title: Unacceptable cosmesis in a protocol investigating intensity-modulated radiotherapy with active breathing control for accelerated partial-breast irradiation.
abstract: OBJECTIVE
  To report interim cosmetic results and toxicity from a prospective study evaluating accelerated partial-breast irradiation (APBI) administered using a highly conformal external beam approach.
  
  
  METHODS
  We enrolled breast cancer patients in an institutional review board-approved prospective study of APBI using beamlet intensity-modulated radiotherapy (IMRT) at deep-inspiration breath-hold. Patients received 38.5 Gy in 3.85 Gy fractions twice daily. Dosimetric parameters in patients who maintained acceptable cosmesis were compared with those in patients developing unacceptable cosmesis in follow-up, using t-tests.
  
  
  RESULTS
  Thirty-four patients were enrolled; 2 were excluded from analysis because of fair baseline cosmesis. With a median follow-up of 2.5 years, new unacceptable cosmesis developed in 7 patients, leading to early study closure. We compared patients with new unacceptable cosmesis with those with consistently acceptable cosmesis. Retrospective analysis demonstrated that all but one plan adhered to the dosimetric requirements of the national APBI trial. The mean proportion of a whole-breast reference volume receiving 19.25 Gy (V50) was lower in patients with acceptable cosmesis than in those with unacceptable cosmesis (34.6% vs. 46.1%; p = 0.02). The mean percentage of this reference volume receiving 38.5 Gy (V100) was also lower in patients with acceptable cosmesis (15.5% vs. 23.0%; p = 0.02).
  
  
  CONCLUSIONS
  The hypofractionated schedule and parameters commonly used for external beam APBI and prescribed by the ongoing national trial may be suboptimal, at least when highly conformal techniques such as IMRT with management of breathing motion are used. The V50 and V100 of the breast reference volume seem correlated with cosmetic outcome, and stricter limits may be appropriate in this setting.
authors.affiliation: Department of Radiation Oncology, University of Michigan Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI 48109-5010, USA. rjagsi@med.umich.edu
authors.forename: Reshma
authors.initials: R
authors.lastname: Jagsi
authors.forename: Merav A
authors.initials: MA
authors.lastname: Ben-David
authors.forename: Jean M
authors.initials: JM
authors.lastname: Moran
authors.forename: Robin B
authors.initials: RB
authors.lastname: Marsh
authors.forename: Kent A
authors.initials: KA
authors.lastname: Griffith
authors.forename: James A
authors.initials: JA
authors.lastname: Hayman
authors.forename: Lori J
authors.initials: LJ
authors.lastname: Pierce
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001940:Breast / Q000473:pathology / Q000528:radiation effects*; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000532:radiotherapy*; D019583:Dose Fractionation, Radiation; D004954:Esthetics; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D011859:Radiography; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects* / Q000379:methods; D012119:Respiration; D016896:Treatment Outcome; D047368:Tumor Burden