Large Breast Size Research Articles

"Breasts are getting bigger". Where is the evidence?

Concerns over breast size have gained prominence as progressively more research points to an association between increased breast size and negative health implications. Larger breast sizes are associated with a higher incidence of breast pain (Brown et al., 2014), postural issues (Findikcioglu et al., 2007) and body image dissatisfaction (Sarwer et al., 1998). It has been widely reported in the popular press that female breast size is increasing, however, empirical evidence for this assertion is limited, with support for this notion stemming primarily from bra sales. For example, a 2010 media article reporting an increase in British women’s breast size cited best-selling bra size statistics from retailer John Lewis, increasing from a 34B in 2008 to a 32D in 2010 (Fisher, 2010). Similarly, media articles in the United States of America (USA) report that the average bra cup size is now a 36DD, increasing from an average 34B 10 years ago (Holson, 2009; Hadley, 2012), with these statistics again obtained from lingerie retailers. We argue that bra sales data cannot be used to document breast size, or change in breast size over time, as this data is confounded by a lack of industry sizing standards and the high proportion of women reportedly wearing the incorrect bra size. Size charts and grading methods differ between bra companies resulting in inconsistencies in bra sizes produced by different manufacturers (McGhee & Steele, 2006). Therefore, whilst women may be one bra size in one brand, they may be a different size in another which may impact bra sale statistics. It is also recognised that up to 100% of women are wearing the wrong-sized bra (Greenbaum et al., 2003). There is currently no objective, empirical evidence of secular increases in breast size.

A three-field monoisocentric inverse breast treatment planning technique without half-beam blocking.

The purpose of this study was to introduce a three‐field monoisocentric inverse treatment planning method without half‐beam blocks for breast cancer radiation treatments. Three‐field monoisocentric breast treatment planning with half‐beam blocks limits the tangential field length to 20 cm. A dual‐isocenter approach accommodates patients with larger breasts, but prolongs treatment time and may introduce dose uncertainty at the matching plane due to daily setup variations. We developed a novel monoisocentric, three‐field treatment planning method without half‐beam blocking. The new beam‐matching method utilizes the full field size with a single isocenter. Furthermore, an open/IMRT hybrid inverse optimization method was employed to improve dose uniformity and coverage. Geometric beam matching was achieved by rotating the couch, collimator, and gantry together. Formulae for three‐field geometric matching were derived and implemented in Pinnacle scripts. This monoisocentric technique can be used for patients with larger breast size. The new method has no constraints on the length of tangential fields. Compared with the dual‐isocenter method, it can significantly reduce patient setup time and uncertainties.PACS number: 87.55.D‐

Breast cancer tumour growth modelling for studying the association of body size with tumour growth rate and symptomatic detection using case-control data.

IntroductionA large body size is associated with larger breast cancer tumours at diagnosis. Standard regression models for tumour size at diagnosis are not sufficient for unravelling the mechanisms behind the association.MethodsUsing Swedish case-control data, we identified 1352 postmenopausal women with incident invasive breast cancer diagnosed between 1993 and 1995. We used a novel continuous tumour growth model, which models tumour sizes at diagnosis through three submodels: for tumour growth, time to symptomatic detection, and screening sensitivity. Tumour size at other time points is thought of as a latent variable.ResultsWe quantified the relationship between body size with tumour growth and time to symptomatic detection. High body mass index and large breast size are, respectively, significantly associated with fast tumour growth rate and delayed time to symptomatic detection (combined P value = 5.0 × 10−5 and individual P values = 0.089 and 0.022). We also quantified the role of mammographic density in screening sensitivity.ConclusionsThe times at which tumours will be symptomatically detected may vary substantially between women with different breast sizes. The proposed tumour growth model represents a novel and useful approach for quantifying the effects of breast cancer risk factors on tumour growth and detection.

Single-isocenter hybrid IMRT plans versus two-isocenter conventional plans and impact of intrafraction motion for the treatment of breast cancer with supraclavicular lymph nodes involvement.

The purpose of this study was to compare the single‐isocenter, four‐field hybrid IMRT with the two‐isocenter techniques to treat the whole breast and supraclavicular fields and to investigate the intrafraction motions in both techniques in the superior direction. Fifteen breast cancer patients who underwent lumpectomy and adjuvant radiation to the whole breast and supraclavicular (SCV) fossa at our institution were selected for this study. Two planning techniques were compared for the treatment of the breast and SCV lymph nodes. The patients were divided into three subgroups according to the whole breast volume. For the two‐isocenter technique, conventional wedged or field‐within‐a‐field tangents (FIF) were used to match with the same anterior field for the SCV region. For the single‐isocenter technique, four‐field hybrid IMRT was used for the tangent fields matched with a half blocked anterior field for the SCV region. To simulate the intrafraction uncertainties in the longitudinal direction for both techniques, the treatment isocenters were shifted by 1 mm and 2 mm in the superior direction. The average breast clinical tumor volume (CTV) receiving 100% (V100%) of the prescription dose (50 Gy) was 99.3%±0.5% and 96.4%±1.2% for the for two‐isocenter and single‐isocenter plans (p<0.05), respectively. The breast CTV receiving 95% of the prescription dose (V95%) was close to 100% in both techniques. The average breast CTV receiving 105% (V105%) of the prescription dose was 32.4%±19.3% and 23.8%±13.3% (p=0.08). The percentage volume of the breast CTV receiving 110% of the dose was 0.4%±1.2% in the two‐isocentric technique vs. 0.1%±0.2% in the single‐isocentric technique. The average uniformity index was 0.91±0.02 vs. 0.91±0.01 in both techniques (p=0.04), but had no clinical impact. The percentage volume of the contralateral breast receiving a dose of 1 Gy was less than 2.3% in small breast patients and insignificant for medium and large breast sizes. The percentage of the total lung volume receiving g>20 Gy (V20Gy) and the heart receiving >30 Gy (V30Gy) were 13.6% vs. 14.3% (p=0.03) and 1.25% vs. 1.2% (p=0.62), respectively. Shifting the treatment isocenter by 1 mm and 2 mm superiorly showed that the average maximum dose to 1 cc of the breast volume was 55.5±1.8 Gy and 58.6±4.3 Gy in the two‐isocentric technique vs. 56.4±2.1 Gy and 59.1±5.1 Gy in the single‐isocentric technique (p=0.46, 0.87), respectively. The single‐isocenter technique using four‐field hybrid IMRT approach resulted in comparable plan quality as the two‐isocentric technique. The single‐isocenter technique is more sensitive to intrafraction motion in the superior direction compared to the two‐isocentric technique. The advantages of the single‐isocenter include elimination of isocentric errors due to couch and collimator rotations and reduction in treatment time. This study supports consideration of a single‐isocenter four‐field hybrid IMRT technique for patients undergoing breast and supraclavicular nodal irradiation.PACS number: 87.55.D, 87.55.de, 87.55.dk,

Safety and esthetic outcomes of therapeutic mammoplasty using medial pedicle for early breast cancer.

BackgroundAlthough therapeutic mammoplasty (TM) was introduced for treatment of localized ductal carcinoma in situ and invasive breast carcinoma (stages I and II) in females with large breast size, the suitability of medial pedicle TM for treatment of breast tumors at different locations has not been established. The objective of this study was to assess the safety and esthetic outcome of medial pedicle TM for breast tumors at different locations.MethodsThe study was conducted from February 2012 to July 2014. Consecutive patients with early breast carcinoma with medium- and large-sized breasts, with or without ptosis, who were offered medial pedicle TM were included in the study. Patients who were not candidates for breast-conserving surgery or those with tumors located along the medial pedicle were excluded. All patients received immediate postoperative adjuvant chemoradiotherapy.ResultsThirty patients with a mean age of 48.5 years received medial pedicle TM in the breast harboring the tumor or, additionally, the other breast (N=14). The tumors were in the upper (60.0%), lower (26.7%), and lateral (13.3%) quadrants. Minor complications occurred in five cases (5/30, 16.7%) in the ipsilateral and in two (2/14, 14.3%) contralateral breasts. No wound dehiscence or areolar necrosis was recorded. A total of 22 (73.3%) patients were scored as excellent cosmesis. After a median follow-up of 20 months, no locoregional recurrence or distant metastases were observed.ConclusionTM using a medial pedicle is a safe and appealing technique among women with tumors at different locations.

SU‐F‐BRB‐02: Towards Quantitative Clinical Decision On Deep Inspiration Breath Hold (DIBH) Or Prone for Left‐Sided Breast Irradiation

Purpose:To develop quantitative clinical guidelines between supine Deep Inspiratory Breath Hold (DIBH) and prone free breathing treatments for breast patients, we applied 3D deformable phantoms to perform Monte Carlo simulation to predict corresponding Dose to the Organs at Risk (OARs).Methods:The RPI‐adult female phantom (two selected cup sizes: A and D) was used to represent the female patient, and it was simulated using the MCNP6 Monte Carlo code. Doses to OARs were investigated for supine DIBH and prone treatments, considering two breast sizes. The fluence maps of the 6‐MV opposed tangential fields were exported. In the Monte Carlo simulation, the fluence maps allow each simulated photon particle to be weighed in the final dose calculation. The relative error of all dose calculations was kept below 5% by simulating 3*10⁷ photons for each projection.Results:In terms of dosimetric accuracy, the RPI Adult Female phantom with cup size D in DIBH positioning matched with a DIBH treatment plan of the patient. Based on the simulation results, for cup size D phantom, prone positioning reduced the cardiac dose and the dose to other OARs, while cup size A phantom benefits more from DIBH positioning. Comparing simulation results for cup size A and D phantom, dose to OARs was generally higher for the large breast size due to increased scattering arising from a larger portion of the body in the primary beam. The lower dose that was registered for the heart in the large breast phantom in prone positioning was due to the increase of the distance between the heart and the primary beam when the breast was pendulous.Conclusion:Our 3D deformable phantom appears an excellent tool to predict dose to the OARs for the supine DIBH and prone positions, which might help quantitative clinical decisions. Further investigation will be conducted.National Institutes of Health R01EB015478

The impact of breast mass on outcomes of total skin-sparing mastectomy and immediate tissue expander-based breast reconstruction.

Larger breast size has been viewed as a relative contraindication for nipple/areola preservation with mastectomy. Few studies have directly evaluated the effect of quantified breast size on postoperative outcomes. The authors reviewed and assessed 325 total skin-sparing mastectomy cases performed in 224 patients with immediate tissue expander placement that had documented mastectomy specimen mass. Cases were divided into two groups based on having larger (>352 grams) or smaller (≤352 grams) breast mass. Patients in the larger group had a mean body mass index that was 3.6 kg/m2 greater (p < 0.001). Overall, the larger group had an 8.1 percent increase in risk of superficial nipple necrosis (adjusted relative risk 4.0; 95 percent CI, 1.5 to 10.3). There were non-significant trends toward a 4.3 percent increase in risk of minor skin necrosis (adjusted relative risk 2.0; 95 percent CI, 0.7 to 6.4) and a 4.4 percent increase in risk of wound breakdown (adjusted relative risk 1.8; 95 percent CI, 0.8 to 3.7) with larger breast mass. Stratifying by radiation exposure, there was a non-significant trend toward a 5.4 percent increase in risk of wound breakdown (adjusted relative risk 2.9; 95 percent CI, 0.9 to 8.8) with larger breast mass in the stratum without radiation exposure. Larger breast mass was associated with an increased risk of superficial nipple necrosis and trends toward increased risks of minor skin necrosis and wound breakdown. Larger breast mass was not associated with an increased risk of nipple or skin flap necrosis requiring operative management. Risk, II.

Measurement of mean cardiac dose for various breast irradiation techniques and corresponding risk of major cardiovascular event.

After breast conserving surgery, early stage breast cancer patients are currently treated with a wide range of radiation techniques including whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) using high-dose rate (HDR) brachytherapy, or 3D-conformal radiotherapy (3D-CRT). This study compares the mean heart’s doses for a left breast irradiated with different breast techniques. An anthropomorphic Rando phantom was modified with gelatin-based breast of different sizes and tumors located medially or laterally. The breasts were treated with WBI, 3D-CRT, or HDR APBI. The heart’s mean doses were measured with Gafchromic films and controlled with optically stimulated luminescent dosimeters. Following the model reported by Darby (1), major cardiac were estimated assuming a linear risk increase with the mean dose to the heart of 7.4% per gray. WBI lead to the highest mean heart dose (2.99 Gy) compared to 3D-CRT APBI (0.51 Gy), multicatheter (1.58 Gy), and balloon HDR (2.17 Gy) for a medially located tumor. This translated into long-term coronary event increases of 22, 3.8, 11.7, and 16% respectively. The sensitivity analysis showed that the tumor location had almost no effect on the mean heart dose for 3D-CRT APBI and a minimal impact for HDR APBI. In case of WBI large breast size and set-up errors lead to sharp increases of the mean heart dose. Its value reached 10.79 Gy for women with large breast and a set-up error of 1.5 cm. Such a high value could increase the risk of having long-term coronary events by 80%. Comparison among different irradiation techniques demonstrates that 3D-CRT APBI appears to be the safest one with less probability of having cardiovascular events in the future. A sensitivity analysis showed that WBI is the most challenging technique for patients with large breasts or when significant set-up errors are anticipated. In those cases, additional heart shielding techniques are required.

Factors influencing eligibility for breast boost using noninvasive image-guided breast brachytherapy.

Noninvasive image-guided breast brachytherapy (NIBB) allows for accurate targeting of the tumor bed (TB) for breast boost by using breast immobilization and image guidance. However, not all patients are candidates for this technique. Consecutive patients treated for breast cancer were evaluated. Patients with verysmall breast size (cup ≤ A) for whom immobilization could not be achieved were treatedwith electrons. All others underwent simulation for NIBB boost. The rate of eligibilityforNIBB, reasons for ineligibility, and related patient and anatomic factors were analyzed. Of 52 patients evaluated, 6 patients were ineligible for NIBB because of small breast size. Of the remaining patients who underwent simulation for NIBB boost, 33 patients (72%) were treated with NIBB. Reasons for ineligibility were the absence of identifiable TB (n= 5), inability to position patient/breast to adequately target the TB (n= 4), posterior TB location (n= 3), and discomfort during compression (n= 1). The likelihood of being eligible for NIBB boost was dependent on breast size: ≤A (0%), B (50%), C (71%), D-DD (77%), and >DD (80%) (p= 0.002). The presence of surgical clips also predicted eligibility for NIBB: 79% clips vs. 45% without clips (p= 0.05). A posterior TB location was not associated with ineligibility (p= 0.2). NIBB boost is feasible in most patients. Patients with larger breast size are more likely to be good candidates. Posterior TB location can be challenging for NIBB, but most patients are still candidates. Surgical clips are very helpful in defining the TB and greatly increase the likelihood of eligibility for NIBB.

Factors Influencing Eligibility for Breast Boost Using Non-Invasive Image-Guided Breast Brachytherapy

The intact breast presents a challenge for targeting of the tumor bed (TB) due to patient, breast, and respiratory motion. Non-invasive image-guided breast brachytherapy (NIBB) allows for accurate targeting of the TB for breast boost by utilizing breast immobilization and image-guidance. However, not all patients are ideal candidates for this technique. We evaluated our clinical experience using NIBB to indentify patient and anatomic factors which predict suitability for this technique. Consecutive patients with early stage breast cancer treated with breast conserving therapy were evaluated from April to November 2013. Only patients who were candidates for boost were included in this analysis. Patients with very small breast size (cup size A or smaller) for whom breast immobilization could not be achieved using NIBB were treated with en face electrons. All other patients underwent simulation for NIBB boost. NIBB was delivered using the AccuBoost System (Advanced Radiation Therapy, Inc., Billerica, MA). Patients who were found to be ineligible for NIBB boost on simulation underwent boost treatment with en face electrons or 3D conformal photons. The rate of eligibility for NIBB, reasons for ineligibility, and related patient and anatomic factors were analyzed. Fifty-two patients were evaluated of which 6 patients were ineligible for NIBB due to small breast size. Of the remaining patients who underwent simulation for NIBB boost, 33 patients (72%) were treated with NIBB. The most common reasons for ineligibility were absence of identifiable TB (n=5), inability to position the patient/breast to adequately target the TB (n=4), posterior TB location (n=3), and discomfort during breast compression (n=1). The likelihood of being eligible for NIBB boost was dependent on breast size and breast quadrant. The eligibility for NIBB according to breast cup size was: ≤ A (0%), B (50%), C (71%), D-DD (77%), and >DD (80%), p=0.002. The eligibility based on breast quadrant was: retroareolar/central (100%), upper outer (72%), upper inner (67%), lower outer (38%), lower inner (25%), p=0.07. For patients with a posterior TB, located along the chest wall, 73% were good candidates for NIBB. This was not statistically different compared to a non-posterior location, p=0.2. For patients without clips defining the TB only 45% were candidates for NIBB as compared with 79% of patients who had clips, p=0.05. NIBB boost is feasible in the majority of patients. Patients with larger breast size and a tumor bed located in the central breast or upper outer quadrant are more likely to be good candidates. Posterior TB location can be challenging for NIBB but the majority of patients are still candidates. Surgical clips are very helpful in defining the tumor bed for boost and greatly increase the likelihood of eligibility for NIBB.

Hormonal and morphological predictors of women’s body attractiveness

Does women’s body attractiveness predict indices of reproductive capacity? Prior research has provided evidence that large breast size and low waist-to-hip ratio (WHR) are positively associated with women’s estrogen and progesterone concentrations, but no previous studies appear to have directly tested whether ratings of women's body attractiveness are predicted by higher concentrations of ovarian hormones measured across broad regions of the menstrual cycle. Here, we collected daily saliva samples across 1–2 menstrual cycles from a sample of young women; assayed the samples for estradiol, progesterone, and testosterone; obtained anthropometric measurements of the women’s bodies; and also obtained attractiveness ratings of the women’s bodies from photographs of them taken in standardized clothing with faces obscured. Contrary to previous research, mean hormone concentrations were uncorrelated with breast size and WHR. Body mass index (BMI) was a very strong negative predictor of body attractiveness ratings, similar to previous findings. Zero-order associations between women’s mean hormone concentrations and mean attractiveness ratings were not significant; however, after controlling for BMI, attractiveness ratings were independently and positively associated with both estradiol and testosterone concentrations. Discussion focuses on the implications of these findings for whether attractiveness assessment mechanisms are specialized for the detection of cues of differential fecundity in young women’s bodies.

Mismatch in Breast and Detector Size during Screening and Diagnostic Mammography Results in Increased Patient Radiation Dose

When using mammographic detectors of different sizes, it can be difficult to match patient breast size to optimal detector size. We studied whether a mismatch between breast size and optimal detector size resulted in increased radiation exposure. All screening and diagnostic (Dx) mammography patients during a 6-week period in November-December 2009 (864 patients) were evaluated (institutional review board exemption for quality assurance studies). Data gathered included breast size (large or small), detector size used, number of views obtained, mean glandular dose (MGD) per breast, and patient waiting time. Average MGD and average waiting time was calculated for imaging performed on appropriately matched or mismatched breast size-detector size pairs. Screening mammography patients with large breasts imaged on a small detector received a significantly higher radiation dose (4.9 vs. 3.3mGy, P<.05) and a greater number of views (5.9 vs. 4.6, P<.05) compared to optimally matched breast-detector pairs. Dx mammography patients with large breasts imaged on a small detector received a higher radiation dose (8.2 vs. 6.7mGy, P<.05) compared to optimally matched breast-detector pairs, although without an increased number of views. Waiting times were longer for a large detector. A mismatch in breast-detector sizes results in a significantly greater radiation dose to patients with large breasts imaged on a small detector. Pressure to minimize patient waiting time may inadvertently result in increased radiation dose. Detector size should be matched to breast size whenever possible, but particularly for patients with larger breast sizes.

Local Recurrence and Survival for the German Centers in the TARGIT-A (TARGeted Intraoperative Radiation Therapy - Alone) Trial

Results: The incidence of radiation induced moist desquamation was 38.9% across 54 patients. Higher values of V105%, V107% and total breast volume were all associated with a significant increase in risk of radiation induced moist desquamation. For V105% >20% (nZ 25), the rate of moist desquamation was 56.0% compared to 24.1% for V105% 5% (n Z 28), the rate of moist desquamation was 57.1% compared to 19.2% for V107% 1200 cm; nZ 21) was an independent predictor of an increase in breast desquamation (p Z .001; RR, 3.1; 95% CI, 1.5 e 6.5). On subset analysis, in women with larger breast size, both the impact of V107% >5% (p Z .004; RR, 3.4) and the impact of V105% >20% (pZ .026; RR, 2.8) was significant. In women with smaller breast size, no significant difference was observed for the impact of V105% (p Z .78; RR, 1.2) or V107% (p Z .28; RR, 2). Conclusions: When treating the whole breast with forward planned IMRT, limiting the volume of breast tissue receiving greater than 105% and 107% of the prescribed dose is associated with a decrease in radiation-induced moist desquamation. Institutional guidelines such as keeping V105% below 20% and V107% below 5% may benefit in ensuring that women are not exposed to an unnecessary risk of acute skin toxicity. The importance is especially evident in the women with larger breasts; intensive efforts should be made to lower the volume of tissue receiving greater than 105% and 107% of the prescribed dose. Author Disclosure: X. Zhao: None. N. Detorie: None. B. Wood: None. P. Sanghvi: None. S. Advani: None. G. Mansy: None.

SU‐C‐108‐07: Possible Implications for Skin Toxicity in Large Breasted Women with the Use of Enhance Dynamic‐Wedged (EDW) Tangential Fields

Purpose: It has been reported that women with large breast sizes (&gt;300 cc) may experience increased skin toxicity when undergoing post‐lumpectomy radiation therapy. Studies have shown that skin dose increases with the use of dynamic wedges during chest wall irradiations. This study will evaluate the increase in skin dose due to using hard‐vs. dynamic‐wedged fields for various breast volumes. We hypothesize the use of enhanced dynamic‐wedged tangential radiation fields will Result in clinically important changes in skin toxicity. Methods: Three phantoms were build with breast volumes 300, 400, and 500 cc. The phantoms were CT scanned and the scans were imported to the TPS for planning. For each phantom, two dosimetrically matched plans were created, one with hard wedged tangential fields and the other using enhanced dynamic‐wedges (EDW). EBT film pieces were placed on various areas on the breast surface for dose measurements. The plans were delivered to each phantom using 6x photon beams. Results: The film data showed an increase of 151%, 22%, and 26% in skin dose due to the use of EDW for 300, 400, and 500 cc breast volumes, respectively. This increase in skin dose was between 9% – 13% of the total prescription dose for EDW and 8% – 10% for HW system. The increased skin dose was evaluated by our clinicians. An increase of 26% was deemed too large and likely to Result in clinically relevant implications for skin toxicity. Conclusion: Based on these results the use of EDW for tangential field radiation therapy of patients with large breasts may increase skin toxicity

Evaluation the consistency of location of moist desquamation and skin high dose area for breast cancer patients receiving adjuvant radiotherapy after breast conservative surgery

BackgroundTo evaluate whether the location of moist desquamation matches high dose area for breast cancer patients receiving adjuvant radiotherapy (RT) after breast conservative surgery.MethodsOne hundred and nine breast cancer patients were enrolled to this study. Their highest skin dose area (the hot spot) was estimated from the treatment planning. We divided the irradiated field into breast; sternal/parasternal; axillary; and inframammary fold areas. The location for moist desquamation was recorded to see if it matches the hot spot. We also analyzed other possible risk factors which may be related to the moist desquamation.ResultsForty-eight patients with 65 locations developed moist desquamation during the RT course. Patients with larger breast sizes and easy to sweat are two independent risk factors for moist desquamation. The distribution of moist desquamation occurred most in the axillary area. All nine patients with the hot spots located at the axillary area developed moist desquamation at the axillary area, and six out of seven patients with the hot spots located at the inframammary fold developed moist desquamation there. The majority of patients with moist desquamation over the breast or sternal/parasternal areas had the hot spots located at these areas.ConclusionsFor a patient with moist desquamation, if a hot spot is located at the axillary or inframammary fold areas, it is very likely to have moist desquamation occur there. On the other hand, if moist desquamation occurs over the breast or sternal/parasternal areas, we can highly expect these two areas are also the hot spot locations.

Long-term follow-up of late morbidity, cosmetic outcome and body image after breast conserving therapy. A study from the Danish Breast Cancer Cooperative Group (DBCG)

The Danish Breast Cancer Cooperative Group (DBCG) introduced BCT as a standard treatment in Denmark in 1990. The aim of this study was to investigate late morbidity, cosmetic outcome, and body image after BCT and to associate these outcome variables with patient, tumor, and treatment characteristics. Material and methods. A total of 214 patients treated with BCT from 1989–2002 participated in a long-term follow-up visit comprising an interview, clinical examination, photos of the breast region and completion of a questionnaire on Body Image. Results. Median follow-up time was 12 years (range 7–20). Moderate to severe fibrosis was found in 23% of patients and was associated with chemotherapy [OR 2.6, CI (1.1; 5.9), p = 0.02], large breast size [OR 3.2, CI (1.6; 6.4), p = 0.001], and smoking [OR 2.4, CI (1.1; 4.9), p = 0.02]. Patients with a satisfactory cosmetic outcome, when assessed by a clinician, were characterized by small tumors [OR 3.2, CI (1.5; 6.8), p = 0.003] and small to medium sized breasts [OR 2.0, CI (1.1; 3.5), p = 0.002]. Fifty percent of patients scored good or excellent when assessed by a clinician compared to 88% when reported by the patients themselves. Patients satisfied with their own cosmetic outcome were the younger patients [< 50 years; OR 3.2, CI (1.1; 8.6), p = 0.03] with no postoperative complications [OR 3.3, CI (1.2; 9.2), p = 0.02]. Regarding body image 15% felt less feminine, 25% felt less sexually attractive, and 28% of patients had changed their clothing habits as a result of the disease or treatment. Conclusion. The majority of patients were satisfied with their cosmetic outcome after BCT, whereas only half of the patients were found to have a good or excellent cosmetic outcome when assessed by the clinician. Body image was found to be only minimally disturbed in the majority of patients. The level of moderate to severe fibrosis was acceptable compared to both national and international studies with similar patient compositions.

Five-year Results of Whole Breast Intensity Modulated Radiation Therapy for the Treatment of Early Stage Breast Cancer: The Fox Chase Cancer Center Experience

To report the 5-year outcomes using whole-breast intensity-modulated radiation therapy (IMRT) for the treatment of early-stage-breast cancer at the Fox Chase Cancer Center. A total of 946 women with early-stage breast cancer (stage 0, I, or II) were treated with IMRT after surgery with or without systemic therapy from 2003-2010. Whole-breast radiation was delivered via an IMRT technique with a median whole-breast radiation dose of 46 Gy and median tumor bed boost of 14 Gy. Endpoints included local-regional recurrence, cosmesis, and late complications. With a median follow-up of 31 months (range, 1-97 months), there were 12 ipsilateral breast tumor recurrences (IBTR) and one locoregional recurrence. The 5-year actuarial IBTR and locoregional recurrence rates were 2.0% and 2.4%. Physician-reported cosmestic outcomes were available for 645 patients: 63% were considered "excellent", 33% "good", and <1.5% "fair/poor". For physician-reported cosmesis, boost doses≥16 Gy, breast size>900 cc, or boost volumes>34 cc were significantly associated with a "fair/poor" cosmetic outcome. Fibrosis, edema, erythema, and telangectasia were also associated with "fair/poor" physician-reported cosmesis; erythema and telangectasia remained significant on multivariate analysis. Patient-reported cosmesis was available for 548 patients, and 33%, 50%, and 17% of patients reported "excellent", "good", and "fair/poor" cosmesis, respectively. The use of a boost and increased boost volume: breast volume ratio were significantly associated with "fair/poor" outcomes. No parameter for patient-reported cosmesis was significant on multivariate analysis. The chances of experiencing a treatment related effect was significantly associated with a boost dose≥16 Gy, receipt of chemotherapy and endocrine therapy, large breast size, and electron boost energy. Whole-breast IMRT is associated with very low rates of local recurrence at 5 years, 83%-98% "good/excellent" cosmetic outcomes, and minimal chronic toxicity, including late fibrosis.

Given breast cancer, does breast size matter? Data from a prospective breast cancer cohort

Body mass index (BMI), waist-to-hip ratio (WHR), and tumor characteristics affect disease-free survival. Larger breast size may increase breast cancer risk, but its influence on disease-free survival is unclear. The purpose of this study was to elucidate whether breast size independently influenced disease-free survival in breast cancer patients. Body measurements were obtained preoperatively from 772 breast cancer patients in a population-based ongoing cohort from southern Sweden. The research nurse measured breast volumes with plastic cups used by plastic surgeons doing breast reductions. Clinical data were obtained from patient charts and pathology reports. Patients with a BMI≥25kg/m(2) had larger tumors (p<0.001) and more axillary nodal involvement (p=0.030). Patients with a WHR>0.85 had larger tumors (p=0.013), more advanced histological grade (p=0.0016), and more axillary nodal involvement (p=0.012). Patients with right+left breast volume≥850mL were more likely to have larger tumor sizes (p=0.018), more advanced histological grade (p=0.031), and more axillary nodal involvement (p=0.025). There were 62 breast cancer events during the 7-year follow-up. Breast volume≥850mL was associated with shorter disease-free survival (p=0.004) and distant metastasis-free survival (p=0.001) in patients with estrogen receptor (ER)-positive tumors independent of other anthropometric measurements and age. In patients with ER-positive tumors, breast size was an independent predictor of shorter disease-free (HR 3.64; 95% CI 1.42-9.35) and distant metastasis-free survival (HR 6.33; 95%CI 1.36-29.43), adjusted for tumor characteristics, BMI, age, and treatment. A simple and cheap anthropometric measurement with standardized tools may help identify a subgroup of patients in need of tailored breast cancer therapy.

Reconstruction mammaire et irradiation adjuvante des cancers du sein

Radical mastectomy is still required in many cases, such as inflammatory breast cancer, multicentric breast cancer, large tumour volume and small breast size. In this setting, immediate breast reconstruction is more and more offered for breast cancer patients. But such plastic surgery is still debated, owing to risks of implant complications when postoperative radiotherapy of chest wall is mandatory in locoregional breast cancer management. Here, the review is focused on different type of immediate breast reconstruction and on risk of implants complications with or without postoperative radiotherapy.

Hypofractionated Whole-Breast Radiation Therapy: Does Breast Size Matter?

To evaluate the effects of breast size on dose-volume histogram parameters and clinical toxicity in whole-breast hypofractionated radiation therapy using intensity modulated radiation therapy (IMRT). In this retrospective study, all patients undergoing breast-conserving therapy between 2005 and 2009 were screened, and qualifying consecutive patients were included in 1 of 2 cohorts: large-breasted patients (chest wall separation>25 cm or planning target volume [PTV]>1500 cm3) (n=97) and small-breasted patients (chest wall separation<25 cm and PTV<1500 cm3) (n=32). All patients were treated prone or supine with hypofractionated IMRT to the whole breast (42.4 Gy in 16 fractions) followed by a boost dose (9.6 Gy in 4 fractions). Dosimetric and clinical toxicity data were collected and analyzed using the R statistical package (version 2.12). The mean PTV V95 (percentage of volume receiving>=95% of prescribed dose) was 90.18% and the mean V105 percentage of volume receiving>=105% of prescribed dose was 3.55% with no dose greater than 107%. PTV dose was independent of breast size, whereas heart dose and maximum point dose to skin correlated with increasing breast size. Lung dose was markedly decreased in prone compared with supine treatments. Radiation Therapy Oncology Group grade 0, 1, and 2 skin toxicities were noted acutely in 6%, 69%, and 25% of patients, respectively, and at later follow-up (>3 months) in 43%, 57%, and 0% of patients, respectively. Large breast size contributed to increased acute grade 2 toxicity (28% vs 12%, P=.008). Adequate PTV coverage with acceptable hot spots and excellent sparing of organs at risk was achieved by use of IMRT regardless of treatment position and breast size. Although increasing breast size leads to increased heart dose and maximum skin dose, heart dose remained within our institutional constraints and the incidence of overall skin toxicity was comparable to that reported in the literature. Taken together, these data suggest that hypofractionated radiation therapy using IMRT is a viable and appropriate therapeutic modality in large-breasted patients.