Breast Edema Research Articles

Feasibility of Accelerated Whole-Breast Radiation in the Treatment of Patients with Ductal Carcinoma In Situ of the Breast

Background We report the results of a prospective trial investigating the use of accelerated, hypofractionated whole-breast radiation therapy after breast-conservation surgery for ductal carcinoma in situ (DCIS). Patients and Methods A total of 59 patients with a median age of 54 years (range, 36-78 years) completed a phase I/II study of hypofractionated radiation therapy for treatment of DCIS. Eligibility criteria included patients with mammographically detected DCIS, status after segmental mastectomy with negative margins, and no residual calcifications. All patients were treated with external-beam radiation therapy without a boost, over 3 weeks, to a total dose of 42 Gy to the entire breast (2.8 Gy per fraction in 15 fractions). To optimally spare heart and lung, 34 of the 59 patients (57%) were treated in the prone position. Twenty-nine of 59 patients (49%) received adjuvant hormonal therapy. Results Overall, radiation therapy was well tolerated, with modest acute toxicity limited to grade 1 radiation dermatitis (76%), breast edema (17%), and fatigue (12%). With a median follow-up of 36 months, late toxicities included grade 1 hyperpigmentation changes (85%), induration (66%), asymmetry (64%), and breast fibrosis (17%), with 3 cases of grade 2 fibrosis and 1 case of grade 2 hyperpigmentation. Among the patients with ≥ 3 years of follow-up, cosmesis was scored as good to excellent in 21 patients (91%) and fair in 2 patients (9%). At the time of this report, no ipsilateral or contralateral breast recurrences have occurred. Conclusion These data demonstrate the feasibility of treating the whole breast for DCIS with a hypofractionated regimen, with modest acute and late toxicity.

Reliability of Bioimpedance Spectroscopy and Tonometry after Breast Conserving Cancer Treatment

Measuring the female breast, especially after breast cancer treatment, is problematic due to breast size, texture, and patient positioning. However, being able to accurately measure changes in the breast is important, as it may help in the earlier diagnosis and treatment of early breast edema and later lymphedema. 14 women who had undergone breast conserving surgery for breast cancer (> 12 months ago) were recruited to assess the between subject reproducibility of tonometry and bioimpedance spectroscopy (BIS). With the participant supine, two repeat measurements of the resistance of the tissues to compression (tonometry) and fluid levels (BIS) of the treated and normal breast were taken for each of the four quadrants of the breast. The between subject reproducibility for both measurement techniques was high, with covariance ranging from 1.29% to 3.25% for tonometry and 0.20-0.86% for BIS. The reliability of these two measurement techniques provides an opportunity for researchers and clinicians to easily quantify breast tissue and fluid changes which in turn may lead to the earlier diagnosis and targeted treatment of breast edema and lymphedema.

Unilateral pleural effusion associated with ipsilateral arm and breast oedema: a rare complication of brachiocephalic and SVC stenosis in association with an arteriovenous fistula.

Unilateral pleural effusion associated with ipsilateral arm and breast oedema: a rare complication of brachiocephalic and SVC stenosis in association with an arteriovenous fistula.

Venous Congestion of the Breast Mimicking Inflammatory Breast Cancer: Case Report and Review of Literature

Unilateral breast edema can be worrisome for inflammatory breast cancer. We review the literature and present a clinical case of a patient presenting with features concerning for inflammatory breast cancer, but in fact were the result of dialysis access related venous congestion of the breast.

The complexities of managing breast oedema

This article looks at the problems surrounding breast oedema and the complexities that surround this condition: the psychological impact, the distress that it causes, and the absolute need for appropriate referral to a specialist centre when it is diagnosed. There is a case study within this article which clearly identifies how painful the condition is, and how after conservative intervention, the patient feels relief and can resume living again.

Interim Cosmetic Results and Toxicity Using 3D Conformal External Beam Radiotherapy to Deliver Accelerated Partial Breast Irradiation in Patients With Early-Stage Breast Cancer Treated With Breast-Conserving Therapy

We present our ongoing clinical experience utilizing three-dimensional (3D)-conformal radiation therapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI) in patients with early-stage breast cancer treated with breast-conserving therapy. Ninety-one consecutive patients were treated with APBI using our previously reported 3D-CRT technique. The clinical target volume consisted of the lumpectomy cavity plus a 10- to 15 -mm margin. The prescribed dose was 34 or 38.5 Gy in 10 fractions given over 5 consecutive days. The median follow-up was 24 months. Twelve patients have been followed for > or =4 years, 20 for > or =3.5 years, 29 for >3.0 years, 33 for > or =2.5 years, and 46 for > or =2.0 years. No local recurrences developed. Cosmetic results were rated as good/excellent in 100% of evaluable patients at > or = 6 months (n = 47), 93% at 1 year (n = 43), 91% at 2 years (n = 21), and in 90% at > or =3 years (n = 10). Erythema, hyperpigmentation, breast edema, breast pain, telangiectasias, fibrosis, and fat necrosis were evaluated at 6, 24, and 36 months after treatment. All factors stabilized by 3 years posttreatment with grade I or II rates of 0%, 0%, 0%, 0%, 9%, 18%, and 9%, respectively. Only 2 patients (3%) developed grade III toxicity (breast pain), which resolved with time. Delivery of APBI with 3D-CRT resulted in minimal chronic (> or =6 months) toxicity to date with good/excellent cosmetic results. Additional follow-up is needed to assess the long-term efficacy of this form of APBI.

Differenzialdiagnose inflammatorisches Mammakarzinom: Brustödem nach Thrombose der V. brachiocephalica

Nicht immer ist eine unilaterale Rötung, Volumenzunahme, Überwärmung und Peau d'Orange der weiblichen Brust Ausdruck eines zugrunde liegenden inflammatorischen Mammakarzinoms. Wir stellen drei Fälle mit täuschend ähnlicher Klinik vor, bei denen sich ein Brustödem aufgrund einer vorgängigen venösen Thrombose in der Vena brachiocephalica entwickelte. Zweimal zeigte sich die Klinik bei Leukämiepatientinnen nach Chemotherapie und Knochenmarkstransplantation. Der dritte Fall fand sich bei einer Hämodialysepatientin mit arteriovenöser Fistel. Soweit wir die Literatur überblicken, präsentieren wir hier die ersten Fälle unilateraler Brustödeme mit Thrombosierung der Vena brachiocephalica als Komplikation nach zentraler Venenkathetereinlage bei Leukämiepatientinnen. Ein inflammatorisches Mammakarzinom konnte bei allen drei Patientinnen mittels klinischer Untersuchung, Bildgebung und Haut-/Brustbiopsie ausgeschlossen werden.

Hypofractionation for early breast cancer: First results of the UK standardization of breast radiotherapy (START) trials

LBA518 Background: The START Trials (ST-A and ST-B) test the hypothesis that breast cancer is as sensitive to fraction (Fr) size as late reacting normal tissues, with an a/β value of about 4Gy. Methods: The phase III randomised START Trials tested hypofractionated post-operative RT in women with completely excised invasive breast cancer (T1–3, N0–1, M0). Centres opted for either ST-A or ST-B. ST-A tested 50Gy in 25Fr (5 wks) vs 41.6Gy vs 39Gy, both in 13Fr (5 wks). ST-B tested 50Gy in 25Fr (5 wks) vs 40Gy in 15Fr (3 wks). Stratification was by centre, surgery and boost. The primary endpoint was local-regional (LR) relapse. Late normal tissue effects (NTE) were assessed by breast photographs, clinical examination and quality of life (QL) questionnaires. Survival analysis methods were used to estimate rates of relapse and NTEs, and hazard ratios (HR) (with 95%CI). Smoothed estimates of absolute differences in relapse rates were obtained from the rates in the 50Gy control arms and the HR. Results: 2236 (ST-A) and 2215 (ST-B) patients were recruited from 35 UK centres during 1999–2002. Median follow-up is 5.1 years (ST-A) and 6.0 years (ST-B). There were 93 LR relapses in ST-A (4.1% at 5 years, 3.2- 5.0%), with absolute differences in LR relapse rates at 5 years compared with 50Gy of 0.2% (−1.3%−2.6%) for 41.6Gy and 0.9% (−0.8%−3.7%) for 39Gy. The a/β estimate for tumour control was 5.0Gy (−2.7–12.7). In ST-B, there were 65 LR relapses (2.8% at 5 years, 2.1–3.5%), with an absolute difference in LR relapse rates at 5 years of −0.6% (−1.7%−0.9%) for 40Gy vs 50Gy. In ST-A the rate of mild/marked change in photographic breast appearance was lower in 39Gy vs 50Gy (HR 0.69, 0.52–0.91), and similarly for 40Gy vs 50Gy in ST-B (HR 0.83, 0.66–1.04). The a/β estimate for change in breast appearance was 3.1Gy (1.6–4.6). Rates of induration, telangiectasia and breast oedema were lower in 39Gy (ST-A) and 40Gy (ST-B) compared with the 50Gy arms. QL results were consistent with the clinical findings. Conclusions: The fractionation sensitivity of breast cancer is comparable to that of late reacting normal tissues, confirming the results of a recent pilot trial. These results support the use of hypofractionated RT schedules for early breast cancer. No significant financial relationships to disclose.

Intensity-Modulated Radiotherapy Results in Significant Decrease in Clinical Toxicities Compared With Conventional Wedge-Based Breast Radiotherapy

We have previously demonstrated that intensity-modulated radiotherapy (IMRT) with a static multileaf collimator process results in a more homogenous dose distribution compared with conventional wedge-based whole breast irradiation (WBI). In the present analysis, we reviewed the acute and chronic toxicity of this IMRT approach compared with conventional wedge-based treatment. A total of 172 patients with Stage 0-IIB breast cancer were treated with lumpectomy followed by WBI. All patients underwent treatment planning computed tomography and received WBI (median dose, 45 Gy) followed by a boost to 61 Gy. Of the 172 patients, 93 (54%) were treated with IMRT, and the 79 patients (46%) treated with wedge-based RT in a consecutive fashion immediately before this cohort served as the control group. The median follow-up was 4.7 years. A significant reduction in acute Grade 2 or worse dermatitis, edema, and hyperpigmentation was seen with IMRT compared with wedges. A trend was found toward reduced acute Grade 3 or greater dermatitis (6% vs. 1%, p = 0.09) in favor of IMRT. Chronic Grade 2 or worse breast edema was significantly reduced with IMRT compared with conventional wedges. No difference was found in cosmesis scores between the two groups. In patients with larger breasts (> or =1,600 cm(3), n = 64), IMRT resulted in reduced acute (Grade 2 or greater) breast edema (0% vs. 36%, p <0.001) and hyperpigmentation (3% vs. 41%, p = 0.001) and chronic (Grade 2 or greater) long-term edema (3% vs. 30%, p = 0.007). The use of IMRT in the treatment of the whole breast results in a significant decrease in acute dermatitis, edema, and hyperpigmentation and a reduction in the development of chronic breast edema compared with conventional wedge-based RT.

Breast Edema in Patients Undergoing Breast-Conserving Treatment for Breast Cancer: Assessment via High Frequency Ultrasound

To identify factors that can influence breast edema in women undergoing breast-conserving therapy. Breast edema was assessed clinically and via high frequency ultrasound (HFUS) prior to, during and following radiotherapy. Fifty-four women were assessed. Breast edema was present prior to radiotherapy in patients who had undergone level 2 node dissection or had wound infection after sentinel node dissection. Edema increased during and after radiotherapy and peaked at 4-6 months. The time course of breast edema was related to the extent of nodal dissection, postoperative wound infection and regional radiotherapy. HFUS prior to irradiation was found to be no better than clinical assessment in predicting prolonged parenchymal breast edema but was significantly better at the end of irradiation. Breast edema levels are minimal in patients who do not undergo axillary node dissection or have an uncomplicated sentinel node dissection. Most edema is due to compromise of the draining lymphatics, which relates largely to the extent of axillary node dissection. HFUS appears to be a useful in the research setting in quantifying the effect of techniques that aim to reduce complications such as edema.

Functional effects of preserving the intercostobrachial nerve and the lateral thoracic vein during axillary dissection in breast cancer conservative surgery

Conventional axillary dissection in breast cancer surgery implicates the section of the neurovascular elements passing through the dissected tissue: the intercostobrachial nerve (ICBN) and lateral thoracic vein (LTV). Preservation of the ICBN during axillary dissection is well documented in the literature, with slightly contradictory results of its influence to postoperative pain. There is no published data, as far as we know, on the functional effects of preserving the LTV. We supposed that ligation of the LTV contributes to the emergence of postoperative breast edema, which is common in breast cancer conservative surgery. The preservation of venous drainage could diminish the frequency of this undesired occurrence. In a prospective study, 126 patients undergoing axillary node clearance for breast cancer of stages I and II were randomly selected for preservation of ICBN and LTV (n=65), or for conventional dissection (n=61). Sensory deficit, pain and breast edema as a dichotomized characteristics were examined in the first two weeks after the surgery. No difference in the number of dissected nodes was seen between the two groups (p = 0.7). The loss of sensitivity was significantly less common in the group randomized for ICBN preservation (16/65 vs. 30/61,p < 0.005), while there was no difference in the pain intensity and duration (49/65 vs 44/61, p > 0.05). LTV was preserved in 22 patients in the group for preservation, and in none of the control group. Breast edema was registered in 33 patients from the group for preservation (51%) and in 37 patients from the control group (61%). The difference in distribution was not significant, and the same results were obtained when the frequency of breast edema in the group with preserved LTV (22 patients, 10 of them without breast edema) was compared with the all others (p > 0.05). The preservation of the ICBN significantly improved the functional effect of the axillary dissection for breast cancer by reducing sensory loss, while there was no difference in pain intensity and duration. Although we did not prove that the preservation of LTV prevents breast edema after conservative surgery for breast cancer, we think that more complex analysis, including parameters such as the extent of resection of breast tissue, the dimension and constitutional characteristics of the breast, tumor location, obesity, and further developments in surgical technique, would reveal at least discrete improvements in the functional results of this surgical approach.

Central Vein Stenosis: A Nephrologist's Perspective

Central vein stenosis is commonly associated with placement of central venous catheters and devices. Central vein stenosis can jeopardize the future of arteriovenous fistula and arteriovenous graft in the ipsilateral extremity. Occurrence of central vein stenosis in association with indwelling intravascular devices including short-term, small-diameter catheters such as peripherally inserted central catheters, long-term hemodialysis catheters, as well as pacemaker wires, has been recognized for over two decades. Placement of multiple catheters, longer duration, location in subclavian vein, and placement on the left-hand side of neck seem to predispose to the development of central vein stenosis. Endothelial injury with subsequent changes in the vessel wall results in development of microthrombi, smooth muscle proliferation, and central vein stenosis. Central vein stenosis is often asymptomatic in nondialysis patients, but can result in edema of ipsilateral extremity and breast when challenged by increased flow from an arteriovenous fistula or arteriovenous graft. Bilateral central vein stenosis or superior vena cava stenosis can produce a clinical picture of superior vena cava syndrome, associated with engorgement of face and neck. Endovascular interventions are the mainstay of management of central vein stenosis. Percutaneous angioplasty and stent placement for elastic and recurring lesions can restore the functionality of the vascular access, at least temporarily. Frequent or multiple interventions are usually required. In recalcitrant cases, surgical bypass of the obstruction is an option. In resistant cases with severe symptoms, occlusion of the functioning vascular access will usually provide relief of symptoms. Further study of mechanisms of development of central vein stenosis and search for a targeted therapy is likely to lead to better ways of managing central vein stenosis. Prevention of central vein stenosis is the key to avoid access failure and other complications from central vein stenosis and relies upon avoidance of central vein stenosis placement and timely placement of arteriovenous fistula in prospective dialysis patient.

The effects of an oestrogen-free, desogestrel-containing oral contraceptive in women with cyclical symptoms: Results from two studies on oestrogen-related symptoms and dysmenorrhoea

Objectives To evaluate the effects of an oestrogen-free oral contraceptive (Cerazette®; 75 mcg/day desogestrel) in women with oestrogen-related symptoms during previous combined oral contraceptive (COC) use (ERS study) and in women with dysmenorrhoea (DYS study).Methods Two similarly designed prospective, non-comparative multicentre observational studies were carried out in Germany. Altogether, 403 women with oestrogen-related symptoms during previous COC use and 406 women with dysmenorrhoea took Cerazette® continuously. Symptom-related assessments were made at baseline and after 3–4 months, along with bleeding pattern and treatment satisfaction.Results In the ERS study, the four oestrogen-related symptoms studied resolved or improved in over 70% of women. Nausea improved/resolved most (92% of women), followed by breast tenderness (90%), oestrogen-related headache (84%) and oedema (74%). In the DYS study, dysmenorrhoea resolved or considerably improved in 93% of the study population. Correspondingly, use of analgesics dropped from 70% of women at baseline to 8% at study end. Adverse events were reported by 7–8% of both study populations and were mainly bleeding irregularities. Most women in both studies were satisfied with treatment (∼90%) and wished to continue treatment after study completion (∼85%).Conclusions Cerazette® in this study set-up improved oestrogen-related symptoms and dysmenorrhoea in women affected and treatment was well accepted.

Delayed breast cellulitis: An evolving complication of breast conservation

Delayed breast cellulitis (DBC) is characterized by the late onset of breast erythema, edema, tenderness, and warmth. This retrospective study analyzes the risk factors and clinical course of DBC. From 1985 through 2004, 580 sequential women with 601 stage T0-2N0-1 breast cancers underwent breast conserving therapy. Cases of DBC were identified according to accepted clinical criteria: diffuse breast erythema, edema, tenderness, and warmth occurring >3 months after definitive surgery and >3 weeks after radiotherapy. Potential risk factors analyzed included patient comorbidity, operative technique, acute complications, and details of adjunctive therapy. Response to treatment and long-term outcome were analyzed to characterize the natural course of this syndrome. Of the 601 cases, 16%, 52%, and 32% were Stage 0, I, and II, respectively. The overall incidence of DBC was 8% (50/601). Obesity, ecchymoses, T stage, the presence and aspiration of a breast hematoma/seroma, removal of >5 axillary lymph nodes, and arm lymphedema were significantly associated with DBC. The median time to onset of DBC from the date of definitive surgery was 226 days. Ninety-two percent of DBC patients were empirically treated with antibiotics. Fourteen percent required more invasive intervention. Twenty-two percent had recurrent episodes of DBC. Ultimately, 2 patients (4%) underwent mastectomy for intractable breast pain related to DBC. Although multifactorial, we believe DBC is primarily related to a bacterial infection in the setting of impaired lymphatic drainage and may appear months after completion of radiotherapy. Invasive testing before a trial of antibiotics is generally not recommended.

166: Delayed Breast Cellulitis: An Evolving Complication of Breast Conservation

166: Delayed Breast Cellulitis: An Evolving Complication of Breast Conservation

2013: Breast Irradiation in the Prone Position Using 3-Dimensional Planning in Women With Large Pendulous Breasts Undergoing Breast Conservation for Early Stage Disease

Heavier women and/or those with large, pendulous breasts have documented higher rates of severe acute and late toxicity and poorer cosmetic outcomes from whole breast irradiation (WBI) after lumpectomy for breast conservation. Using contour based 3-D treatment planning in the prone position for breast irradiation this institution sought to improve these outcomes. Between 1999 - 2005, 83 women received breast irradiation in the prone position due to large pendulous breasts and/or their, body habitus - 78 have > 1 year follow-up. All patients underwent CT planning in the prone position. Target breast volume (TBV), lumpectomy volume, ipsilateral lung and heart (left sided) were contoured for each case. Treatment goals were: 95% of the TBV minimally receive 90% of the dose prescribed to isocenter for the WBI, and 95% of the lumpectomy volume received 100% of the final prescribed dose. WBI was delivered with a mean dose of 49 Gy using an average of 3 beams. Mixed beam energy was used for 76%. A boost was given to 78% (10 Gy over 5 fractions with photons for 95%). Acute and late toxicity were scored according to the Common Toxicity Criteria Version 3.0. Cosmetic outcome is assessed by the Harvard Scale. Analyses were done assessing the influence of BMI and TBV on rates of Grade 2- 3 toxicities of dermatitis, breast pain, fibrosis and fair-poor cosmesis. The patient population was an average 63′ tall (58–71) and 201 lbs(114–322), corresponding to a BMI of 35 (22–51). The mean TBV was 1579cc (345–4800). Mean age at diagnosis was 61, and 77 % were postmenopausal. The tumors were Tis 16%, T-1 65%, T-2 16%, T-3 2%, and 14 % had positive axillary nodes. Chemotherapy was delivered to 33% prior to RT. The median follow-up is 26 months. Acute toxicity was as follows: Dermatitis- Grade (G) I 27%, G- II 68%, G- III 5 %. Breast edema - G- I 14%, G-II 1% G-III 1%. Breast pain - G- I 42%, G-II 25%, G- III 0% .Fatigue - G-I 68%, G-II 1%, G-III 0%. Moist desquamation developed in 15% and was confined to infra-mammary folds in 14% of these. For late toxicity: hyper pigmentation G-I 29%, telangiectasias 5% and fibrosis which was G-I 44%, G-II in 5%. Nipple/ areola deformity and volume loss leading to asymmetry was seen in a total of 11% and 25% patients respectively. Overall 6% experienced grade II or greater late toxicity. The cosmetic result was good or excellent in 85%, fair in 8% and poor in 1%. BMI was associate with both breast pain and cosmesis as follows: Grade 2–3 breast pain was 42% in those with a BMI >36, 19% for a BMI 33–35, and 17% for a BMI <32 (p=0.038). A fair-poor cosmesis was seen in 20% of patients with a BMI >36, 8% for a BMI 33–35-%, and 0% for a BMI <32 (p=0.024). There was no effect of BMI on higher rates of dermatitis and TBV size was not associated with higher rates of grade 2–3 toxicity or poor-fair cosmesis. In this patient population of fuller stature breast cancer patients with large pendulous breast, the use of contour-based 3-DCRT in the prone position resulted in an acceptable rate of acute toxicity, a low rate of late toxicity, and a high rate of good- excellent cosmetic outcomes.

Long-term toxicity of an intraoperative radiotherapy boost using low energy X-rays during breast-conserving surgery

Intraoperative radiotherapy (IORT) as a boost for breast cancer delivers a high single dose of radiation to a late-reacting tissue; therefore late toxicity is of particular interest, and long-term follow-up is warranted. To date there are only limited data available on breast cancer patients treated with IORT using low energy X-rays. We analyzed toxicity and cosmesis after IORT as a boost with a minimum follow-up of 18 months. A total of 73 patients treated with IORT (20 Gy/50 kV X-rays; INTRABEAM [Carl Zeiss Surgical, Oberkochen, Germany]) to the tumor bed during breast-conserving surgery as a boost followed by whole-breast radiotherapy (WBRT, 46 Gy) underwent a prospective, predefined follow-up (median, 25 months; range 18-44 months), including clinical examination and breast ultrasound at 6-months and mammographies at 1-year intervals. Toxicities were documented using the common toxicity criteria (CTC)/European Organization for Research and Treatment of Cancer and the LENT-SOMA score. Cosmesis was evaluated with a score from 1 to 4. The IORT in combination with WBRT was well tolerated, with no Grade 3 or 4 skin toxicities and no telangiectasias. Fibrosis of the entire breast was observed in 5% of the patients. A circumscribed fibrosis around the tumor bed was palpable in up to 27% with a peak around 18 months after therapy and a decline thereafter. The observed toxicitiy rates were not influenced by age, tumor stage, or systemic therapy. The cosmetic outcome was good to excellent in>or=90% of cases. After IORT of the breast using low-energy X-rays, no unexpected toxicity rates were observed during long-term-follow-up.

Thymic carcinoma – an unusual cause for unilateral breast oedema

An 83-year-old lady presented with oedema of the right breast with no focal masses and was found to have a tumour of thymic origin in the anterior mediastinum. We describe this interesting case along with a review of the causes of unilateral breast oedema.

TU-EE-A1-02: Quality Assurance of Partial Breast Irradiation Using Permanent Breast 103Pd Seed Implant (PBSI)

Purpose ‐ For early stage breast cancer, accelerated partial breast irradiation using High Dose Rate brachytherapy appears as effective as whole breast radiation. A permanent breast seed implant (PBSI) technique has been developed that realizes the implantation of 103Pd seeds under ultrasound guidance in a single one‐hour session. The objective of this study is to compare early and delayed post‐implant dose distribution to assess the Quality of the procedure. Material and Methods ‐ A Phase I/II clinical trial has been activated in May 2004 and as of February 2006 fourty seven patients have received PBSI. A minimal peripheral dose of 90Gy was prescribed to a volume corresponding to the CTV plus a margin of 1.5 cm. Each patient has a CT scan immediately following seed implantation and another one at two months. After identification of the seeds, new plans were calculated using the MMS TPS. Results: ‐ On average, 70 seeds are used per patient, with an activity ranging from 1.59U to 2.7U per seed. The V100 values demonstrate a satisfactory coverage and minimal variations over the course of 2 months. V100 were improving over time demonstrating a learning curve. The V200 for both the PTV and CTV shows significant and dramatic increases over time (65% and 87% respectively, p<0.001). The mean PTV and CTV volumes were small and do not vary significantly between the “immediate” and two month post‐implant. Conclusions ‐ Post‐implant PBSI Quality Assurance data shows adequate dose coverage of the target volumes that remains stable over time suggesting that there is no significant seed motion. Significant changes in the hot‐dose sleeves are seen two months from seed implantation. This could be due to a breast oedema at the time of implant that disappears with time and/or to the development of a retractile fibrosis over time.

La chimiothérapie concomitante de la radiothérapie augmente la toxicité tardive après chirurgie conservatrice du cancer du sein

Purpose In 1996, a multicenter randomized study comparing after breast-conservative surgery, sequential vs concurrent adjuvant chemotherapy (CT) with radiation therapy (RT) was initiated (ARCOSEIN study). Seven hundred sixteen patients were included in this trial. After a median follow-up of 6.7 (4.3–9) years, we decided to prospectively evaluate the late effects of these two strategies. Patients and methods A total of 297 patients were asked to follow-up from the five larger including institutions. Seventy-two percent (214 patients) were eligible for late toxicity. After breast-conserving surgery with axillary dissection, patients were treated either with sequential treatment with CT first followed by RT (arm A) or CT administered concurrently with RT (arm B). In all patients, CT regimen combined mitoxantrone (12 mg/m 2), 5-FU (500 mg/m 2), and cyclophosphamide (500 mg/m 2), 6 cycles (day 1-day 21). In arm B, patients received concurrently the first 3 cycles of CT with RT. In arm A, RT started 3 to 5 weeks after the 6th cycle of CT. Conventional RT was delivered to the whole breast using a 2 Gy-fraction protocol to a total dose of 50 Gy (± boost to the primary tumour bed). The assessment of toxicity was blinded to treatment and was graded by the radiation oncologist according to the LENT–SOMA scale. Skin pigmentation was also evaluated using a personal 5-points scoring system (excellent, good, moderate, poor, very poor). Results Among the 214 evaluated patients, 107 were treated in each arm. The two populations were homogeneous for patients', tumors' and treatment characteristics. Subcutaneous fibrosis (SF), telengectasia (T), skin pigmentation (SP), and breast atrophy (BA) were significantly increased in arm B. Twenty patients experienced grade superior or equal to 2 (SF) in arm B vs five in arm A ( P = 0.003). Twenty-five and seven patients showed grade superior or equal to 2 (T) in arm B and A, respectively ( P = 0.001). Forty-four and twenty patients showed grade superior or equal to 2 (BA) in arm B and A, respectively ( P = 0.0006). Thirty patients experienced grade superior or equal to 3 (SP) in arm B vs fifteen in arm A ( P = 0.02). No statistical difference was observed between the two arms concerning grade superior or equal to 2 pain, breast oedema, and lymphoedema. No deaths were caused by late toxicity. Conclusion Following breast conserving surgery, the concurrent use of CT with RT is significantly associated with an increase incidence of grade 2 or greater late side effects.