Breast Edema Research Articles

Efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy in breast-conserving surgery for early-stage breast cancer: a single-centre study in China.

The purpose of this study was to evaluate the efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy for the treatment of Chinese patients with early-stage breast cancer. Between September 2014 and May 2017, breast cancer patients undergoing targeted intraoperative radiotherapy at our facility were retrospectively recruited for this study. Intraoperative radiotherapy was performed with a 50-kV X-ray source in an Intrabeam system (Carl Zeiss Meditec, Oberkochen, Germany). The one-time prescribed irradiation dose to the tumour bed was 20Gy. Recurrence, death, late complications, and cosmetic outcomes were recorded. Late radiotoxicity was assessed based on the grading criteria of the Radiation Therapy Oncology Group. A total of 77 patients who were treated with targeted intraoperative radiotherapy only were recruited. The cohort had a mean age of 58years; patients with T1, N0, and invasive ductal carcinoma accounted for 75.3, 89.6, and 84.4%, respectively; the median follow-up duration was 40months; there were 2 patients of recurrence and 2 patients of death. There were no patients of cardiac toxicity or skin or lung radiotoxicity of grade 2 or above. The main complications were breast oedema (18.2%), seroma (15.6%), chromatosis (9.1%), induration (7.8%), pain (5.2%), skin depression (2.6%), mild dry cough (2.6%), delayed wound healing (1.3%), and wound infection (1.3%). Seventy-three patients participated in the cosmetic outcome evaluation, which yielded an excellent or good rate of 95.9%. Due to its low recurrence rates, lack of high-grade late radiotoxicity, and excellent cosmetic outcomes, targeted intraoperative radiotherapy may be a suitable treatment for select early-stage breast cancer patients in China.

Tubulopapillary Carcinoma of the Mammary Gland in a Mare

Background: Mammary gland neoplasia are often observed in bitches and cats, rarely in cows, goats, sheep, sows, and mares. Among the neoplasia that affect mares, breast tumors are rare, as they occur more frequently in older animals. In horses, mammary gland tumors occur more frequently in older animals. In this species there are reports of cases describing carcinomas and adenocarcinomas and several subtypes. Mammary neoplasms in equines tend to be locally aggressive and promote metastases to the regional lymph nodes and other organs, including the lungs, and may cause pleural effusion. The aim objective of the present case report was to describe the clinical-pathological and immunohistochemical findings of a tubulopapillary carcinoma of the mammary gland in mare.Case: Was received a biopsy of a tumor mass of the mammary gland of a 15-year-old Quarter Horse mare. According to the veterinarian, the mare presented an increase in volume with ulceration of the mammary gland three months before the biopsy. Macroscopically, the mass was firm to the cut with white surface measuring 12x12 cm. The fragment was fixed in 10% formalin, routinely processed for histology, paraffin embedded, and stained with hematoxylin and eosin. Microscopically, we observed proliferation of epithelial neoplastic cells arranged in tubules and papillary projections, some with two to three layers of cells. Neoplastic cells had oval, moderate and distinct cytoplasm. The nuclei were rounded with dense chromatin and an apparent nucleolus. There were two figures of mitosis per field of high magnification. Proliferation of neoplastic cells invaded adjacent tissues, and in lymph vessels of the region, neoplastic cells were observed as well as inflammation in adjacent tissue. In addition, the breast fragment was submitted to the immunohistochemistry technique using anti-pancytokeratin and anti-vimentin antibody. In immunohistochemistry for pancytokeratin, there was immunoreactivity with marked cytoplasm in neoplastic epithelial cells. In immunohistochemistry for vimentin, there was cytoplasmic labeling in cells of the supporting tissue (fibroblasts and endothelial cells). After approximately six months of the initial diagnosis, the mare died.Discussion: The diagnosis of tubulopapillary carcinoma of the mammary gland in a mare was based on the clinical-pathological and immunohistochemical findings. In mares, descriptions of breasts neoplasia are uncommon and found in animals aged over 12 years. In a study carried out in slaughterhouses in France, with approximately 40,000 horses slaughtered, only 45 breast neoplasms (0.11%) were observed, most of them consisting of carcinomas. In these equines, the absolute incidence of neoplasia of the reproductive system increases with age and tumors generally appear as deep, multifocal, and ulcerating skin nodules. Thus, important differential diagnoses include chronic mastitis and prepartum breast edema. In mares with neoplasia of the mammary gland, unilateral or bilateral volume increase, pain, warm area, redness and suppurative serous discharge are frequently observed. There are also reports of skin ulceration or necrosis. In the present report, the mare showed increased volume of the mammary gland, with focal hyperthermia, fistulated area and serum-blood secretion. The literature suggests a reserved prognosis for any mare presenting mammary neoplasia. Histopathology and immunohistochemistry were fundamental for the diagnosis of tubulopapillary carcinoma of the mammary gland in the present study. Mammary neoplasiss in mares are rare, but should be considered in the diagnosis of mammary pathologies in this species.

Comparison of Toxicity and Cosmetic Outcomes After Accelerated Partial Breast Irradiation or Whole Breast Irradiation Using 3-Dimensional Conformal External Beam Radiation Therapy

PurposeTo compare rates of acute and late skin toxicities and cosmetic outcomes after accelerated partial breast irradiation (APBI) or whole breast irradiation (WBI) using 3-dimensional conformal external beam radiation therapy in women with breast cancer after breast conservation surgery (BCS). Methods and MaterialsWomen >35 years of age with invasive or noninvasive breast cancer ≤4 cm treated by BCS were randomized to 3D-CRT APBI (34 Gy/10 fractions/5 days) or WBI (40 Gy/16 fractions/3 weeks ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence. Important secondary outcomes were skin toxicities using Radiation Therapy Oncology Group scores, Late Effects Normal Tissue Task Force and Subjective, Objective, Management, Analytic scales, and adverse cosmetic outcome. This interim analysis focuses on the secondary endpoints of radiation toxicities and cosmesis. Patient and tumor characteristics and rates of adverse cosmetic outcomes and skin toxicities were compared using Fisher exact tests. All statistical tests were 2 sided, with P < .05 considered statistically significant. ResultsBetween June 2011 and December 2015, 133 women with breast cancer were randomized to 3D-CRT APBI or WBI. Patient and tumor characteristics were balanced between the 2 arms. Median follow-up was 60 months (range, 12-93 months). Grade 4 late toxicity was not seen in either of the treatment arms, and grade 3 toxicity was very low for each endpoint assessed in both the groups. The rates of grade ≥2 acute dermatitis were 8% and 15%, respectively, for APBI and WBI (P = .18). Rates of grade ≥1 late radiation toxicities were higher in the WBI arm compared with the APBI arm for breast shrinkage (P = .008), pigmentation (P = .028), fibrosis (P = .040), induration (P = .048), and edema (P = .33). Adverse cosmesis at last follow-up was significantly higher in patients treated with WBI: 33% compared with 6% with APBI (P < .001). ConclusionsIn women with breast cancer after BCS, APBI was associated with better cosmetic outcome and fewer late radiation toxicities than WBI.

A Multimodality Imaging Evaluation of Unilateral Breast Edema: It's Not Just Cancer

A Multimodality Imaging Evaluation of Unilateral Breast Edema: It's Not Just Cancer

A Multimodality Imaging Evaluation of Unilateral Breast Edema: It's Not Just Cancer

This article presents a review of the differential diagnosis and pathophysiology of benign and malignant, unilateral breast edema, including mammary, nonmammary, and systemic causes. Abnormal imaging findings related to unilateral breast edema have been described using multiple imaging modalities and a case-based approach. Accurate diagnosis of unilateral breast edema involves assessment of the clinical history, physical examination, and imaging studies.

Compression Treatment of Breast Edema: A Randomized Controlled Pilot Study.

Background: Patients treated for breast cancer with breast conserving surgery and radiotherapy (RT) often complain about swelling, heaviness, and pain in the treated breast. This pilot study was undertaken to examine if compression therapy was effective as an early treatment to reduce breast edema and symptoms assessed by Visual Analogue Scale (VAS). Methods and Results: Fifty-six breast cancer-treated women with breast edema, diagnosed by the measurement of tissue water content by tissue dielectric constant (TDC) technique 3 months post-RT, were randomized to either an intervention group, wearing a sports bra of compression type, or a control group, wearing a standard bra daily for 9 months when tissue water content in breast, upper arm, and lateral thorax of the operated side, and symptoms assessed by VAS were evaluated. No differences were found between the groups at start or end of study concerning tissue water content or VAS. However, within both groups, a significant reduction in tissue water content and experience of heaviness was found. Conclusion: Breast edema as well as experience of heaviness in the affected breast found at 3 months post-RT decreased after 9 months independent of whether a sports bra of compression type or a standard bra was used.

Clinical observation of early-stage breast cancer after breast-conserving surgery with hypofractionated radiotherapy

Objective To observe the long-term effect, adverse reaction and cosmetic outcome of early-stage breast cancer with hypofractionated whole-breast irradiation (HF-WBI) after breast-conserving surgery. Methods A total of 206 patients with stage 0-Ⅱ breast cancer after breast-conserving surgery were included in Shandong Cancer Hospital Affiliated to Shandong University from May 2014 to August 2017. According to radiotherapy fraction, patients were divided into HF-WBI group and conventional whole-breast irradiation (CF-WBI) group. In HF-WBI group, 116 patients received whole-breast radiation to 42.56 Gy in 16 fractions followed by tumor bed boost of 9 Gy in 3 fractions or 10 Gy in 5 fractions. In CF-WBI group, 90 patients received whole breast radiation to 50 Gy in 25 fractions followed by tumor bed boost of 10 Gy in 5 fractions. The 2-year local recurrence rate, 2-year mortality rate, acute adverse reaction, late adverse reaction and cosmetic outcome of the two groups were analyzed. Results The 2-year local recurrence rates of HF-WBI group and CF-WBI group were 0.86% (1/116) and 2.22% (2/90) respectively, and there was no significant difference between the two groups (χ2=0.049, P=0.824). The 2-year mortality rates of the two groups were 0.86% (1/116) and 0 (0/90) respectively, and there was no significant difference (P>0.999). There were 108 cases (93.1%) in HF-WBI group and 84 cases (93.3%) in CF-WBI group with grade 0-1 acute dermatitis, and 8 cases (6.9%) and 6 cases (6.7%) with grade 2-3 respectively, with no statistically significant difference (χ2=0.004, P=0.948). There were 97 cases (83.6%) in HF-WBI group and 79 cases (87.8%) in CF-WBI group with grade 0-1 bone marrow suppression, and 19 cases (16.4%) and 11 cases (12.2%) with grade 2-4 respectively, with no statistically significant difference (χ2=0.704, P=0.401). In the two groups, there were 1 case (0.9%) and 3 cases (3.3%) with grade 1-2 radiation pneumonitis, and 115 cases (99.1%) and 87 cases (96.7%) with no radiation pneumonitis respectively, and the difference was not statistically significant (χ2=1.626, P=0.202). There was 1 case (0.9%, 1.1%) with grade 1 breast edema in each group, and 115 cases (99.1%) and 89 cases (98.9%) did not occur breast edema, with no statistically significant difference (χ2=0.033, P=0.857). In the late adverse reactions, there were 5 cases (4.3%) and 3 cases (3.3%) with skin pigmentation in HF-WBI group and CF-WBI group respectively. There were 2 cases (1.7%, 2.2%) with grade 1 subcutaneous tissue fibrosis in each group, and there were 1 case (0.8%) and 2 cases (2.2%) with grade 1 pulmonary fibrosis respectively. The differences between the two groups were not statistically significant (χ2=0.000, P>0.999; χ2=0.000, P>0.999; χ2=0.049, P=0.824). The 6-month, 1-year and 2-year cosmetic outcome good rates in HF-WBI and CF-WBI group were 96.5% (111/115) and 93.3% (84/90), 92.1% (105/114) and 90.0% (81/90), 91.4% (53/58) and 87.2% (41/47) respectively. The differences between the two groups were not statistically significant (χ2=0.526, P=0.468; χ2=0.277, P=0.599; χ2=0.476, P=0.490). The whole course of radiotherapy time in HF-WBI group was 25 days or 29 days, which was significantly shorter than the 40 days of CF-WBI group. Conclusion HF-WBI after breast-conserving surgery has the similar long-term effect, acute and late adverse reaction and cosmetic outcome compared with CF-WBI, and the treatment time is significantly shorter. It can be further promoted as the optimal adjuvant radiotherapy for early-stage breast cancer after breast-conserving surgery. Key words: Breast neoplasms; Radiotherapy; Treatment outcome

Compression Vest Treatment for Symptomatic Breast Edema in Women Treated for Breast Cancer: A Pilot Study.

Background: Lymphedema of the breast/chest wall after breast cancer treatment is often associated with pain and reduced quality of life. We conducted a pilot study to evaluate whether the use of a compression vest reduced symptoms of breast/chest wall edema in breast cancer patients. Methods and Results: This single-center study included patients (n = 25) with symptomatic breast/chest wall edema with a pain score of ≥3 on the Numerical Rating Scales (range 1-10). The patients were instructed to wear a compression vest (Lymphatrex, Class II) for 6 months. Wilcoxon signed-rank tests were used to compare differences in patient-reported pain intensity/severity. Analyses included all patients with available data. In total, 17 (68%) continued to wear their vests for 6 months, whereas the other 8 withdrew prematurely. At baseline, median pain severity (4.9, interquartile range [IQR] 3.6-6.0) and pain interference (4.3, IQR 2.1-5.9) scores were significantly higher compared with pain scores after wearing the compression vest for 6 months (1.8 IQR 1.0-4.8 and 1.4 IQR 0.9-4.4, resp.). Patient-reported breast/chest wall swelling decreased from 92% (n = 22) at baseline to 71% (n = 12) at 6 months. The prevalence of moderate/severe patient-reported breast/chest wall pain declined from 63% (n = 15) at baseline to 18% (n = 3) at 6 months. Physical, emotional, and social functioning improved over time and was comparable to scores of the Dutch reference population. Conclusion: The results of this pilot study suggest that a compression vest could be an acceptable and effective treatment option for patients with painful breast/chest wall edema. In compliant patients, swelling and pain was significantly reduced.

Breast Edema Following Breast-Conserving Surgery and Radiotherapy: Patient-Reported Prevalence, Determinants, and Effect on Health-Related Quality of Life

BackgroundThe association between lymphedema of the arm and impaired health-related QoL (HR-QoL) has led to changes in clinical practice. However, data on lymphedema of the breast (ie, breast edema) are lacking. We prospectively evaluated patient-reported prevalence and determinants of breast edema and its effect on patient-reported HR-QoL and breast pain.MethodsWe prospectively included 836 patients undergoing breast-conserving surgery followed by radiotherapy between October 2013 and October 2016 (UMBRELLA cohort). Patient-reported breast edema, HR-QoL, and breast pain were assessed by means of European Organisation for Research and Treatment of Cancer-C30/BR23 before starting radiotherapy and at 3, 6, 12, and 18 months thereafter. We assessed which patient, tumor, and treatment characteristics were associated with breast edema. With mixed-effects models, we assessed the impact of breast edema on patient-reported HR-QoL domains and breast pain over time, adjusting for confounders.ResultsWithin a median follow-up of 28 months (interquartile range [IQR] = 15), 207 (24.8%) patients reported breast edema at some point in time. Prevalence of breast edema was highest at 6 months (12.4%, 95% confidence interval [CI] = 10.0 to 14.7). Larger tumor size, oncoplastic surgery, axillary lymph node dissection, locoregional radiotherapy, radiotherapy boost on the tumor bed, and adjuvant chemotherapy were associated with breast edema. Breast edema was independently associated with more breast pain and with poorer QoL, physical functioning, and body image.ConclusionsBreast edema occurs frequently within the first year after breast-conserving surgery and radiotherapy and is independently associated with impaired HR-QoL and more breast pain. This information is important for use in clinical practice and should be discussed with patients during shared decision making.

Idiopathic Granulomatous Mastitis - a new approach in diagnostics and treatment.

Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease mimicking carcinoma and puerperal or non-puerperal mastitis. The primary purpose of this prospectively performed case control study was to compare clinical and imaging signs of IGM with the reference group of nonspecific, non- puerperal mastitis (NM) to identify the most typical clinical and imaging signs essential for a correct differential diagnosis. The secondary purpose was to present a new approach to non-invasive treatment. Thirty-nine women with histologically proven IGM and twenty-six patients with nonspecific mastitis underwent clinical examination, breast ultrasound (US), mammography (MG) and MRI examination. The most typical signs were selected for each group, and method and were statistically evaluated. The effectivity of colchicine, vitamin E and ribwort plantain tincture in treatment was assessed by clinical examination and imaging. Typical clinical signs of IGM included unilateral acute onset of breast edema, redness, palpable masses, missing fever, lymphadenopathy, no response to antibiotics or surgical interventions. Ultrasound revealed: "finger-like" structures (100%), ductectasias (76.9%), abscesses (76.9%), and lymphadenopathy (15.4%), while in MRI skin and tissue edema (100%), multicentric lesions (100%), abscesses (76.9%), ring enhancement (84.6%), lymphadenopathy (15.4%) and small enhancing lymph nodes (38.5%) were observed. Among the clinical signs, fistulas, hypoechoic mass, ductectasias and diffusion weighted images (DWI) restriction were significantly more frequent in patients with IGM than in those with NM. Treatment effectivity yielded 100% with a complete response between 6-19 months, depending on the disease extent. Targeted questions together with imaging can speed up selection for proper treatment with colchicine, vitamin E and local treatment. Long lasting use of antibiotics and repeated surgical interventions should be avoided.

Digital Mammographic Features of Breast Cancer Recurrences and Benign Lesions Mimicking Malignancy Following Breast-Conserving Surgery and Radiation Therapy.

Mammography after breast-conserving surgery and radiation therapy is an important tool for followup. Early diagnosis of local recurrence enables prompt treatment decisions, which may affect patient prognosis. For complicated post-treatment changes, radiologists sometimes have difficulties in interpreting follow-up mammography. Fat necrosis, dystrophic calcifications, suture calcification features, breast edema, seroma and distorted breast are benign changes related to treatment. These findings may mimic or hide tumor recurrence making it difficult to diagnose recurrences or prevent inappropriate biopsies. Recurrent tumors in follow-up mammography show several typical findings such as increasing asymmetric density, enlarging mass, reappearance of breast edema, and micro-calcifications. The purpose of this pictorial review is to demonstrate and discuss mammographic findings of recurrent tumors and important post-treatment changes that may mimic benign or malignant lesions, also using breast ultrasound images or breast magnetic resonance images. Recognizing post-treatment changes may help radiologists to more effectively identify candidates for suspected local recurrences.

Simultaneous integrated boost by Intensity Modulated Radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery – A clinical and dosimetric perspective

AimTo study feasibility of simultaneous integrated boost by intensity modulated radiotherapy (SIB-IMRT) in patients undergoing breast conserving surgery and its impact on cosmesis and dosimetry. Patients and methodsBetween January 2014 and June 2017, all breast cancer patients fulfilling inclusion and exclusion criteria were enrolled in a prospective study conducted at a tertiary cancer centre in North India. All patients received adjuvant radiotherapy by simultaneous integrated boost technique following breast conserving surgery. Clinical information including patient and pathological characteristics, observed acute and chronic toxicities along with cosmesis using Harvard score were recorded and analysed. Univariate analysis and multivariate logistic regression analysis were performed for those variables which were found to be significant (p < 0.050) to study the influence of clinicopathological and dosimetric factors on toxicity and cosmetic outcome. ResultsMaximum acute skin toxicity during treatment was Grade 0–1 in 68.2% and Grade 2–3 in 31.8% of cases, respectively. Fibrosis was the commonest late toxicity with ≥Grade II fibrosis being noted in 16.3% of cases. Assessment of global cosmesis at 12 months follow-up showed good/excellent cosmesis in 88.4% of cases. Mean age, tumor size and homogeneity index (HI) were the significant factors associated with fair or poor cosmetic outcome and ≥Grade 2 fibrosis on multivariate analysis. Telengectasia and breast edema were more frequent in patients with larger tumor size/GTV volume. There were 5 recurrences including 1 ipsilateral local breast tumor recurrence. ConclusionSIB-IMRT is a dosimetrically feasible option in patients undergoing breast conserving surgery and provides good/excellent cosmetic outcome.

Topical atorvastatin 1% for prevention of skin toxicity in patients receiving radiation therapy for breast cancer: a randomized, double-blind, placebo-controlled trial.

The purpose of this randomized, placebo-controlled, double-blind study was to investigate the preventive effect of topical administration of atorvastatin (ATV) on the acute radiation-induced skin toxicity in patients with breast cancer. Seventy breast cancer patients were randomly assigned to use topical ATV 1% or placebo gels during radiotherapy twice daily. Radiation-induced dermatitis was classified according to the radiation therapy oncology group (RTOG) criteria, as well as pain and itching were scored according to VAS (visual analogue scale) for 6weeks of treatment. Topical administration of ATV gel during radiotherapy reduced significantly radiation-induced breast swelling, itching, and pain in breast cancer patients by factors of 1.8, 1.7, and 1.5, respectively. ATV reduced the redness caused by radiotherapy in patients as compared with placebo; however, this difference was statistically not significant. ATV was able to reduce significantly itching, breast edema, and pain in patients during radiotherapy.

Patient Reported Outcomes Over 5 Years Following Whole or Partial Breast Radiotherapy: Longitudinal Analysis of the IMPORT LOW (CRUK/06/003) Phase III Randomised Controlled Trial

Background: IMPORT LOW demonstrated non-inferiority of partial-breast and reduced-dose radiotherapy compared with whole-breast for local relapse, and similar or reduced toxicity at 5 years following radiotherapy. Comprehensive patient reported outcome measures (PROMs) collected at serial time-points are now reported. Methods: IMPORT LOW (ISRCTN12852634) recruited women aged ≥50 years after breast conserving surgery for low risk invasive breast cancer. Patients were randomly assigned to 40Gy whole-breast radiotherapy (control), 36Gy whole-breast and 40Gy to partial-breast (reduced-dose), or 40Gy to partial-breast only (partial-breast) in 15 daily fractions. EORTC QLQ-C30, QLQ-BR23, Body Image Scale, protocol-specific items and Hospital Anxiety and Depression Scales were administered at baseline, 6 months, 1, 2 and 5 years. Patterns of moderate/marked adverse effects (AE) were assessed using longitudinal regression models and baseline predictors investigated. Findings: Patients from 41/71 participating centres took part in the PROMs sub-study where 1265/1333 (95%) patients consented. 557/962 (58%) patients reported no moderate/marked AEs at 5 years. Breast appearance change was most prevalent and persisted over time (around 20% at each time-point). Prevalence of breast hardness, pain, oversensitivity, oedema and skin changes reduced over time (p<0.001 for each), whereas breast shrinkage increased (p<0.001). Analysis by treatment group showed average number of AEs per person at each time point was lower in the partial-breast (incidence rate ratio [IRR] 0.77, 95%CI 0.71-0.84, p<0.001) and reduced-dose (IRR 0.83, 95%CI 0.76-0.90, p<0.001) groups compared with the whole-breast group, and decreased over time in all groups. Younger age, larger breast size/surgical deficit, lymph node positivity, and higher levels of anxiety/depression were baseline predictors of subsequent AE reporting. Interpretation: The majority of AEs reduced over time. There were fewer AEs in the partial and reduced-dose groups and baseline predictors of AEs were identified. These findings will facilitate informed discussion and shared-decision making for future patients receiving moderately hypofractionated breast radiotherapy. Funding Statement: We acknowledge support from Cancer Research UK (grant number C1491/A6035), the National Institute for Health Research (NIHR) Cancer Research Network (CRN), National Health Service Research Scotland, Health and Care Research Wales and the National Institute of Health Research Royal Marsden/ Institute of Cancer Research Biomedical Research Centre. In addition Dr Charlotte Coles is supported by the Cambridge National Institute of Health Research Biomedical Research Centre. Dr Indrani Bhattacharya is supported by a Cancer Research UK clinical trial fellowship (C1491/A8895). Declaration of Interests: The authors declare they have no conflicts of interest. Ethics Approval Statement: This was approved by the Oxfordshire Research Ethics Committee B (06/Q1605/128) and conducted in accordance with the principles of Good Clinical Practice. Requests are reviewed by the TMG in terms of scientific merit and ethical considerations including patient consent. Data sharing is undertaken if proposed projects have a sound scientific or patient benefit rationale as agreed by the TMG and approved by the independent Trial Steering Committee with input from the Independent Data Monitoring Committee as required.

One-step intraoperative radiotherapy optimizes conservative treatment of breast cancer with advantages in quality of life and work resumption

BackgroundIntraoperative radiotherapy (IORT) could be not-inferior to external beam radiotherapy (EBRT) in selected patients, but toxicities, self-perception of body image, quality of life, and resumption of work or daily activities have been poorly explored. The aim of the present study was to compare these outcomes between EBRT, IORT full-dose (IORT-f) and IORT boost (IORT-b). Methods443 consecutive patients, candidates for breast-conserving surgery, were included: EBRT was performed in 220 patients (49.7%), IORT-f in 140 patients (31.6%), and IORT-b in 83 patients (18.7%). Radiotherapy-related toxicities were registered. Patients were evaluated at 6 months for Body Image after Breast Cancer Questionnaire (BIBCQ) to assess possible changes in self-perception of body image and limitations. A second questionnaire explored the impact of EBRT, IORT-f and IORT-b on resumption of work and normal daily activities. ResultsEBRT had a higher risk of breast fibrosis and retraction (OR 3.58, 95% CI 1.024–12.526, p = 0.046) and breast edema (OR 6, 95% CI 2.077–17.335, p = 0.001) compared to IORT-f, but a lower risk of seroma compared to IORT-b (OR 0.36, 95% CI 0.166–0.785, p = 0.01). The BIBCQ scores showed a better outcome in arm concerns with IORT-f (−3.3) vs. IORT-b (−1.3, p = 0.002) and EBRT (−1.7, p = 0.006), although biased by the lower rate in axillary dissections. Return to daily activities occurred after 70.6 days with EBRT vs. 41 days with IORT-f (p < 0.0001) and 53.3 days with IORT-b (p = 0.07), without any effect of age or axillary dissection. ConclusionIORT could reduce adverse effects, allowing faster resumption of job and houseworks.

Reduction mammoplasty as a treatment for symptomatic central venous stenosis.

Central venous stenosis is a rare cause of unilateral breast edema occurring in hemodialysis patients that needs to be differentiated from other differential diagnoses, including, but not limited to, inflammatory breast carcinoma, mastitis, lymphedema, and congestive heart failure. All reports of similar cases in the available literature have described improvement or resolution of the edema after treatment. Herein, we report and discuss the pathophysiology of breast edema formation in a patient who presented with massive left-sided breast edema 7 years after being diagnosed with central venous stenosis. Medical and minimally invasive therapy had not been successful, so she underwent reduction mammoplasty to relieve the symptoms.

Acute and Chronic Toxicities from Multilumen Versus Single Lumen Brachytherapy: Correlating Clinical Outcome With Dosimetry

Prior studies have shown improved dosimetry with lower skin doses using multi-lumen (ML) catheter brachytherapy compared to single lumen (SL) devices for accelerated partial breast irradiation (APBI). However, there are no long-term clinical data to correlate the improved dosimetry with less early and late toxicities. We hypothesized that ML APBI had a more favorable side effect profile and dosimetry compared to SL APBI. A total of 191 patients were treated between 6/30/2000 and 2/22/2013 using either SL MammoSite (N=129; single or multi-dwell), ML MammoSite (N=22), or ML Contura applicators (N=40). All patients were treated with 34 Gy prescribed to a depth of 1 cm from the applicator in 10 twice daily fractions. Only patients with more than 3 years of follow-up data were included in this study. The median follow-up was 8 years. Toxicities including dermatitis, hyperpigmentation, hypopigmentation, breast pain, breast edema, telangiectasia, and induration were assessed at each follow-up visit using the CTCAE (v3.0) criteria. Acute toxicity was defined as <6 months from the date of radiotherapy completion, and chronic toxicity was defined as >6 months. Skin spacing and maximum skin dose were measured for each patient. Differences in acute and chronic toxicities were compared using chi-square and log-rank tests. Mean maximum skin doses were compared using a t-test. Patients treated with ML applicators had significantly less acute dermatitis (grade 1-4: ML 42.4%/SL 66.7%, P=0.003; grade 2-4: ML 8.5%/SL 9.4%, P=0.785), chronic dermatitis (grade 1-4: ML 14.5%/SL 30.5%, P=0.018; grade 2-4: ML 0%/SL 3.9%, P=0.135), and chronic telangiectasia (grade 1-4: ML 19.4%/SL 34.6%, P=0.031; grade 2-4: ML 14.6%/SL 17.3%, P=0.681) compared to SL MammoSite. There were no significant differences between ML and SL in the rates of acute or chronic hyperpigmentation, hypopigmentation, breast pain, breast edema, and induration. Using a log-rank test, patients treated with ML applicators had less chronic dermatitis compared to SL MammoSite (P=0.05). The mean maximum skin dose was significantly lower for ML (34.1 Gy) compared to SL (36.3 Gy) when the skin spacing was between 6-11 mm (P=0.038). However, the mean maximum skin dose was not significantly different between ML and SL when skin spacing was <6 mm (P=0.086) or >12 mm (P=0.419). Regardless of skin spacing, the median maximum skin doses were 32.2 Gy for ML and 33.7 Gy for SL. ML applicators resulted in less acute and chronic toxicities compared to SL MammoSite. ML devices also had significantly lower mean maximum skin doses when skin spacing was between 6-11 mm.

Cosmetic Outcome and Late Breast Toxicity After Intraoperative Radiation Therapy as a Single Modality or as a Boost Using the Intrabeam® Device: A Prospective Study

We aim to report our results in terms of late toxicities and cosmetic outcomes after intraoperative radiotherapy (IORT) using kV X-rays in women treated for early breast cancer at our institution. Patients were eligible if they met the following criteria: age ≥50, non-metastatic grade 1-2, Erb2 negative hormone receptor positive unicentric-unifocal and ≤ 3 cm non-lobular early breast carcinoma. Patients were treated with IORT using the kV X-rays Intrabeam® device following lumpectomy and sentinel node biospy. IORT was completed by whole breast radiotherapy (WBRT) at the dose of 46 in 23 fractions to 50.4 Gy in 28 fractions (depending on breast size) in case of adverse pathologic criteria on the final specimen examination. Breast toxicity was graded using the LENT SOMA scale every 6 months and cosmetic outcomes were evaluated at 36 months by patient self-evaluation and by 2 radiation oncologists on a 1-10 scale. Between April 2011 and November 2014, 71 patients were included. Forty-one women received IORT only and 30 patients received IORT followed by WBRT. After a median follow up of 38.9 months, no locoregional or distant recurrence occurred. After IORT only, 2.4% of grade ≥2 breast fibrosis, 41.5% of grade 1 breast retraction, and 7.3% of grade 1 breast edema was observed. No patient developed another grade ≥2 toxicity. In the IORT +WBRT group, grade ≥2 fibrosis, grade ≥2 breast retraction, and grade 1 breast edema were 43.3%, 23.3% and 16.7%, respectively. There was a significant difference in terms of skin grade ≥2 toxicity between IORT only and IORT +WBRT (2.4% versus 46.6%) (p=0,0001). Objective cosmetic outcomes were very good and significantly better in the IORT only group compared to the IORT+ WBRT group (8.87 vs 6.96) (p<0.001). IORT using the Intrabeam® is well tolerated with very little late skin and breast toxicity and very good cosmetic outcome. However, a high rate of grade ≥2 late skin toxicity was observed when IORT had to be completed by WBRT.

Identification, assessment and management of breast oedema after treatment for cancer.

Advances in breast cancer management, including breast-conserving surgery, have resulted in an increase in the incidence of breast oedema. However, this is addressed by professionals less often than arm lymphoedema. Breast oedema results in significant physical and psychological morbidity, makes finding a comfortably fitting bra very difficult, and can act as a reminder of the initial breast cancer diagnosis. Psychological difficulties can be compounded by clinicians' failure to acknowledge the impact. Assessing and managing breast oedema requires a sensitive, skilled approach to ensure all the relevant issues are identified and addressed in a comprehensive care plan; taking time to listen to patients and acknowledging the impact can be very therapeutic. The principles of managing breast oedema are based on lymphoedema practice, particularly manual lymphatic drainage and kinesio taping. This article gives an overview of the identification, assessment and management of breast oedema following treatment of cancer.

Reliability and Diagnostic Thresholds for Ultrasound Measurements of Dermal Thickness in Breast Lymphedema.

Lymphedema of the breast, secondary to treatment for breast cancer, is difficult to assess due to the shape of the breast and the nature of the tissue. Ultrasound measurement of dermal thickness has been previously used to assess breast swelling; however, the reliability of the measurements, or what should be considered an abnormal thickness, is currently known. Thirty-eight women with breast edema were recruited and underwent assessment using ultrasound. During the assessment, the four quadrants (superior, inferior, medial, and lateral) of the affected and unaffected breasts were imaged three times each. Dermal thickness was then measured by two assessors, on two occasions for each captured image. The interimage, intrarater, and inter-rater reliability was all found to be excellent (Cronbach's alpha = 0.995; ICC(3,1) = 0.962 and 0.851; and ICC(2,1) = 0.977, respectively). A dermal thickness of >1.6 mm in the superior and lateral quadrants and 2.0 mm in the medial and inferior quadrants was determined, by receiver-operating characteristics curve analysis, as the optimal diagnostic threshold to detect breast edema. Dermal thickness measurements can be reliably completed on breasts with edema secondary to breast cancer. Future study is needed to determine the utility of the dermal thickness thresholds established as well as to investigate changes in dermal thickness as a response to treatment of breast edema.