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Aims: Breast radiotherapy-associated toxicity is often reported using clinical and photographic assessments. The addition of patient-reported outcome measures (PROMs) is becoming more common. This study investigated the concordance between clinician- and patient-reported outcomes., Materials and Methods: The Cambridge Breast Intensity-modulated Radiotherapy (IMRT) trial prospectively collected data on clinician assessment and PROMs at 2 and 5 years after breast radiotherapy. Clinician assessment included physical examination and photographic assessment. PROMs included European Organization for Research and Treatment of Cancer (EORTC) BR23 questionnaire and four breast radiotherapy-specific questions. The correlation between patient and clinician scores were analysed on an independent patient basis using percentage agreement, Cohen's kappa coefficient (k) and Bowker's test of symmetry. The analysis was repeated after stratifying patients based on age, baseline Hospital Anxiety and Depression Score (HADS) and baseline body image score., Results: At 2 and 5 years, a weak level of concordance was seen between the clinician-based assessment and PROMS for all the five toxicity end points (k = 0.05-0.21), with individual patient-based agreement of 32.9-78.3% and a highly discordant Bowker's test of symmetry (P < 0.001). The most frequently reported moderate-severe toxicity by patients was change in breast appearance (14% at both 2 and 5 years), whereas it was breast induration (36% and 25% at 2 and 5 years, respectively) by the clinicians. The lack of concordance was not affected by patient's age, baseline HADS and baseline body image score., Conclusions: This study found that moderate-severe toxicity reported by patients is low and the overall concordance between clinicians and patients is low. This could be due to methodological limitations or alternatively reflects the subjective nature of PROMs. Incorporation of a patient's perception on treatment-related toxicity will have important implications for treatment decisions and follow-up care., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Aims: The target volume for breast radiotherapy after conservative surgery for breast cancer may be affected by breathing motion. We investigated differences between conventional and four-dimensional computed tomography-based treatment planning and whether gating could improve dose volume parameters., Materials and Methods: Ten patients with left-sided breast cancer and surgical clips at the excision site had conventional treatment planning computed tomography and four-dimensional computed tomography. Treatment plans using two tangential beams (6 MV X-rays) were optimised for target coverage and homogeneity using a field in field technique for the three-dimensional scan. This plan was applied directly to four-dimensional datasets representing individual phases of the breathing cycle and combinations thereof (average and maximum intensity projection). Optimised plans were generated for the maximum inhalation scan to study what could potentially be achieved in gated radiotherapy., Results: Four-dimensional computed tomography with effective doses of around 10 mSv proved to be adequate for treatment planning in all patients. The average motion of the surgical clips was 3.7 mm (range 1.7-6.5mm), which was similar to the movement of the chest wall. With a margin of 7 mm for the whole breast to planning target volume, conventional three-dimensional computed tomography-based planning was found to adequately cover the target as seen on four-dimensional computed tomography without significant differences in normal tissue sparing. Improved sparing of the heart and lung could only be achieved by reducing the posterior margin of the target volume, which may be justified if four-dimensional computed tomography is used to determine the target and its motion., Conclusion: No significant benefit has been shown for the use of four-dimensional computed tomography-based planning if motion management is not implemented concurrently with a reduced posterior margin between clinical and planning target volumes., (Copyright © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: To report the radiation planning dosimetric aspects and clinical outcomes of patients with implanted cardiac pacemakers., Materials and Methods: Between 2005 and 2009, eight patients with in situ cardiac pacemakers of varied primary site were treated at our hospital. All patients underwent computed tomography-based treatment planning. The target volumes, organs at risk and pacemaker device were all contoured. A treatment plan optimally covering the target area and maximally sparing the pacemaker was generated. All patients were evaluated at baseline, during radiotherapy and after radiotherapy conclusion by a cardiologist as well as pacemaker company personnel., Results: The median age at presentation was 67 (range 53-77) years. There were three men with head and neck primaries, two men with lung primaries and three women with breast primaries. The prescribed dose ranged from 45 to 70 Gy in 25-35 fractions with a daily dose of 1.8-2.0 Gy. Four patients had the pacemaker implanted on the same side as the radiotherapy target. The dose ranges for the minimum, mean and maximum doses to the pacemaker were 0.06-2.0, 0.07-20.6 and 0.14-60.0 Gy, respectively. Radiation therapy was safely delivered in all patients without any untoward effects. At 5 months of median follow-up, all patients were well with no malfunction of the pacemaker., Conclusion: A series of eight patients with in situ pacemakers treated with radiotherapy is reported. Radiotherapy can be safely delivered in patients with implanted cardiac pacemakers. However, it mandates a cautious approach in planning and treatment delivery to ensure the least possible dose to the pacemaker. Close liaison with the cardiologist and a pacemaker clinic before, during and after the course of treatment is essential to ensure patient safety., (Copyright © 2010 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: Post-lumpectomy breast radiation is the standard of care for all patient subgroups. However, elderly women with stage I breast cancer on adjuvant tamoxifen therapy have a 4% risk of local recurrence after lumpectomy without adjuvant breast radiation. The purpose of this study was to explore the attitudes of Canadian radiation oncologists who treat breast cancer with respect to their use of adjuvant post-lumpectomy radiotherapy, and their willingness to implement a decision aid for this patient population., Materials and Methods: The questionnaire was mailed to 141 Canadian radiation oncologists who treat breast cancer. The respondents were asked to complete an online survey consisting of four parts: (1) demographic information; (2) factors determining post-lumpectomy radiation treatment decisions; (3) hypothetical case scenarios; (4) interest in using a decision aid in their practice., Results: Among the 61 (43%) physicians who completed the survey, there was substantial response variation. After contraindications to radiotherapy, patient overall health and patient preference had the greatest influence on their decision to offer radiotherapy to this patient subgroup. Margin status and use of hormonal therapy were given less importance. For each of the case scenarios, 60-83% of physicians (depending on the case scenario) would offer the patient a choice; far fewer (12-57%) would be comfortable not irradiating. Sixty-four per cent of respondents welcomed the concept of a decision aid for this population., Conclusions: Although there is significant variation in practice patterns and attitudes among radiation oncologists regarding post-lumpectomy radiotherapy for elderly, low-risk breast cancer patients, the vast majority value patient choice and would be willing to use a decision aid designed for this population in their practice., (2009 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aims: A pilot study was undertaken with the aim of documenting acute skin reactions and 2-year late adverse effects of a five-fraction course of adjuvant whole breast radiotherapy delivered over 15 days after local tumour excision of early breast cancer., Materials and Methods: Thirty women with early invasive breast cancer aged>or=50 years with a pathological tumour size<3 cm, complete microscopic resection, negative axillary node status and no requirement for cytotoxic therapy were prescribed 30 Gy in five fractions over 15 days to the whole breast using tangential 6-10 MV X-ray beams and three-dimensional dose compensation with written informed consent. Post-surgical baseline photographs of the breasts were taken, and acute skin erythema and moist desquamation were each scored weekly for 7 weeks using four-point graded scales (grade 0=none, 1=mild, 2=moderate, 3=severe). This was followed by an annual clinical assessment, including repeat photographs at 2 years., Results: Nine patients (30%, 95% confidence interval 14.7-49.4%) developed grade 2 erythema, with the remaining 21 patients developing milder degrees of reaction. Four (13.3%, 95% confidence interval 3.7-30.7) patients developed moist desquamation, grade 1 in three women and grade 2 in the fourth. At 2 years after treatment, 23/30 (77%) patients scored no change in photographic breast appearance compared with the pre-treatment baseline; seven (23%, 95% confidence interval 9.9-42.3) scored a mild change in breast appearance, and none developed a marked change. After a mean follow-up of 3.1 years (standard deviation 0.37, range 2.1-3.9 years) there have been no ipsilateral local tumour relapses., Conclusions: Further evaluation of a five-fraction regimen of adjuvant whole breast radiotherapy in a phase III randomised trial is justified, including a regimen delivered in a total of 5 days.

Aims: To evaluate the incidence of locoregional recurrence (LRR) and the cosmetic results in a group of patients with breast cancer treated with a hypofractionated schedule of adjuvant radiotherapy after conservative surgery., Materials and Methods: In total, 539 patients with pTis-pT1-pT2 breast cancer underwent radiotherapy treatment after conservative surgery at the University of Florence and at the Pistoia Hospital. The dose delivered was 44 Gy (2.75 Gy daily fraction). The tumour bed boost (10 Gy) was given by electrons., Results: At the time of the analysis, 1.8% of patients (10/539) had breast relapse. No patients developed nodal recurrence (supraclavicular, axillary and internal mammary nodes). The 3- and 5-year actuarial rates for LRR were 1.2% (+/- 0.5% standard error) and 2.1% (+/- 0.6% standard error), respectively. Considering the late toxicity, we found that 412 (76.4%) patients had grade 0 or grade 1 late toxicity, 113 patients (20.9%) had grade 2 late toxicity and 14 patients (2.5%) had grade 3 late toxicity. No patients developed grade 4 toxicity., Conclusion: This type of approach resulted in an effective treatment in terms of local control in patients with negative or one to three positive axillary nodes and negative surgical margins. Patients treated with a hypofractionated schedule showed very good cosmesis.

Randomised trials have established that the addition of a boost dose of radiotherapy to the lumpectomy site after whole-breast adjuvant radiotherapy further improves local control achieved by whole-breast radiotherapy alone. The absolute size of this benefit varies according to the baseline risk of local recurrence. Age is the strongest predictor of benefit. Below the age of 40 years, the absolute benefit of a boost seems to be substantial, and there are no clearly identified groups unlikely to benefit. Above the age of 50 years, the benefit is small, and several additional risk factors for local failure would need to be present to merit boost treatment. These may include tumour size, high grade, high mitotic rate, lymphovascular invasion, extensive and high grade associated with intraduct carcinoma, receptor-positive tumours when avoidance of anti-oestrogen therapy is desired or receptor-negative tumours. Other independent reasonable indications for the use of a boost would be positive margins where further surgery is not indicated. If a boost is indicated, a variety of techniques may be used and toxicity and cosmetic results remain highly acceptable. Overall, there seems to be no substantial differences in boost technique results; however, interstitial techniques may have advantages for deeper targets compared with electrons. Irrespective of technique, accurate localisation will maximise the benefit of a boost. Surgical clips are strongly recommended to facilitate localisation.

Whole-breast irradiation after lumpectomy for early-stage breast cancer appears to prevent relapse only at the site of initial involvement, and therefore it is likely that radiation can safely be limited to tissues immediately surrounding the excision cavity. Accelerated partial-breast irradiation (APBI) with the MammoSite catheter (Proxima Therapeutics, Alpharetta, GA) has been proposed as a means through which APBI can be offered to a wide range of patients. Although sufficient follow-up is not yet available regarding local control, survival, late toxicity, and long-term cosmetic results, early results are promising. This article reviews the current literature reflecting treatment, dose optimization, outcomes, and toxicity of APBI with the MammoSite brachytherapy catheter.

Aim: To assess the clinical outcome of breast cancer patients with immediate autologous breast reconstruction and post-mastectomy radiotherapy (PMRT) as primary treatment., Materials and Methods: Twenty-five women with breast cancer treated with immediate autologous breast reconstruction and post-mastectomy radiotherapy as primary treatment between 1995 and 2001 in Pamela Youde Nethersole Eastern Hospital of Hong Kong were retrospectively studied. Radiation doses of 50 Gy (in 2 Gy daily fraction) were given to the reconstructed breasts, except one who was given 45 Gy (in 1.8 Gy daily fraction). Nine women (36%) were treated without bolus, whereas the other 16 women (64%) were treated with 0.5 cm thick bolus on alternate days. The main outcome measures include local control, treatment complications and cosmetic outcome., Results: Median follow-up was 3.7 years (range: 1.0-6.6 years). Two women (8%), who were treated without bolus, developed chest wall recurrences. The overall 5-year, actuarial, local failure-free rate and disease-specific survival rate were 89.8% and 77.9%, respectively. Apart from mild acute skin reactions, no significant acute radiotherapy side-effects were observed. No flap necrosis or flap loss was seen. The cosmesis of the reconstructed breasts were rated as good to excellent in 85% of the surviving patients. There was no observed adverse effect on cosmesis by adding bolus on alternate days., Conclusion: PMRT after immediate autologous tissue-flap breast reconstruction is well tolerated and is not associated with increased incidence of complications. Adding 0.5 cm bolus on alternate days might improve local control without causing adverse cosmetic effect. The concern of adverse effects of radiotherapy should not exclude the choice of immediate breast reconstruction in suitable patients.

The dramatic increase in the incidence of ductal carcinoma in situ (DCIS) of the breast has made it imperative for all clinicians to develop a better understanding of this disease. Although this preinvasive form of breast cancer is not life-threatening, treatment options may include mastectomy, breast-conserving surgery, radiotherapy, or tamoxifen. Current treatment modalities may be overly aggressive because many cases of DCIS may not recur or progress to invasive cancer. Until we are better able to identify those patients at low risk for progression, it is unlikely that current treatment will change. The adequate understanding of risk assessment is fundamental to the treatment planning for DCIS, and physicians are encouraged to include patients in the decision-making process.

The commonest radiation-induced neoplasms are sarcomas. Ionizing radiation is not usually associated with the development of malignant melanoma. We report two patients with malignant melanoma occurring within a previously irradiated area. There is evidence to support radiation in the pathogenesis of melanoma but the family histories, especially in one patient, suggest that genetic mutations may also have played a role, particularly in relation to the short latent period.

The treatment outcomes were reviewed for all the patients at this institute who underwent breast irradiation after breast conserving surgery in 1991. Of a total of 643 patients treated, 194 (30%) had presented with tumours detected by screening mammography. The breast was irradiated with a tangential pair of fields, giving a dose of 40 Gy in 15 fractions over 3 weeks in 97% of these patients. A boost was not used. With a median follow-up of 4.7 years, there was better cancer related survival in patients with screen detected cancers compared with those that were non-screen detected (94% versus 84% at 5 years; P = 0.002). The breast recurrence rate at 5 years was 1% for screen detected cancers compared with 6% for those that were non-screen detected (P = 0.01). Factors additional to screen detected status that were found to be significant for cancer survival were pathological stage (P = 0.03) and histological grade (P = 0.01). In a Cox multivariate analysis, only two factors were significant for breast recurrence: screen detected status (P = 0.023) and histological grade (P = 0.016). This study suggests that breast irradiation with 40 Gy given over 3 weeks after breast conserving surgery for screen detected breast cancer gives a high level of local control out to 5 years.

A male patient with ductal carcinoma in situ (DCIS) of the breast, treated with lumpectomy and postoperative breast irradiation, is presented. Because of associated obesity, the patient felt that mastectomy would leave him with a noticeable cosmetically unacceptable deformity. Radiotherapy was administered using the exact techniques used to treat the female breast. At 44 months following completion of radiotherapy, the patient is free of disease and has an excellent cosmetic result. Thus, if there are compelling reasons to avoid mastectomy in a male patient, lumpectomy and breast irradiation should be considered as a reasonable alternative for treatment of DCIS.

Late radiotherapy-induced arteriopathy is recognized as an important cause of cerebrovascular disease in patients treated with radiotherapy, usually for head and neck cancers. This case report is an example of radiotherapy-induced left subclavian artery stenosis, which resulted in serious posterior cerebral circulation events after adjuvant radiotherapy for carcinoma of the left breast. In view of the relatively good long term outlook for this disease, it is important to recognize and consider early medical or surgical intervention of such arterial lesions. In this patient, earlier intensive investigations probably would have prevented disabling iatrogenic morbidity.

The combination of breast-conserving surgery and radiation therapy is now accepted as a standard treatment option for most women with clinical stage I or II invasive breast cancer. The great majority of individuals with early stage breast cancer are potential candidates for treatment with conservative surgery and radiation therapy. Nonetheless, for a few patients, such treatment may be absolutely or relatively contraindicated due to toxicity concerns, poor anticipated cosmetic results, or a heightened risk of local failure. This article will discuss the patient, clinical, and pathologic factors relevant to selecting patients for this treatment approach.

This paper describes the results of a national survey on the non-surgical treatment of early breast cancer in the UK relating to the management of ductal carcinoma in-situ (DCIS), and the rationale for the current status of the UK DCIS trial. The survey shows that there is considerable clinical uncertainty, which can only be resolved by the trial.

A rare complication occurring in a female patient who underwent conservative surgery and radiation therapy for breast cancer is described. Three weeks after the completion of radiotherapy, a diffuse bullous pemphigoid eruption developed in the irradiated area, spreading thereafter to the whole body. Although systemic cutaneous side effects have been reported after radiation therapy, this is the first occurrence of bullous pemphigoid ever reported in a female patient following treatment for breast cancer. Having made the diagnosis, an effective therapeutic regimen including nicotinamide and tetracycline was started. As the conservative management of breast cancer is now widely adopted, oncologists and physicians should be aware of such rare side effects due to radiation therapy.

We report a patient with carcinoma of the breast who was undergoing postoperative radiotherapy, and who developed transient acute diarrhoea due to the presence of diaphragmatic eventration.

The most profound impact in the field of breast cancer during the last 15 years has been the development and acceptance of screening mammography: a test capable of finding nonpalpable cancer years before it would have become clinically evident. Many of these nonpalpable lesions are noninvasive; many of them are not even real cancers. The spectrum of treatment for noninvasive breast cancer runs from nothing more than excisional biopsy to bilateral mastectomy. No wonder noninvasive breast cancer is one of the most confusing problems in oncology today, for both patients and physicians.

In 1990, we published the results of a clinical trial involving 708 patients with breast carcinoma of 4 cm or less in diameter, who, following lumpectomy, were randomized to have radiotherapy to the tumour bed only (limited field, LF group) or to the whole breast and regional nodes (wide field, WF group). No adjuvant systemic therapy was prescribed. At the time the median follow-up was 37 months. We present the updated results after an extended median follow-up of 65 months. The overall survival is 72.7% and 71.2% for the LF and WF groups respectively. The actuarial breast recurrence rate (first event) is 15% (LF) versus 11% (WF) for infiltrating ductal carcinoma, whereas, for infiltrating lobular carcinoma, the recurrence rate was 34% (LF) versus 8% (WF). A high actual recurrence rate of 21% (LF) and 14% (WF) was also found for extensive ductal carcinoma in situ. It was extremely rare for medullary, mucoid or tubular carcinomas to recur. Salvage surgery was possible in 86% (LF) and 90% (WF) respectively. The recurrence rate in the breast following lumpectomy and wide field irradiation is comparable with others reported in the literature. This trial also shows the lumpectomy with limited field irradiation is feasible, albeit with a higher breast recurrence rate; the latter could be reduced by improved selection and refinement of the technique.