMRT group, and in the overlapping area between medial tangent and IMN field (36/55) in the control group. The incidence of Grade 2 radiation pneumonitis was similar for both groups (1.7% vs 1.1%). Conclusions: This study reveals a lower incidence of Grade 3 radiation dermatitis in the linac IMRT group than in the control group. Patients receiving IMN irradiation are likely to benefit from this IMRT technique. Author Disclosure: J. Ma: None. J. Li: None. J. Chen: None.
patient received sentinel lymph node biopsy, 92% patients underwent I/II levels axillary lymph node dissection. The mean number of axillary nodes sampled was 10 (range, 0-38). Forty-six percent patients received radiation therapy after mastectomy, and 64% received chemotherapy as neoadjuvant or adjuvant therapy, whereas 42% received hormonal therapy. The actuarial rate of any BCRL was 53.9% and 36.2% for the entire cohort by subjective and objective assessment, respectively. BCRL was more likely to develop in patients with lymph node metastases (43.5% vs 13.2%; p < 0.01), those with stage III (50.2% vs 18.1%; p Z 0.00), and those who received irradiation (38.8% vs 12.1%; p < 0.05). BMI, age, the numbers of lymph nodes removed, receipt of chemotherapy, and/or hormonal therapy were not significant independent risk factors in development of BCRL. Conclusions: BCRL is common complication for breast cancer patients who underwent radical mastectomy. Advanced stage, axillary node positive, and receipt of radiation therapy were independent risk factor in development of BCRL. Author Disclosure: Y.Q. Zhu: None. Y. Tian: None. J. Wu: None. G. Jiang: None. X. Zhu: None.
2009 Lymphedema After Radical Mastectomy for Breast Cancer in Chinese Women Y.Q. Zhu,1 Y. Tian,1 J. Wu,1 G. Jiang,2 and X. Zhu2; 1Department of Radiotherapy & Oncology, Second Affiliated Hospital, Soochow University, Suzhou, China, 2Breast Disease Center, Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China Purpose/Objective(s): In recent years, breast cancer mortality rates have significantly declined, and increased survival rates have highlighted the importance of preventing and managing morbidity resulting from treatment effects in order to maximize the quality of life of breast cancer survivors. Breast cancer-related lymphedema (BCRL) is one of the most distressing long-term consequences of breast cancer treatment. But there are inadequate data about the incidence of lymphedema, the range is about 5% to 66%. Limited data exist on the risk of BCRL, Many patient, treatment and behavioral characteristics bear inconsistent relationships to secondary lymphedema risk. This study aimed to examine incidence and risk factors (body mass index [BMI], age, stage, surgical procedure, axillary node status, number of axillary nodes removed, radiation therapy, chemotherapy, and hormonal therapy) for BCRL. Materials/Methods: A total of 224 patients with breast cancer were received radical mastectomy at our hospital from January 2009 to December 2010, with 186 patients available for analysis. Estimate of BCRL was based on clinical assessment and self-administered questionnaire. Definition of BCRL was more than 2 cm increase in arm circumference by clinical assessment, the questionnaire was based loosely on the telephone questionnaire to characterize lymphedema of Norman. Differences in clinical, pathologic, and treatment characteristics between patients were also evaluated. Analysis of risk factors for the development of BCRL was performed finally. Univariate analysis was performed by using chi-square test, and multivariable analysis was performed by using binary logistic regression. Results: A total of 186 patients were available for evaluation. The median age was 49 years (range, 28-83 years). In the management of the axilla, no
2010 The Incidence of Fat Necrosis in Balloon-Based Breast Brachytherapy N.N. Paryani, L. Vallow, W. Magalhaes, M. Heckman, S. Kim, A. Smith, N. Diehl, and S. McLaughlin; Mayo Clinic, Jacksonville, FL Purpose/Objective(s): To investigate the incidence of and potential risk factors for fat necrosis in high dose-rate (HDR) balloon-based breast brachytherapy (BBB). Secondary objectives included local control, survival, and other treatment-related toxicities. Materials/Methods: Fifty-four patients were treated postoperatively with HDR-BBB between May 2007 and December 2010. Median age was 71 years (range, 50-88 years). Median tumor size was 1 cm (range, 0.1-2.7 cm). Ninety-three percent of lesions were ER positive. Forty-seven had invasive histology; 52% were grade 1, 30% grade 2, and 18% grade 3. In situ lesions were split equally between low-intermediate and high grade. The median margin size was 0.7 cm (range, 0-1.5 cm); one patient had a positive pectoralis margin. Five patients underwent re-excision. The majority of lesions (n Z 28) were located in the upper-outer-quadrant, and more than half (n Z 30) were in the left breast. All patients were treated with 34 Gy in 10 fractions twice daily via Ir-192 prescribed to 1 cm from the balloon-edge. Median distance between balloon edge and skin was 15 mm (range, 7-47 mm). Median maximum skin dose was 266 cGy (range, 67-420 cGy). Eight patients received chemotherapy. Results: With a median follow-up of 2.9 years (range, 0.5-5.2 years), local control was 98% with only one in-breast failure, and overall survival was 89%. Fifty percent of patients experienced fat necrosis. Only 7 patients were symptomatic, with the remainder detected by mammography alone. Two patients required surgical resection with pathology confirming fat necrosis; 1 required IV steroids. At 1, 3, and 5 years following treatment, estimated cumulative incidences of fat necrosis were 7.5%, 52.7%, and 60.6%. Breast laterality, location, tumor size, histology, margin size, balloon volume, skin distance, skin dose, and number of dwell positions were not significantly associated with fat necrosis on univariate analysis. Other complications included infection requiring PO antibiotics (n Z 4), seroma requiring intervention (n Z 2), wound healing issues (n Z 1), and a single episode of painless bloody nipple discharge (n Z 1). Conclusions: In this retrospective review of HDR-BBB, we found a high incidence of both asymptomatic and symptomatic fat necrosis. Only three patients, however, required intervention. None of the risk factors considered were significantly associated with fat necrosis; however, this result should not be over-interpreted owing to relatively small number of events in this study. Larger studies may better evaluate risk factors for fat necrosis following HDR-BBB. Author Disclosure: N.N. Paryani: None. L. Vallow: None. W. Magalhaes: None. M. Heckman: None. S. Kim: None. A. Smith: None. N. Diehl: None. S. McLaughlin: None.
International Journal of Radiation Oncology Biology Physics
to conventional technique is worthy to be investigated. We herein conduct a case-control study comparing acute toxicities in patients undergoing PMRT using a linac IMRT technique vs conventional technique. Materials/Methods: Between June 2009 and December 2010, 116 prospectively selected patients with positive axillary lymph nodes were treated with a linac IMRT technique. A total dose of 50 Gy in 25 fractions was delivered to the whole PTV including chest wall and supra/infraclavicular region +/- internal mammary nodes. During the same period, 170 patients, who had indications for PMRT but were treated with conventional technique (chest wall tangents, and separate anterior fields for supra/ infraclavicular region +/- internal mammary nodes), were selected as controls. Of these, 52 patients received IMN irradiation in the IMRT group, and 82 in the control group. All patients were followed up regularly for up to 6 months. Acute toxicities were assessed using the common terminology of criteria for adverse effects (CTCAE v4.0) issued by the National Cancer Institutes. Differences in acute toxicities between groups were compared using chi-square test or Fisher exact test. The p values of 0.05 were considered statistically significant. Results: The rate of Grade 2 or worse radiation dermatitis was 42.2% (49/ 116) in the IMRT group and 52.9% (90/170) in the control group (chisquare Z 3.16; p Z 0.636). The corresponding rates of Grade 3 radiation dermatitis was 12.9% and 32.3% (15 vs 55; chi-square Z 74.53; p < 0.001). The site of Grade 3 dermatitis (i.e., moist desquamation other than anterior axillary skin folds) was most frequently occurred in the surgical scars (9/15) in the IMRT group, and in the overlapping area between medial tangent and IMN field (36/55) in the control group. The incidence of Grade 2 radiation pneumonitis was similar for both groups (1.7% vs 1.1%). Conclusions: This study reveals a lower incidence of Grade 3 radiation dermatitis in the linac IMRT group than in the control group. Patients receiving IMN irradiation are likely to benefit from this IMRT technique. Author Disclosure: J. Ma: None. J. Li: None. J. Chen: None.
patient received sentinel lymph node biopsy, 92% patients underwent I/II levels axillary lymph node dissection. The mean number of axillary nodes sampled was 10 (range, 0-38). Forty-six percent patients received radiation therapy after mastectomy, and 64% received chemotherapy as neoadjuvant or adjuvant therapy, whereas 42% received hormonal therapy. The actuarial rate of any BCRL was 53.9% and 36.2% for the entire cohort by subjective and objective assessment, respectively. BCRL was more likely to develop in patients with lymph node metastases (43.5% vs 13.2%; p < 0.01), those with stage III (50.2% vs 18.1%; p Z 0.00), and those who received irradiation (38.8% vs 12.1%; p < 0.05). BMI, age, the numbers of lymph nodes removed, receipt of chemotherapy, and/or hormonal therapy were not significant independent risk factors in development of BCRL. Conclusions: BCRL is common complication for breast cancer patients who underwent radical mastectomy. Advanced stage, axillary node positive, and receipt of radiation therapy were independent risk factor in development of BCRL. Author Disclosure: Y.Q. Zhu: None. Y. Tian: None. J. Wu: None. G. Jiang: None. X. Zhu: None.
2009 Lymphedema After Radical Mastectomy for Breast Cancer in Chinese Women Y.Q. Zhu,1 Y. Tian,1 J. Wu,1 G. Jiang,2 and X. Zhu2; 1Department of Radiotherapy & Oncology, Second Affiliated Hospital, Soochow University, Suzhou, China, 2Breast Disease Center, Department of General Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China Purpose/Objective(s): In recent years, breast cancer mortality rates have significantly declined, and increased survival rates have highlighted the importance of preventing and managing morbidity resulting from treatment effects in order to maximize the quality of life of breast cancer survivors. Breast cancer-related lymphedema (BCRL) is one of the most distressing long-term consequences of breast cancer treatment. But there are inadequate data about the incidence of lymphedema, the range is about 5% to 66%. Limited data exist on the risk of BCRL, Many patient, treatment and behavioral characteristics bear inconsistent relationships to secondary lymphedema risk. This study aimed to examine incidence and risk factors (body mass index [BMI], age, stage, surgical procedure, axillary node status, number of axillary nodes removed, radiation therapy, chemotherapy, and hormonal therapy) for BCRL. Materials/Methods: A total of 224 patients with breast cancer were received radical mastectomy at our hospital from January 2009 to December 2010, with 186 patients available for analysis. Estimate of BCRL was based on clinical assessment and self-administered questionnaire. Definition of BCRL was more than 2 cm increase in arm circumference by clinical assessment, the questionnaire was based loosely on the telephone questionnaire to characterize lymphedema of Norman. Differences in clinical, pathologic, and treatment characteristics between patients were also evaluated. Analysis of risk factors for the development of BCRL was performed finally. Univariate analysis was performed by using chi-square test, and multivariable analysis was performed by using binary logistic regression. Results: A total of 186 patients were available for evaluation. The median age was 49 years (range, 28-83 years). In the management of the axilla, no
2010 The Incidence of Fat Necrosis in Balloon-Based Breast Brachytherapy N.N. Paryani, L. Vallow, W. Magalhaes, M. Heckman, S. Kim, A. Smith, N. Diehl, and S. McLaughlin; Mayo Clinic, Jacksonville, FL Purpose/Objective(s): To investigate the incidence of and potential risk factors for fat necrosis in high dose-rate (HDR) balloon-based breast brachytherapy (BBB). Secondary objectives included local control, survival, and other treatment-related toxicities. Materials/Methods: Fifty-four patients were treated postoperatively with HDR-BBB between May 2007 and December 2010. Median age was 71 years (range, 50-88 years). Median tumor size was 1 cm (range, 0.1-2.7 cm). Ninety-three percent of lesions were ER positive. Forty-seven had invasive histology; 52% were grade 1, 30% grade 2, and 18% grade 3. In situ lesions were split equally between low-intermediate and high grade. The median margin size was 0.7 cm (range, 0-1.5 cm); one patient had a positive pectoralis margin. Five patients underwent re-excision. The majority of lesions (n Z 28) were located in the upper-outer-quadrant, and more than half (n Z 30) were in the left breast. All patients were treated with 34 Gy in 10 fractions twice daily via Ir-192 prescribed to 1 cm from the balloon-edge. Median distance between balloon edge and skin was 15 mm (range, 7-47 mm). Median maximum skin dose was 266 cGy (range, 67-420 cGy). Eight patients received chemotherapy. Results: With a median follow-up of 2.9 years (range, 0.5-5.2 years), local control was 98% with only one in-breast failure, and overall survival was 89%. Fifty percent of patients experienced fat necrosis. Only 7 patients were symptomatic, with the remainder detected by mammography alone. Two patients required surgical resection with pathology confirming fat necrosis; 1 required IV steroids. At 1, 3, and 5 years following treatment, estimated cumulative incidences of fat necrosis were 7.5%, 52.7%, and 60.6%. Breast laterality, location, tumor size, histology, margin size, balloon volume, skin distance, skin dose, and number of dwell positions were not significantly associated with fat necrosis on univariate analysis. Other complications included infection requiring PO antibiotics (n Z 4), seroma requiring intervention (n Z 2), wound healing issues (n Z 1), and a single episode of painless bloody nipple discharge (n Z 1). Conclusions: In this retrospective review of HDR-BBB, we found a high incidence of both asymptomatic and symptomatic fat necrosis. Only three patients, however, required intervention. None of the risk factors considered were significantly associated with fat necrosis; however, this result should not be over-interpreted owing to relatively small number of events in this study. Larger studies may better evaluate risk factors for fat necrosis following HDR-BBB. Author Disclosure: N.N. Paryani: None. L. Vallow: None. W. Magalhaes: None. M. Heckman: None. S. Kim: None. A. Smith: None. N. Diehl: None. S. McLaughlin: None.