title: Accelerated partial-breast irradiation with interstitial implants. Analysis of factors affecting cosmetic outcome.
abstract: OBJECTIVE
  To analyze patient-, disease-, and treatment-related factors for their impact on cosmetic outcome (CO) after interstitial multicatheter accelerated partial-breast irradiation (APBI).
  
  
  METHODS
  Between April 2001 and January 2005, 171 patients with early breast cancer were recruited in Erlangen for this subanalysis of the German-Austrian APBI phase II-trial. 58% (99/171) of the patients received pulsed-dose-rate (PDR), and 42% (72/171) high-dose-rate (HDR) brachytherapy. Prescribed reference dose for HDR brachytherapy was 32 Gy in eight fractions of 4 Gy, twice daily. Prescribed reference dose in PDR brachytherapy was 49.8 Gy in 83 consecutive fractions of 0.6 Gy each hour. Total treatment time was 3-4 days. Endpoint of this evaluation was the CO, graded as excellent, good, fair, or poor. Patients were divided in two groups with an excellent (n = 102) or nonexcellent (n = 69) cosmetic result. Various factors were analyzed for their impact on excellent CO.
  
  
  RESULTS
  The median follow-up time was 52 months (range: 21-91 months). Cosmetic results were rated as excellent in 59.6% (102/171), good in 29.8% (51/171), fair in 9.9% (17/171), and poor in 0.6% (1/171). The initial cosmetic status was significantly worse for the nonexcellent CO group (p = 0.000). The percentage of patients who received PDR brachytherapy APBI was higher in the nonexcellent CO group (68.1% vs. 51%; p = 0.026). Acute toxicity was higher in the nonexcellent CO group (24.6% vs. 12.7%; p = 0.045). Furthermore, the presence of any late toxicity was found to be associated with a worse cosmetic result (65.2% vs. 18.6%; p = 0.000). In detail, the appearance of skin hyperpigmentation (p = 0.034), breast tissue fibrosis (p = 0.000), and telangiectasia (p = 0.000) had a negative impact on CO.
  
  
  CONCLUSIONS
  The initial, surgery-associated cosmetic status, brachytherapy modality, and the presence of acute and late toxicities were found to have an impact on overall CO. Our data have proven that further treatment optimization is possible. Investigations are necessary, especially on the basis of CT-based brachytherapy planning, to further improve the treatment results of multicatheter APBI.
authors.affiliation: Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany. oliver.ott@uk-erlangen.de
authors.forename: Oliver J
authors.initials: OJ
authors.lastname: Ott
authors.forename: Michael
authors.initials: M
authors.lastname: Lotter
authors.forename: Rainer
authors.initials: R
authors.lastname: Fietkau
authors.forename: Vratislav
authors.initials: V
authors.lastname: Strnad