Conservative breast cancer treatment: analysis of cosmetic results and the role of concomitant adjuvant chemotherapy

Cosmetic assessment in brachytherapy (interventional radiotherapy) for breast cancer: A multidisciplinary review

PURPOSE

This review was to focus on breast brachytherapy cosmetic assessment methods state of the art and to define the advantages and disadvantages related to.

METHODS AND MATERIALS

We conducted a literature review of the major experience on breast brachytherapy cosmetic assessment methods in several databases (PubMed, Scopus, and Google Scholar databases). To identify the relevant works, a task force screened citations at title and abstract level to identify potentially relevant paper. An expert board reviewed and approved the text. The assessment systems were classified into three main groups: (1) the Oncological Toxicity Scales, (2) the Independent Patients Perspective Measures, (3) the Patient-Related Outcome Measures. Each cosmetic assessment method was evaluated following six parameters: (1) anatomical site, (2) advantages, (3) disadvantages, (4) subjective/objective, (5) quantitative/qualitative, (6) computers or pictures needs.

RESULTS

Eleven assessment methods were selected. Three methods were classified as Oncological Toxicity Scale, six in the Independent Patients Perspective Measures classification, and two as Patient-Related Outcome Measures. Six methods are subjective, while eight are objective. Four systems are classified as quantitative, four as qualitative while three both. Five systems need informatics support. Moreover, each method was discussed individually reporting the main characteristics and peculiarities.

CONCLUSIONS

Cosmesis is one major end point for the patient who has a malignancy of low lethal potential. In modern personalized medicine, there is a need for standardized cosmetic outcome assessments to analyze and compare the results of treatments. No gold standard methods currently exist. The result of this review is to summarize the various cosmesis methods, defining the strengths and weaknesses of each one and giving a line in research and clinical practice.

Multi-institutional evaluation of the reproducibility and the accuracy of the objective breast cosmesis scale

PURPOSE

The aim of the present work is to assess the Objective Breast Cosmesis Scale (OBCS) in a patient cohort that was treated in two hospitals. Their treatment-related cosmetic changes were recorded on nonstandardized photographs.

METHODS AND MATERIALS

Nineteen female patients were enrolled in two radiation oncology centers (Nice, France, and Perugia, Italy). All patients had undergone breast-conserving surgery (BCS) and received adjuvant accelerated partial breast irradiation using interstitial fractionated multicatheter high-dose-rate brachytherapy. One photograph before and another after accelerated partial breast irradiation was taken for each patient to record changes in breast cosmesis. Using the OBCS, before and after photographs were analyzed by measuring distances between anatomic features. OBCS scores from four doctors (two males [one radiation oncologist and one post-grad trainee] and two females [one radiation oncologist and one post-grad trainee]) were compared.

RESULTS

Agreement was high between trainees and specialist, and males and females before and after treatment. The intraclass correlation coefficient ranged from 0.867 to 0.950 before treatment and from 0.876 to 0.952 afterward. The coefficient of variation ranged from 12% to 26.5% before treatment, and from 13% to 21.4% afterward.

CONCLUSIONS

The OBCS is easy, time-efficient, reproducible, cost-effective, and reliable. Its potential practical applications merit further investigation in future studies.

Evaluation of the Esthetic Results of Conservative Treatment of Breast Cancer

Aims and backgrounds

This paper describes the evaluation of a personal series of 106 breast cancer patients, aged 28-75 years (average, 54), treated between 1988 and 1971, to determine the success of a conservative protocol proposed as a means of combining radicality with a better cosmetic result, less alteration of the body image and an improved quality of life.

Methods

All the patients were operated with quadrantectomy and excision of axillary lymph nodes, followed by radiotherapy: 50 Gy to the whole breast plus 10 Gy on the tumor bed (boost irradiation). Adjuvant hormone and/or chemotherapy was also administered in 71/106 cases. The mean follow-up was 22.3 months. Cosmetic assessment was subjective and objective (asymmetry, loss of volume, retraction). All patients were photographed.

Results

The subjective judgements were: excellent 79, satisfactory 25, and poor 2, compared with objective assessments of 72, 20 and 14, respectively. Patients with poor esthetic results were almost all either T2 or treated with chemotherapy.

Conclusions

Conservative treatment of breast cancer using integrated irradiation and surgery can therefore attain the required objective of eradication of the cancer while maintaining a satisfactory esthetic and therefore good psychologic outcome.

Does Concomitant Chemoradiotherapy Influence Cosmetic Outcome in Conservative Treatment of Breast Cancer?

Purpose

To evaluate retrospectively factors influencing the cosmetic outcome after conservative treatment for breast cancer.

Material and methods

From 1988 until 1992, 164 patients were treated with conservative surgery (quadrantectomy) and radiotherapy with 60Co (50 Gy on the whole breast) plus 10 Gy on the surgical bed (300 kV photons) for T1–T2 breast cancers; 46 patients (28%) received concomitant adjuvant chemotherapy (CMF schedule). Cosmesis evaluation was carried out after 24 to 108 months (median, 38 months). A logistic regression analysis was performed to identify independent variables influencing the aesthetic outcome. P values of 0.05 or less were considered significant.

Results

Univariate analysis showed that T2 versus T1 (P = 0.0102), lower quadrants site (P = 0.0002) and concomitant adjuvant chemotherapy (P = 0.0009) produced a worse aesthetic outcome. Multivariate analysis confirmed the same factors: tumor size (P = 0.0020), tumor site (P = 0.0150) and concomitant chemotherapy (P = 0.0024).

Conclusions

The significant negative influence on the cosmetic outcome of concomitant adjuvant chemotherapy implies questions about the timing of radiotherapy and chemotherapy in breast cancer conservative treatment.

Negative Impact of Heat Exposure on Cosmesis after Conservative Treatment for Breast Cancer

Aim and background

To identify the factors influencing cosmesis after conservative treatment in breast cancer.

Methods

Retrospective analysis was done on 424 patients who underwent postoperative radiotherapy after conservative surgery for breast cancer from February 1992 to January 2002. Most of the patients underwent quadrantectomy. Whole breast irradiation up to 50.4 Gy was delivered in 28 fractions followed by a 10 Gy boost in 5 fractions to the tumor bed. Regional lymph node irradiation was administered if indicated. Breast cosmesis was scored in 4 tiers. Breast symmetry was analyzed by the relative distance from the sternal notch to the nipple, using photos taken prior to radiotherapy and 2 years after its completion. Median follow-up was 64 months.

Results

Breast cosmesis was excellent in 15%, good in 63%, fair in 19%, and poor in 3% of the patients. In multivariate analysis, tumors >2 cm ( P = 0.0109), lower quadrant location ( P = 0.0026), lymph node irradiation ( P = 0.0028), and heat exposure ( P = 0.0152) were related to poor cosmesis. The cosmesis score after radiotherapy compared to the pre-radiotherapy score was deteriorated in patients who had undergone lymph node irradiation ( P <0.0001) and heat exposure ( P = 0.0027). Breast symmetry was worse for patients who had tumors >2 cm ( P <0.0001), upper quadrant tumor location ( P <0.0001), chemotherapy in combination with radiotherapy ( P = 0.0136), lymph node irradiation ( P = 0.0006) and heat exposure ( P = 0.0355). Changes in symmetry by radiotherapy were greater for lymph node-irradiated patients ( P <0.0001).

Conclusions

With larger tumor size, lymph node irradiation, and chemotherapy in combination with radiotherapy, heat exposure was found to have a negative impact on cosmesis in patients undergoing conservative treatment for breast cancer. Patients should therefore be advised to avoid heat exposure after breast irradiation.

Oncoplastic breast conserving surgery: Volume replacement vs. volume displacement

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Long-term outcome of breast cancer patients treated with radiofrequency ablation

BACKGROUND

Radiofrequency ablation (RFA) is considered to be the most promising non-surgical ablation technique for the treatment of small breast cancer. However, few data are available regarding long-term follow-up of patients treated with this modality.

METHODS

Since 2005, we have performed RFA and sentinel lymph node (SLN) biopsy in 19 cases. Axillary lymph node dissection (ALND) was performed in patients with positive SLNs. From 24 to 202 days after RFA, the ablated tumour tissue was excised by mammotome biopsy and examined histologically or immunohistochemically with H&E staining, nicotinamide adenine dinucleotide (NADH)-diaphorase staining, and single-stranded (ss) DNA staining. All cases were followed-up after breast radiation and systemic therapies.

RESULTS

Although complete response was histologically confirmed in only 8 cases, NADH-diaphorase and ssDNA staining did not demonstrate any viable tumour cells in the ablated lesions. At a mean follow-up of 60 months (follow-up range, 37-82 months), there were no cases of in-breast recurrence, although one patient died due to hepatic metastases. Cosmesis of the conserved breast was excellent or good in all of the cases, but a hard lump was persistent after RFA in half of the cases.

CONCLUSIONS

The long-term outcome of patients treated with RFA is encouraging with regard to cosmesis and local control. Because a persisted lump may cause patient discomfort, anxiety and fear, however, further studies are needed to establish the optimal technique. Moreover, a prospective study will be required to determine the equivalency in local recurrence rates between the RFA therapy and conventional breast-conserving treatment.

Oncological and cosmetic outcome in breast cancer patients undergoing "moving window" operation

An inappropriate skin incision on the breast reduces the cosmetic benefit of breast-conserving surgery (BCS). To improve the cosmetic outcome, we have performed "moving window" operation in which BCS can be performed via a periareolar incision (periareolar approach) and/or axillary incision (axillary approach) under direct visualization. Axillary lymph node dissection is also performed via an axillary incision. The periareolar and axillary approaches were used in 65 and 43 patients, respectively. Average operation time was 130 min in periareolar approach and 131 min in axillary approach. Average blood loss was 37 and 50 ml, respectively. Postoperatively, the surgical margin of breast tissue was histologically confirmed to be negative in 107 (99%) of 108 patients, one patients underwent subsequently reoperation because of positive surgical margin. Fifty-two patients (85%) in periareolar approach and 37 patients (86%) in axillary approach had excellent or good cosmetic results. With a mean follow-up of 36 months, four patients developed in-breast recurrence, but three of them had neoadjuvant chemotherapy before surgery. The moving window operation can improve cosmetic outcome of BCS without compromising oncological safety. Moreover, it can reduce operation time and blood loss in comparison to endoscope-assisted BCS.

Radiotherapy breast boost with reduced whole-breast dose is associated with improved cosmesis: the results of a comprehensive assessment from the St. George and Wollongong randomized breast boost trial

PURPOSE

To evaluate comprehensively the effect of a radiotherapy boost on breast cosmetic outcomes after 5 years in patients treated with breast-conserving surgery.

METHODS

The St. George and Wollongong trial (NCT00138814) randomized 688 patients with histologically proven Tis-2, N 0-1, M0 carcinoma to the control arm of 50 Gy in 25 fractions (342 patients) and the boost arm of 45 Gy in 25 fractions to the whole breast followed by a 16 Gy in 8 fraction electron boost (346 patients). Five-year cosmetic outcomes were assessed by a panel subjectively in 385 patients and objectively using pBRA (relative breast retraction assessment). A subset of patients also had absolute BRA measurements. Clinician assessment and patient self-assessment of overall cosmetic and specific items as well as computer BCCT.core analysis were also performed.

RESULTS

The boost arm had improved cosmetic overall outcomes as scored by the panel and BCCT.core software with 79% (p = 0.016) and 81% (p = 0.004) excellent/good cosmesis respectively compared with 68% in no-boost arm. The boost arm also had lower pBRA and BRA values with a mean difference of 0.60 and 1.82 mm, respectively, but was not statistically significant. There was a very high proportion of overall excellent/good cosmetic outcome in 95% and 93% in the boost and no-boost arms using patient self-assessment. However, no difference in overall and specific items scored by clinician assessment and patient self-assessment was found.

CONCLUSION

The results show the negative cosmetic effect of a 16-Gy boost is offset by a lower whole-breast dose of 45 Gy.

Effect of adjuvant systemic treatment on cosmetic outcome and late normal-tissue reactions after breast conservation

To investigate whether adjuvant treatment with CMF or tamoxifen predisposes to an unfavorable cosmetic outcome or increased breast morbidity after radiotherapy in breast conservation. Data from 266 patients who entered a randomized breast conservation trial (DBCG-82TM protocol) was analyzed. The patients were treated with lumpectomy and axillary dissection followed by external beam radiotherapy to the residual breast. High-risk patients (n = 94), as well as 31 low-risk patients, received additional radiation to the regional lymph nodes. Adjuvant systemic treatment was given to all high-risk patients: premenopausal patients (n = 67) received eight cycles of CMF intravenously (600/40/600 mg per m2) every fourth week; postmenopausal patients (n = 27) received 30 mg of tamoxifen daily for one year. Clinical assessments included cosmetic outcome, breast fibrosis, skin telangiectasia, and dyspigmentation which were scored on a 4-point categorical scale after median 6.6 years. The observations were analyzed in multivariate logistic regression analysis which included potential risk factors on outcome related to systemic treatment, surgery, radiation technique, tumor, and patient characteristics. In premenopausal patients, systemic treatment with CMF independently predicted a fair/poor cosmetic outcome, RR = 2.2 (95% CI 1.2-4.2), as well as increased skin telangiectasia, RR = 3.3 (1.4-8.2). There was no impact of tamoxifen treatment on cosmetic outcome in postmenopausal patients (p = 0.32). However, univariate analysis showed that tamoxifen was significantly associated with breast fibrosis (p < 0.004), as was radiation to the regional lymph nodes (p < 0.0001). A strong interaction between axillary irradiation and tamoxifen treatment occurred since 26 of 27 high-risk postmenopausal patients had received both tamoxifen and axillary irradiation. In multivariate regression analysis, axillary irradiation independently predicted moderate/severe breast fibrosis with a relative risk of 5.0 (2.0-12.5) and 9.6 (3.3-27.7) in premenopausal and postmenopausal patients, respectively. To circumvent the strong interaction between tamoxifen treatment and axillary irradiation, a subsequent analysis omitting axillary treatment from the multivariate regression showed a significant effect of both tamoxifen and CMF on the occurrence of breast fibrosis with relative risks of 5.3 (CI 1.8-15.8) and 4.4 (1.8-10.3), respectively. Adjuvant systemic treatment with CMF given sequentially to radiotherapy independently predicted an adverse cosmetic outcome as well as increased skin telangiectasia after breast conserving treatment. Due to a strong interaction between tamoxifen administration and radiation to the regional lymph nodes, the effect of tamoxifen on the development of fibrosis could not be fully discerned in this study. Axillary irradiation increased the incidence of moderate to severe breast fibrosis in both premenopausal and postmenopausal patients.

Oncoplastic breast surgery: a review and systematic approach

Oncoplastic breast surgery (OBS) is relatively new, but has made rapid progress from its tentative steps of infancy in the 1990s. The recent Milanese Consensus Conference on Breast Conservation concluded that, firstly, oncoplastic techniques are warranted to allow wide excision and clear margins without compromising cosmesis. Secondly, such surgery is ideally performed at the same time as oncological excision. Whilst technically more challenging than standard breast conserving therapy (BCT), OBS is well proven, if not yet widely practised, both oncologically and aesthetically and a review of the available techniques is perhaps timely. The roots of breast conserving therapy can be traced to the 1930s, actually due to advances made in radiotherapy, and the last 20 years have seen it become firmly established. This review aims to summarise the key historical developments and latest innovations in OBS. Not only are our patients, who expect not only safe cancer treatment but a satisfactory aesthetic outcome, increasingly informed and demanding, but longer follow up has stimulated surgeons to improve outcomes. In many cases, particularly with ptosis and macromastia, the cancer can be treated, usually with wider excision margins, simultaneously improving the aesthetic appearance. Present at the birth of OBS, the Institut Curie has continued to introduce innovative techniques over the last two decades and a systematic approach, comprising nine basic techniques, has evolved to allow high quality treatment of any and all breast cancers suitable for OBS.

Prognosis of the upper limb following surgery and radiation for breast cancer

The aim of this systematic review was to identify the prevalence and severity of upper limb problems following surgery and radiation for early breast cancer. Additionally, the independent prognostic contribution of radiation, type of breast surgery, type of axillary surgery, age and body mass index (BMI) was evaluated. Searches of electronic databases were conducted to identify articles that reported upper limb and quality of life outcomes after breast cancer surgery and external radiation. Eligible studies for prognosis were longitudinal in design, with > or =95% of patients treated by surgery and radiation that excluded the axilla. Cross-sectional studies were also included for identification of prognostic factors. Where possible, the contribution of independent prognostic factors was analyzed. The review identified 32 relevant studies. Shoulder restriction was reported in between <1% and 67% of participants, lymphedema was reported in between 0 and 34% of participants, shoulder/arm pain was reported in between 9 and 68% of participants and arm weakness was reported in between 9 and 28% of participants. Quality of life was high across studies. Irradiated patients had slightly increased odds of lymphedema (OR = 1.46, 95% CI 1.16-1.84) and shoulder restriction (OR = 1.67, 95% CI 0.98-2.86) compared with non-irradiated patients. For patients undergoing surgery and radiation for breast cancer, the prognosis is good in terms of the upper limb and quality of life. Radiation that excludes the axilla does not appear to be a strong prognostic indicator of adverse upper limb outcomes.

Does Concurrent Radiochemotherapy Affect Cosmetic Results in the Adjuvant Setting After Breast-Conserving Surgery? Results of the ARCOSEIN Multicenter, Phase III Study: Patients’ and Doctors’ Views

PURPOSE

To evaluate the cosmetic results of sequential vs. concurrent adjuvant chemotherapy with radiotherapy after breast-conserving surgery for breast cancer, and to compare ratings by patients and physicians.

METHODS AND MATERIALS

From 1996 to 2000, 716 patients with Stage I-II breast cancers were included in a multicenter, Phase III trial (the ARCOSEIN study) comparing, after breast-conserving surgery with axillary dissection, sequential treatment with chemotherapy first followed by radiotherapy vs. chemotherapy administered concurrently with radiotherapy. Cosmetic results with regard to both the overall aspect of the breast and specific changes (color, scar) were evaluated in a total of 214 patients (107 in each arm) by means of questionnaires to both the patient and a physician whose rating was blinded to treatment allocation.

RESULTS

Patients' overall satisfaction with cosmesis was not statistically different between the two arms, with approximately 92% with at least satisfactory results (p = 0.72), although differences between the treated and untreated breasts were greater after the concurrent regimen (29% vs. 14% with more than moderate differences; p = 0.0015). Physician assessment of overall cosmesis was less favorable, with lower rates of at least satisfactory results in the concurrent arm (60% vs. 85%; p = 0.001). Consequently, the concordance for overall satisfaction with cosmesis between patients and doctors was only fair (kappa = 0.62).

CONCLUSION

After breast-conserving surgery, the concurrent use of chemotherapy with radiotherapy is significantly associated with greater differences between the breasts. These differences do not translate into patients' lessened satisfaction with cosmesis.

Inverse planning of energy-modulated electron beams in radiotherapy

The use of megavoltage electron beams often poses a clinical challenge in that the planning target volume (PTV) is anterior to other radiosensitive structures and has variable depth. To ensure that skin as well as the deepest extent of the PTV receives the prescribed dose entails prescribing to a point beyond the depth of peak dose for a single electron energy. This causes dose inhomogeneities and heightened potential for tissue fibrosis, scarring, and possible soft tissue necrosis. Use of bolus on the skin improves the entrant dose at the cost of decreasing the therapeutic depth that can be treated. Selection of a higher energy to improve dose homogeneity results in increased dose to structures beyond the PTV, as well as enlargement of the volume receiving heightened dose. Measured electron data from a linear accelerator was used as input to create an inverse planning tool employing energy and intensity modulation using bolus (e-IMRT). Using tools readily available in a radiotherapy department, the applications of energy and intensity modulation on the central axis makes it possible to remove hot spots of 115% or more over the depths clinically encountered. The e-IMRT algorithm enables the development of patient-specific dose distributions with user-defined positions of peak dose, range, and reduced dose to points beyond the prescription point.

Cosmetic outcomes following breast conservation therapy: in search of a reliable scale

INTRODUCTION

Multiple scales to evaluate breast cosmesis following breast conserving treatment (BCT) have been developed, however reliability is a problem. Panel scores, where scores from two or more individuals are combined, were assessed to examine their effect on reliability for two different cosmetic scales.

METHODS

Women, two or more years following BCT, were recruited from a single breast centre. Photographs of each participant were evaluated independently by six health care professionals on two separate occasions. A simple four-point scale and more involved multi-item scale were used to assess cosmetic outcome. Reliability was assessed with the weighted kappa statistic for increasing panel sizes.

RESULTS

Ninety-nine women were evaluated. Intra rater reliability increased from 0.73 to 0.83 for the four-point scale, for increasing panel sizes, however 95% confidence intervals generally overlapped. A smaller and more unpredictable effect was seen on the multi-item subscale, range 0.69 to 0.73. Inter rater reliability increased from 0.68 to 0.93 for the four-point scale, and 0.75 to 0.96 for the multi-item scale, for increasing panel sizes; 95% confidence intervals did not overlap. A panel of three for either scale provided almost perfect kappa values with only small improvements with larger panel sizes.

CONCLUSIONS

Care should be used in interpreting results where cosmetic outcomes have been obtained from a single evaluator. Panel scores can be used to significantly improve inter-rater, but not intra rater reliability, for the scales studied. Comparable reliability, in combination with simplicity of use and interpretation, would favour the four-point scale for breast cosmetic evaluation over the multi-item scale.

Determining the optimal approach to breast reconstruction after partial mastectomy

BACKGROUND

Unfortunately, patients who desire repair of contour deformities after partial mastectomy usually present after radiation therapy, which may increase the risk of complications and result in a poor aesthetic outcome. The authors reviewed their experience with repair of partial mastectomy defects to determine the optimal approach to breast reconstruction after partial mastectomy.

METHODS

Sixty-nine patients who underwent repair of a partial mastectomy defect and received radiation therapy were included in this analysis. The reconstructive techniques were categorized as local tissue rearrangement (LTR), breast reduction, or use of a latissimus dorsi myocutaneous flap or thoracoepigastric skin flap (hereafter referred to as "flap").

RESULTS

Fifty patients underwent immediate reconstruction before radiation therapy, and 19 underwent delayed reconstruction after radiation therapy. The reconstructive techniques in patients with immediate reconstruction were local tissue rearrangement in 28 percent, breast reduction in 66 percent, and flaps in 6 percent. In patients with delayed reconstruction, 32 percent had local tissue rearrangement, 42 percent had breast reduction, and 26 percent had flaps. The complication rates for immediate and delayed reconstruction were 26 percent and 42 percent, respectively. Overall, and in the setting of immediate reconstruction, the flap technique was associated with a higher complication rate than local tissue rearrangement and breast reduction. However, in the setting of delayed reconstruction, the flap technique was associated with a lower complication rate than the other two techniques. Fifty-seven percent of the immediate reconstructions performed with the local tissue rearrangement or breast reduction technique, but only 33 percent of the immediate reconstructions performed with the flap technique, were associated with an excellent or good aesthetic outcome.

CONCLUSION

Immediate repair of partial mastectomy defects with local tissues results in a lower risk of complications and better aesthetic outcomes than immediate repair of partial mastectomy defects with a latissimus dorsi flap.

A cosmetic evaluation of breast cancer treatment: A randomized study of radiotherapy boost technique

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 6-month basis, with a final evaluation at 36 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 self-assessment 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 follow-up, 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, concomitant 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 quadrant 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.

Modelling ordinal relations with SVMs: An application to objective aesthetic evaluation of breast cancer conservative treatment

The cosmetic result is an important endpoint for breast cancer conservative treatment (BCCT), but the verification of this outcome remains without a standard. Objective assessment methods are preferred to overcome the drawbacks of subjective evaluation. In this paper a novel algorithm is proposed, based on support vector machines, for the classification of ordinal categorical data. This classifier is then applied as a new methodology for the objective assessment of the aesthetic result of BCCT. Based on the new classifier, a semi-objective score for quantification of the aesthetic results of BCCT was developed, allowing the discrimination of patients into four classes.

Irradiation et chimiothérapie concomitante après chirurgie pour cancer du sein

In breast cancer, radiation therapy improves local control rate and survival. When chemotherapy and radiation are indicated the sequencing of the two treatments is still controversial. Several studies have suggested that adjuvant radiotherapy could be safely delayed until adjuvant chemotherapy was completed. Other studies, most of them retrospective, pointed out that a delay in the initiation of radiotherapy to give chemotherapy first, will result in a increased rate of local recurrence. Concomitant administration of the two treatments is an alternative. Pilot studies have suggested the feasibility of simultaneous administration using selected regimen as CMF or FNC. A randomized phase III trials has been conducted to compare sequential treatment with chemotherapy first and radiation versus concomitant treatments. Preliminary results of this study are presented.

A prospective study of concurrent cyclophosphamide/methotrexate/5-fluorouracil and reduced-dose radiotherapy in patients with early-stage breast carcinoma

BACKGROUND

Concurrent administration of chemotherapy and radiotherapy has the potential advantage of delaying neither treatment and providing radiation sensitization. However, the optimal approach to concurrent treatment in women with early-stage breast carcinoma remains undefined. We present updated results of a prospective protocol of concurrent cyclophosphamide/methotrexate/5-fluorouracil (CMF) and reduced-dose radiotherapy, focusing on tumor control and patient tolerance.

METHODS

One hundred twelve women with AJCC Stage I or Stage II breast carcinoma with 0-3 positive axillary lymph nodes were enrolled in a prospective single-arm study of concurrent CMF and reduced-dose radiotherapy (39.6 gray [Gy] to the whole breast, 16-Gy boost). A high proportion of women had risk factors associated with an increased risk of local disease recurrence, including age <40 (32%), close or positive margins (37%), or lymphatic/vascular invasion (51%). The median follow-up period was 94 months.

RESULTS

The 5-year overall survival rate was 94%. By 60 months, 5 patients (4%) experienced local disease recurrence and 19 patients (17%) experienced distant metastasis. There were no isolated regional lymph node recurrences. Local disease recurrence occurred in 1 of 25 patients (4%), 1 of 16 patients (6%), and 3 of 70 patients (4%) with positive, close (<1 mm), and negative margins, respectively. One patient developed acute myelogenous leukemia. An additional patient developed Grade 2 pneumonitis. Cosmetic results were not recorded uniformly for all patients and therefore could not be reliably analyzed.

CONCLUSIONS

Concurrent CMF and reduced-dose radiotherapy resulted in a low level of late toxicity and excellent local tumor control, despite the large proportion of patients with substantial risk factors for local disease recurrence. Future studies of concurrent regimens, particularly in patients at high risk of local disease recurrence, are warranted.

Individual radiosensitivity measured with lymphocytes may be used to predict the risk of fibrosis after radiotherapy for breast cancer

BACKGROUND AND PURPOSE

To analyse the relationship of individual cellular radiosensitivity and fibrosis after breast conserving therapy. A new model was used describing the percentage of patients developing fibrosis per year and per patient at risk.

PATIENTS AND METHODS

In a retrospective study, 86 patients were included, who had undergone breast conserving surgery and irradiation of the breast with a median dose of 55 Gy (54-55 Gy) given at 2.5 Gy/fraction (n=57) or 2 Gy/fraction (n=29). Median age was 62 years (range 44-86) and median follow-up was 7.5 years (range 5-17). Patients were examined for fibrosis according to the LENT/SOMA score. For analysis, fibrosis was classified as grade 0 and grade 1 (G0-1) or present grade 2 and grade 3 (G2-3). The time to complete development of fibrosis was determined by analysis of yearly mammograms. Individual cellular radiosensitivity was determined by scoring lethal chromosomal aberrations in in vitro irradiated (6 Gy) lymphocytes using metaphase technique. Patients with low/intermediate cellular radiosensitivity were compared with patients with high cellular radiosensitivity using actuarial methods.

RESULTS

Ten patients developed fibrosis at 1-8 years after radiotherapy. Individual cellular radiosensitivity was described by normal distribution of lethal chromosomal aberrations, the average was 5.47 lethal aberrations per cell (standard deviation (SD) 0.71). Cellular radiosensitivity was defined as low/intermediate (< or =6.18 lethal aberrations) in 73 patients and high (>6.18 lethal aberrations; mean+SD) in 13 patients. In both groups, the actuarial rate of fibrosis-free patients decreased exponentially with time after radiotherapy. Patients with high cellular radiosensitivity showed a 2.3-fold higher annual rate for fibrosis than patients with intermediate and low radiosensitivity (3.6 versus 1.6% per year).

CONCLUSIONS

In breast cancer patients, high individual cellular radiosensitivity as determined by the number of lethal chromosome aberrations in in vitro irradiated lymphocytes might be associated with an enhanced annual rate of fibrosis.

Cosmesis from the patient's and the doctor's view

PURPOSE

Long-term cosmesis from the patient's perspective is compared to the doctor's appraisal. Factors that determine judgment of cosmesis are analyzed. Also, a patient questionnaire was designed to screen for normal tissue reactions and is evaluated.

METHODS AND PATIENTS

With structured questions, patients rated their satisfaction considering cosmesis, the difference in overall appearance, and specific changes of the breast. Two doctors rated cosmesis and radiation late effects (LENT/SOMA). Ratings were compared, and the relative impact of single items was studied. Two hundred eighty-seven patients with unilateral breast carcinoma were examined after a median follow-up of 8 years. They were treated between 1981 and 1995 with lumpectomy and radiotherapy of the breast with 1.8-2.5 Gy fractions with a median total dose of 55 Gy (range: 50-65 Gy).

RESULTS

One hundred sixty-one patients rated cosmesis as satisfying, 73 patients rated it as acceptable, and 25 patients as poor. Eighty-nine patients noted severe changes of appearance. Severe firmness and extensive scars were the most frequent complaint; the most important single item for judging cosmesis as poor was highly visible scars. Generally, doctors rated cosmesis less favorably (satisfactory, 150 patients; poor, 43 patients). Severe fibrosis was more important than discoloration of the breast or scars. Correlation between patients' and doctors' rating of cosmesis was modest (Cohen's weighted kappa 0.29), whereas the doctor's rating correlated well (0.55). Specificity and sensitivity of the questionnaire item for severe fibrosis (using doctors' judgments as gold standard) was 0.8; Cohen's weighted kappa was 0.34 (95% confidence interval: 0.21-0.48).

CONCLUSION

Rating of cosmesis is subjective. Patients' satisfaction with cosmesis is greater than the doctors' and is determined not only by radiation late effects, but also by factors unrelated to the appearance of the breast. Severe fibrosis may be detected by a patient questionnaire.

Integration of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery

There is no consensus on the optimal combination of systemic therapy and radiation therapy for patients with early-stage breast cancer treated with conservative surgery. This article reviews prospective and retrospective studies that shed light on this topic. Patients with positive, close, or unknown microscopic margins appear to benefit from relatively early initiation of radiation therapy, whereas those with wider tumor-free margin widths do not. For patients at high risk of distant failure (such as those with = 4 positive axillary nodes), chemotherapy may be more effective when it begins before radiation therapy rather than after. Regimens of concurrent radiation therapy and chemotherapy tend to have higher acute and subacute complication rates than sequential regimens, but the actual rates vary substantially with the exact details of the overall treatment program. There are no data on the impact of the timing of tamoxifen administration on the effectiveness of radiation therapy. Tamoxifen does not appear to increase complication rates relative to the use of radiation therapy alone. Thus, the best way of giving combined-modality therapy is uncertain. Further retrospective and prospective studies to investigate the issues discussed herein should be performed.

Long-term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-SOMA scoring system

PURPOSE

To evaluate the long-term toxicity after breast-conserving therapy in women with early-stage breast cancer.

METHODS AND MATERIALS

Late toxicity according to the late effects of normal tissue-subjective, objective, management, and analytic (LENT-SOMA) criteria and cosmetic outcome (graded by physicians) were evaluated in 590 of 2943 women with early-stage breast cancer who were irradiated between 1983 and 1995 using the following fractionation schedules: group A, 1983-1987, 2.5 Gy 4x/wk to 60 Gy; group B, 1988-1993, 2.5 Gy 4x/wk to 55 Gy, group C, 1994-1995, 2.0 Gy 5x/wk to 55 Gy.

RESULTS

LENT-SOMA Grade 3-4 toxicity was observed as follows: group A (median follow-up 171 months; range 154-222 months), fibrosis 16% (7 of 45), telangiectasia 18% (8 of 45), and atrophy 4% (2 of 45); group B (median follow-up 113 months; range 78-164 months), pain 2% (8 of 345), fibrosis 10% (34 of 345), telangiectasia 10% (33 of 345), arm edema 1% (2 of 345), and atrophy 8% (27 of 345); and group C (median follow-up 75 months, range 51-96 months, n = 200), occurrence of Grade 3-4 late morbidity <or=2%. The cosmetic outcome was very good to acceptable in 78% (35 of 45) of patients in group A, 83% (286 of 345) in group B, and 94% (187 of 200) in group C.

CONCLUSION

In our population, the long-term side effects after breast-conserving therapy were not rare, but were mainly asymptomatic. The LENT-SOMA breast module is a practical tool to assess radiation-induced long-term toxicity.

The impact of dose-specification policies upon nominal radiation dose received by breast tissue in the conservation treatment of breast cancer

PURPOSE

In the context of breast conservation treatment, absorbed dose is influenced by (1) prescribed nominal dose, and (2) dose-specification characteristics employed. Breast doses are generally specified either at tangent isocenter, varying anatomical points within the breast, or at isodoses varying from 90% to 100%. Boost doses are generally specified at 80-100%.

METHODS

An idealized axial slice of breast tissue at central axis is presented. Assuming varying dose-specification characteristics, absorbed doses are normalized and compared to those received by nominal prescriptions of 46 Gy to the breast and 20 Gy to the boost volume, both specified at 100%.

RESULTS

Absorbed doses vary from the normalized total of 66 Gy (with specification of breast and boost at 100%) in gradations up to a maximum of 76.11 Gy (when breast dose is specified at the 90% isodose and boost dose at 80%), a 13.3% difference.

CONCLUSION

The impact of dose specification is largely ignored in the breast irradiation literature and unappreciated in clinical practice. Its impact, however, is illustrated as dwarfing modest nominal dose escalations commonly recommended and prescribed among margin compromised patients. Progress in delineation of a dose-response relationship for treatment of breast cancer requires consensus as to dose specification. Arguments are offered that ICRU Report 50 dose-specification standards, as verified for reproducibility by the EORTC (22881/10882) trial group, constitutes the best data source currently available from which dose-specification consensus may be reached (1, 2). Dose to PTV(1) (whole breast plus 1- to 2-cm margin) should be specified at the tangent beam intersection on the central plane or, where such point is irrelevant, at two-thirds distance from dorsal beam edge to skin along the perpendicular breast bisector. Where irradiated via electrons, dose to the boost PTV(2) (lumpectomy cavity plus 1- to 3-cm margins) should be specified at 90%. Electron energy sufficient to provide 85% isodose coverage to all aspects of PTV(2) is recommended.

Validation of the methods of cosmetic assessment after breast-conserving therapy in the EORTC "boost versus no boost" trial. EORTC Radiotherapy and Breast Cancer Cooperative Groups. European Organization for Research and Treatment of Cancer

PURPOSE

To evaluate both qualitative and quantitative scoring methods for the cosmetic result after breast-conserving therapy (BCT), and to compare the usefulness and reliability of these methods.

METHODS AND MATERIALS

In EORTC trial 22881/10882, stage I and II breast cancer patients were treated with tumorectomy and axillary dissection. A total of 5318 patients were randomized between no boost and a boost of 16 Gy following whole-breast irradiation of 50 Gy. The cosmetic result was assessed for 731 patients in two ways. A panel scored the qualitative appearance of the breast using photographs taken after surgery and 3 years later. Digitizer measurements of the displacement of the nipple were also made using these photographs in order to calculate the breast retraction assessment (BRA). The cosmetic results after 3-year follow-up were used to analyze the correlation between the panel evaluation and digitizer measurements.

RESULTS

For the panel evaluation the intraobserver agreement for the global cosmetic score as measured by the simple Kappa statistic was 0.42, considered moderate agreement. The multiple Kappa statistic for interobserver agreement for the global cosmetic score was 0.28, considered fair agreement. The specific cosmetic items scored by the panel were all significantly related to the global cosmetic score; breast size and shape influenced the global score most. For the digitizer measurements, the standard deviation from the average value of 30.0 mm was 2.3 mm (7.7%) for the intraobserver variability and 2.6 mm (8.7%) for the interobserver variability. The two methods were significantly, though moderately, correlated; some items scored by the panel were only correlated to the digitizer measurements if the tumor was not located in the inferior quadrant of the breast.

CONCLUSIONS

The intra- and interobserver variability of the digitizer evaluation of cosmesis was smaller than that of the panel evaluation. However, there are some treatment sequelae, such as disturbing scars and skin changes, that can not be evaluated by BRA measurements. Therefore, the methods of cosmetic evaluation used in a study must be chosen in a way that balances reliability and comprehensiveness.

An approach to the repair of partial mastectomy defects

In many cases, breast deformity caused by partial mastectomy can be reduced or corrected by plastic surgery. Partial breast reconstruction is best performed immediately after the partial mastectomy using an approach determined by the size of the breast and the defect. Small defects in large breasts usually need no reconstruction. For larger defects in large breasts, breast reshaping (similar to reduction mammaplasty) combined with a contralateral breast reduction is usually the best option. For medium-sized or smaller breasts with small to moderate-sized defects, local flaps from the subaxillary region are very useful. If the defect is too large for correction with local tissue, a latissimus dorsi myocutaneous flap is usually the best choice. Using these techniques, patients can achieve aesthetically better outcomes from breast-conservation therapy, even when larger tumors are being treated or when wider margins are taken to reduce the risk of tumor recurrence. By working together with an oncologic surgeon and facilitating the removal of larger tumors, the plastic surgeon can widen the indications for both breast-conservation therapy and breast reconstruction at the same time.

[Radiation and concomitant chemotherapy after surgery for breast cancer: Arcosein study ]

In breast cancer postoperative radiation therapy improves local control rate and survival. When chemotherapy and radiation are indicated, the sequencing of the two treatments is still controversial. Several studies have suggested that adjuvant radiotherapy could be safely delayed until adjuvant chemotherapy was completed. Other studies, most of them retrospective, pointed out that a delay in the initiation of radiotherapy in order to give chemotherapy first may result in an increased rate of local recurrence. Concomitant administration of the two treatments is an attractive alternative. Pilot studies have demonstrated its feasibility. A randomised phase III trial is presently in progress, comparing sequential treatment with chemotherapy first followed by irradiation and radiation versus concomitant treatment. Four-hundred and five patients have been included in 24 months. Toxicity and compliance to the treatment are reported in this evaluation.

Expanding the Role of Breast-Cancerving Therapy Using Immediate Volume Replacement

Preventing local recurrence and preserving cosmetic appearance are often in conflict in breast-conserving therapy. Immediate volume replacement with autogenous tissue has been developed to allow a wider excision without compromising the aesthetic results. A review of the literature regarding immediate volume replacement in breast-conserving therapy has led to the following conclusions. When excision of the skin overlying the tumor is unnecessary, a transverse or lateral incision should be used which allows wide excision and immediate volume replacement with autogenous tissue while minimizing scar morbidity. The options for immediate volume replacement include the latissimus dorsi flap with adipose tissue, the latissimus dorsi myocutaneous flap, and the lateral thoracic adipose tissue flap. The choice of technique depends on the amount and position of the skin, subcutaneous tissue, and breast tissue which must be excised. These procedures can be used to extend the indications for breast-conserving therapy, eliminating the need for mastectomy in selected patients. Future developments in the endoscopic harvesting of flaps may further expand the role of volume replacement.

[Cosmetic results of breast conserving therapy for breast carcinoma. Treatment results from the Heidelberg Radiation Clinic in the years 1984 to 1992]

PURPOSE

In this study we retrospectively analyzed local control, survival rate and late cosmetic results of women with early breast cancer receiving breast conserving therapy.

PATIENTS AND METHODS

All patients (1984 through 1992) of the Department of Radio-Oncology (University of Heidelberg), who received breast conserving therapy consisting of conservative surgery followed by radiotherapy, were interviewed and asked to come. Subjective estimation of the cosmetic results of therapy was evaluated by means of a questionnaire. Cosmesis, circumferences and temperatures of different mammary regions were assessed and measured. Side effects and late sequelae were valued by the EORTC/RTOG-score.

RESULTS

Mean follow-up time of 192 women (pT1: 71.9%, pT2: 28.1%) was 4.5 years (median: 4.0 years). 26.6% of them were nodal positive. Positive nodal status correlated with high tumor grading (p = 0.0001). Ten patients developed distant metastases; one of them subsequent to having suffered a loco-regional failure. Eight loco-regional failures occurred, 3 of them before radiotherapy (salvage). Following radiotherapy altogether 5 loco-regional failures (= 2.6%) were found; 3 women concerning were pre-, 2 postmenopausal. Three of these patients died, in 1 case occurred distant metastasis. Seventeen patients died, 3 of them presenting loco-regional failure, 8 of them showing distant metastasis. Sixty-four women were examined for cosmesis with the following result: a poor result was observed twice, a fair result 13 times, a good result 34 and an excellent result 15 times. Self-assessment was significantly better than observer's assessment. Third-degree late sequelae were found once, second-degree was seen 11 times, first-degree 38 times and no visible late sequelae were observed 14 times. The use of wedges was followed with borderline significance (p = 0.06) either by a better cosmesis and fewer late sequelae. Neither the type of surgery nor the width of the fields nor the quality of radiation (Co60 or 6 MVX) nor boost-application influenced the cosmetic result. Measured circumferences and distances showed no significant differences in the groups of the patients with poor or fair and good or excellent cosmesis. The temperature of the seized and contralateral breast showed no significant difference as well. With increasing distance from primary therapy the cosmetic results deteriorated.

CONCLUSION

Breast conserving therapy consisting of conservative surgery followed by radiotherapy causes predominantly excellent to good cosmetic results combined with an acceptable amount of late side effects. The decreased rate of good and excellent cosmetic long-term results is biological interesting and requires further studies.

Consistency of patient- and doctor-assessed cosmetic outcome after conservative treatment of breast cancer

The cosmetic results of the breast (144 patients) were analysed after segmental resection and axillary dissection with or without postoperative radiotherapy for early low-risk breast cancers. Cosmetic results were assessed over time (3, 9, 18, 36, 48 months respectively) by the patient and by the physician. Patients rated the overall cosmetic result good or excellent in 92% of cases after 3 months. The proportion of good or excellent cosmetic results decreased over time and after four years 89% of patients classified themselves in this category, whereas the physician assessed the outcome as good or excellent in 91% of cases after 3 months and 75% after 4 years. The inter-observer consistency between physician and patient in assessing the cosmetic outcome was kappa = 0.42 at the beginning and decreased over time (kappa = 0.07 after 4 years). The intra-observer variation over time was kappa = 0.53 for the patient and kappa = 0.32 for the physician. Inter-observer consistency between patient and physician was moderate immediately following treatment but decreased over time. The feeling of satisfaction of the patient was relatively stable whereas the opinion of the physician became somewhat more critical over time. Therefore the intra-observer consistency over time was somewhat better for the patient than for the physician.

[Role of radiotherapy in the management of adenocarcinoma of the breast accessible to conservative surgery]

Standard treatment for limited stage adenocarcinoma of the breast includes lumpectomy (or a quadrantectomy), axillary node dissection, regional radiation therapy and, if the prognostic factors are unfavourable, chemotherapy and/or hormone therapy. This is supported by the results of American and European randomised trials. There have been many attempts at improving the modalities of conservative surgery and postoperative radiation therapy in order to maximize local control and minimize late sequellae. It is also likely that induction chemotherapy and external beam radiotherapy applied in selected cases increase the proportion of patients who can be offered conservative surgery.

Breast preservation in stage I and II carcinoma of the breast. The University of Chicago experience

BACKGROUND

Although breast conservation has received increased acceptance, there are still unresolved issues regarding local treatment techniques, such as the extent of surgery, in relation to the final margins of excision and the use of tumor bed boost radiation. The goal of this study was to determine the local control and breast preservation with particular emphasis on the importance of the final microscopic margins in patients receiving tumor bed boost therapy.

METHODS

The authors analyzed 869 cases of Stage I and II breast carcinoma in 852 women who were treated with breast-conserving surgery and radiation therapy between 1984 and 1994. The median follow-up was 43 months. Final microscopic margins were negative in 762 (88%), microscopically positive in 82 (9%), and unknown in 25 (3%) of the patients. Negative margins were defined as no tumor cells at the surgical margin. The patients were treated with external beam radiation therapy to the entire breast to a median dose of 46 Gray (Gy). A boost to the tumor bed was delivered to 863 (99%) of the patients. The median tumor bed dose was 60 Gy. A multivariate analysis of factors impacting on the local control and overall survival was performed. Variables introduced into the model included size, age, lymph node status, microscopic margins, nuclear grade, histologic grade, and estrogen and progesterone receptor status.

RESULTS

The actuarial 5-year local control rate was 97%. The median time to local failure was 32 months (range, 14-69 months). In multivariate analysis, the only significant factor affecting local control was the status of margins. In patients receiving boost radiation to the excision site, the local control rate at 5 years was 98% and 89%, respectively, if the margins were negative or positive (P < 0.01). This resulted in 5-year actuarial breast preservation rates of 98% and 92% (P = 0.03). In the patients in whom the margins of excision were microscopically positive, the local control rate was 91% if the total dose to the tumor bed was > 60 Gy compared with 76% for a dose < or = 60 Gy (P = 0.05). The 5-year actuarial overall survival rate was 89%. Approximately 94% of the women considered their cosmetic outcome good to excellent.

CONCLUSIONS

By obtaining microscopically negative margins and using tumor bed boost therapy, excellent local control, breast preservation, and cosmesis can be achieved. In patients with microscopically positive margins, an acceptable local control rate can be achieved if a tumor bed boost is given.

The effects of sequence and type of chemotherapy and radiation therapy on cosmesis and complications after breast conservation therapy

PURPOSE

Chemotherapy plays an increasingly important role in the treatment of both node-negative and node-positive breast cancer patients, but the optimal sequencing of chemotherapy and radiation therapy is not well established. The purpose of this study is to evaluate the interaction of sequence and type of chemotherapy and hormonal therapy given with radiation therapy on the cosmetic outcome and the incidence of complications of Stage I and II breast cancer patients treated with breast-conserving therapy.

METHODS AND MATERIALS

The records of 1053 Stage I and II breast cancer patients treated with curative intent with breast-conserving surgery, axillary dissection, and radiation therapy between 1977-1991 were reviewed. Median follow-up after treatment was 6.7 years. Two hundred fourteen patients received chemotherapy alone, 141 patients received hormonal therapy alone, 86 patients received both, and 612 patients received no adjuvant therapy. Patients who received chemotherapy +/- hormonal therapy were grouped according to sequence of chemotherapy: (a) concurrent = concurrent chemotherapy with radiation therapy followed by chemotherapy; (b) sequential = radiation followed by chemotherapy or chemotherapy followed by radiation; and (c) sandwich = chemotherapy followed by concurrent chemotherapy and radiation followed by chemotherapy. Compared to node negative patients, node-positive patients more commonly received chemotherapy (77 vs. 9%, p < 0.0001) and/or hormonal therapy (40 vs. 14%, p < 0.0001). Among patients who received chemotherapy, the majority (243 patients) received concurrent chemotherapy and radiation therapy with two cycles of cytoxan and 5-fluorouracil (5-FU) administered during radiation followed by six cycles of chemotherapy with cytoxan, 5-fluorouracil and either methotrexate (CMF) or doxorubicin(CAF). For analysis of cosmesis, patients included were relapse free with 3 years minimum follow-up.

RESULTS

The use of chemotherapy had an adverse effect on cosmetic outcome compared to no chemotherapy, which was of borderline significance at 3 years (92% excellent or good cosmetic outcome vs. 96% respectively, p = 0.057); however, cosmesis was not different at 5 years (91 vs. 93% respectively, p = 0.67). Cosmesis was not significantly different between patients treated sequentially and those treated concurrently (3 year: 87 vs. 93% respectively, p = 0.33), nor was it different between patients who received CMF vs. CAF (3 year: 92 vs. 93% respectively, p = 0.89). Hormonal therapy did not influence cosmetic outcome (p = 0.78). The incidence of Grade 4 or 5 arm edema (> or = 2 cm difference in arm circumference) was 2% without chemotherapy vs. 8% with chemotherapy (p = 0.00002). However, the incidence of arm edema was not affected by sequencing or type of chemotherapy (all p > or = 0.52). Patients treated sequentially had a 10% incidence of Grade 4 or 5 arm edema vs. 7% in the patients treated concurrently (p = 0.52). The incidence was 7 vs. 9% in patients treated with CMF vs. CAF (p = 0.73). The incidence of clinical pneumonitis and rib fracture was not influenced by use of chemotherapy, sequence of chemotherapy or use of hormonal therapy (all p > or = 0.06).

CONCLUSIONS

Chemotherapy can be given concurrently with radiation therapy in the treatment of Stage I and II breast cancer with breast-conserving therapy without seriously compromising cosmetic outcome or incidence of complications compared to patients receiving other sequences of chemotherapy. Hormonal therapy did not affect cosmesis or complications. The chemotherapeutic regimen of cytoxan and 5-FU concurrent with radiation therapy followed by more chemotherapy is one reasonable option for breast conservation therapy in patients requiring chemotherapy.

Mammography in the follow-up after breast-conserving treatment in cancer of the breast: suitability for mammographic interpretation, validity and interobserver variation

The aims of this study were to determine the suitability for radiographic interpretation, interobserver variability and validity of mammography after breast-conserving treatment. Initial and post-treatment mammograms of 100 consecutive patients treated between 1982 and 1987, with a minimal follow-up of 5 years, were independently selected for review by two radiologists. Mammograms were classified according to suitability for interpretation and radiological diagnosis based on the presence of characteristics of malignancy. The interobserver variability was expressed in kappa values, the validity in a receiver operating characteristic (ROC) plot. 534 post-treatment and 86 initial mammograms of 92 patients were obtained. Suitability for interpretation was not different from pre-treatment mammograms and was significantly associated with age, being better in the age group over 50 years. No association was observed between suitability for interpretation and treatment-related factors, even if irradiation was combined with concurrent chemotherapy. Reliability of conclusions regarding sensitivity and specificity in this study are limited due to the small number of events. Interobserver agreement concerning classification was moderate (weighted kappa = 0.49). ROC analysis showed an optimal decision threshold between the "uncertain" and "suspect" categories of malignancy, resulting in a sensitivity of 86% and a specificity of 98%. The appearance of new pathological microcalcifications with or without tumour mass seemed to be the most important characteristics of malignancy predicting local relapse. No clear alteration in suitability for interpretation was observed in the mammograms after breast-conserving treatment, even if irradiation was combined with concurrent chemotherapy. Mammography after breast conserving-treatment may be slightly less sensitive but is equally specific compared with mammography in the screening situation.

Organ and functional preservation in the management of breast cancer

Breast conservation surgery combined with radiation therapy has established itself as a good alternative to mastectomy for patients with stage I and II breast cancer. This method can also be used to treat patients with DCIS. Careful clinical, mammographic, and pathological evaluations are essential for appropriate selection of patients for breast conservation treatment. Particular attention must be paid to the application of skillful surgical and radiotherapeutic techniques in order to achieve satisfactory long-term control, survival, and cosmetic results. Adjuvant chemotherapy may be used when indicated. The integration of chemotherapy with radiation therapy may be sequential or concurrent, but the optimal method of integration has not yet been determined.