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Purpose/Objective(s) There is a paucity of data regarding the use of whole breast irradiation (WBI) as part of breast conserving therapy (BCT) in women diagnosed with breast cancer who had undergone prior breast implant-based augmentation. In this population, we investigated various factors that impact radiation related toxicities, including the need for additional cosmetic surgery. Materials/Methods A retrospective review was performed for a single institution, with queries done on health-system medical records, radiation therapy medical records, radiology mammography studies, and internal radiation therapy and toxicity databases. We included patients with a prior history of breast implant-based augmentation who subsequently underwent BCT and WBI. Patient and treatment characteristics were collected and reported, and univariate analyses comparing factors correlating with toxicity endpoints were performed. Long-term cosmesis was assessed by the patient's radiation oncologist during routine follow-up visits via the Harvard grading criteria. Results 35 patients treated at our institution between 2006 and 2020 were included in our analyses, with a median follow up time of 2.4 years. Of these, 28 were treated with conventionally fractionated WBI (1.8-2 Gy/Fx) and 7 were treated with hypofractionated WBI (2.66 Gy/Fx). Good/excellent long-term cosmesis was observed in 94% of all patients. 44% of patients ultimately needed additional cosmetic surgery at some point after radiation. Indications for additional surgery included capsular contracture (10), wound complications (2), implant rupture (1), volume loss (1), and asymmetry (1). Fourteen patients (50%) treated with conventionally fractionated WBI and one patient (14%) patient treated with hypofractionated WBI required additional surgery, but this difference was not significant on UVA (P = 0.12). Other factors found not to be significantly associated with rates of additional surgery included BMI, stage, the volume of the breast receiving 105% or 110% of the prescription dose, and presence or absence of bolus during treatment. No patients experienced local or regional recurrence. Conclusion Patients with a prior history of breast implantation often experience good long-term cosmesis with a moderate risk of needing additional future surgery. The use of hypofractionated WBI was not associated with worse cosmetic outcome or an increase in need for additional cosmetic surgery.

Background This study reports the rate of breast reconstruction failure and cosmetic outcomes after postmastectomy radiation therapy (PMRT) with temporary tissue expanders (TEs) or implants in place. Patients and Methods Ninety-four patients underwent mastectomy (93 unilateral, 1 bilateral; 95 cases total) and immediate TE reconstruction followed by PMRT. Ninety TEs and 5 permanent implants were irradiated. All patients received a dose of 5400 cGy given in 180-cGy fractions to the reconstructed breast. Twenty-one patients (22%) received tangents alone and 74 patients (78%) were treated with tangents and a supraclavicular field using a monoisocentric technique. Bolus was used in 91 patients (96%). Eighty-eight patients (93%) received chemotherapy and 78 patients (82%) received endocrine therapy. Results With a median follow-up of 24.1 months, 19 patients (20%) experienced failure of reconstruction. The 1-, 2-, and 3-year actuarial rate of reconstruction failure was 9.7%, 19.3%, and 25.5%, respectively. Infection was the most common cause of failure. Of the 19 failures, 8 patients underwent salvage procedures with flap reconstruction. Univariate analysis was performed examining age, chemotherapy use, hormone therapy use, use of a supraclavicular field, smoking status, diabetes, hypertension, and menopausal status. No risk factors were found to be associated with reconstruction failure. In patients who did not experience reconstruction failure, good/excellent cosmesis was observed in 75% of patients. Conclusion In the current series of women with a high risk of locoregional recurrence, PMRT with a TE/implant in place provides good cosmesis in the majority of women, with an acceptable risk of expander or implant loss.

Limited data are available on the implementation of a high-risk assessment program in the construct of a community clinical oncology program. The development of a high-risk breast cancer screening program at our institution identified 15%-20% of patients screened as high risk, with limited increases in structural or personnel requirements. Identification of patients as high risk could potentially improve outcomes by allowing for individualized prevention strategies and more appropriate high-risk surveillance.The implementation of a program that incorporates a risk assessment questionnaire (RAQ) to identify high-risk patients in a community-based health system was evaluated.Women with no history of breast cancer or ductal carcinoma in situ who were undergoing annual screening mammography were offered an RAQ. Cases determined to be high risk (Gail lifetime risk ≥20% or as indicated through personal and/or family history) were offered referral to our High-risk Breast Cancer Program. A retrospective data review was conducted on completed questionnaires.A total of 5878 women underwent evaluation with the RAQ between September 2009 and August 2010. The mean age of the cohort was 55 years old, with 84.9% (4990) of participants being white, and 6.8% (400) African American. In the entire population, 45.7% (2446) had at least 1 first-degree relative with breast cancer (BC), and 923 (17.2%) women were found to be high risk by the Gail model. Beyond the Gail model, 53 (0.9%) women had undergone prior chest radiation, 34 (0.6%) had a male relative with BC, 200 (3.4%), had 3 or more relatives with BC on one side of their family, 308 (5.2%) had a relative with breast and ovarian cancer on one side of the family, and 105 (1.8%) noted 2 relatives with BC with onset under age 50 years on the same side of the family.Our experience indicates that the identification of women at high risk for BC can be easily incorporated into an annual screening mammography visit. Identification of these patients as high risk can allow for individualized, more-appropriate surveillance and prevention.

To compare outcomes after accelerated partial breast irradiation (APBI) between node-negative and node-positive patients.A total of 534 patients with early-stage breast cancer received APBI including 39 node-positive (N+) cases. Clinical, pathologic, and treatment-related factors were compared between node-negative (N-) and N+ cohorts. Local recurrence (LR), regional recurrence (RR), axillary failure (AF), distant metastases (DM), disease-free survival (DFS), cause-specific survival (CSS), and overall survival (OS) were analyzed.N+ patients were younger (p = 0.04), had larger tumors (p0.001), and were more likely to receive chemotherapy (p0.001). Mean follow-up was 7.8 years for N+ patients and 6.3 years for N- patients (p = 0.06). No differences were seen in 5-year actuarial rates of LR (2.2% vs. 2.6%, p = 0.86), AF (0% vs. 0%, p = 0.69), DFS (90.0% vs. 88.0%, p = 0.79), or OS (91.0 vs. 84.0%, p = 0.65) between the two groups, whereas higher rates of RR (0% vs. 6.1%, p0.001) and DM (2.2% vs. 8.9%, p = 0.005) were noted in N+ patients. A trend for improved CSS (p = 0.06), was seen in N- patients. Age, tumor size, receptor status, T-stage, chemotherapy, APBI technique, and nodal status (p = 0.86) were not associated with LR, while a trend for an association with LR was noted with close/positive margins, (p = 0.07), and failure to receive adjuvant hormonal therapy (p = 0.06).No differences were seen in the rates of LR or AF between N- and N+ patients after APBI. These results support the continued enrollment of node-positive patients in Phase III trials evaluating the efficacy of APBI including the National Surgical Adjuvant Breast and Bowel Project-B39/Radiation Therapy Oncology Group 0413.

Brachytherapy-Based Accelerated Partial Breast Irradiation Versus Canadian Whole Breast Hypofractionation: A Matched-Pair Analysis of Comparative Effectiveness P.Y. Chen, J. Wilkinson, C.S. Shah, J. Wobb, M. Wallace, H. Ye, P. Benitez, N. Dekhne, D. Brabbins, and F. Vicini; Beaumont Health System, Royal Oak, MI, Summa Akron City/St. Thomas Hospitals, Akron, OH, Michigan Healthcare Professionals/21st Century Oncology of Michigan, Farmington Hills, MI

111 Background: We present the results of an analysis of high-risk breast cancer patients as defined by the NSABP B-39/RTOG 0413 phase III trial, all treated with accelerated partial breast irradiation (APBI) from a single institution. Methods: Between July 1993 and August 2010, 130 patients with any combination of at least one of the high-risk features of estrogen receptor (ER) negativity, age < 50, and/or axillary nodal positivity were treated with 1 of 3 forms of APBI. Sixty-seven patients were treated with interstitial needle-catheter brachytherapy, 44 balloon-based brachytherapy and 19 with 3D conformal external beam radiation therapy. Aside from the high-risk features, general eligibility criteria included infiltrating ductal carcinoma, with inclusion of invasive lobular and DCIS since 2003, margins > 2 mm, and surgically staged axilla. One-hundred eighteen patients had one high-risk factor, 11 had two, and 1 had all three factors. The median tumor size was 12.0 mm with margins > 2 mm in 80% of patients. Greater than 75% had T1 tumors and 50% were ER negative. Thirty-one percent of patients were node positive. Based upon the ASTRO Consensus Guidelines for use of APBI (2009) none of these patients were suitable, 38% cautionary and 62% were unsuitable. Results: Median age was 56.5 yrs (range 40-90). With a median follow-up of 5.3 yrs (0.02-16.9) the 5-yr actuarial local recurrence rate (LR) was 4.2%; regional recurrence (RR) was 2.1%. Median time to LR and RR were 1.2 and 2.8 yrs, respectively. On univariate analysis, the only factor significant for LR was a close/positive margin (p=0.031), as ER/PR, age, nodal status, tumor size, histology, grade, hormonal or chemotherapy were all NS. The 5-yr actuarial cause specific, disease-free, and overall survivals as well as distant metastasis were 94%, 91%, 90%, and 6.4%, respectively. Conclusions: This cohort of NSABP B-39/RTOG 0413 identified high-risk patients who have undergone APBI has yielded local-regional control rates and survival outcomes comparable to standard risk patients undergoing partial breast irradiation. Continued follow-up will be needed to assess the long-term efficacy of such high-risk breast cancer patients treated with APBI.