Objective: To determine the clinically observed incidence and severity of acute skin toxicity with breast intensity modulated radiation therapy (IMRT), and compare the results with a matched cohort of patients treated by conventional radiation therapy. Our hypothesis is that measures to decrease dose inhomogeneity within the breast and skin with IMRT will improve acute skin toxicity. Materials and Methods: The study population consists of 73 women with early stage breast cancer treated with breast-conserving surgery and IMRT. The IMRT technique involves an iteration method for optimization to generate the IMRT plan, Monte Carlo dose calculation, and a step-and-shoot technique using multileaf collimation for beam delivery. Other aspects of the technique including the clinical definition of the clinical target volume by the physician, patient positioning, tangential beam orientation, dose and field sizes were unchanged compared conventional tangential radiation. These patients were matched one-to-one to a control group of 60 women treated with conventional photon radiation by using their bra size and chest wall separation. The study end point was acute skin toxicity. Results: There were no observed differences in the acute toxicity based upon common terminology criteria for adverse events (CTC) for acute radiation dermatitis. There was no desquamation in 42% of IMRT patients, dry desquamation in 37% and moist desquamation in 21%. The degree of desquamation was greater for conventional patients compared with IMRT patients -52% grade 0, 10% grade 1, and 38% grade 2 (P = 0.001). Subgroup analysis showed desquamation was significantly lower with IMRT for small (P = 0.038) and large breast sizes (P = 0.037), but not medium sizes (P = 0.454). For large breast sizes, the incidence of moist desquamation grade 2 was 48% with IMRT compared with 79% in controls. Significant predictors of moist desquamation on stepwise logistic regression were use of IMRT (P = 0.0011) and breast size (P < 0.0001). Conclusions: IMRT is associated with a decrease in severity of acute desquamation compared with a matched control group treated with conventional radiation therapy. As with conventional radiation, breast size remains the most important prognostic factor for acute skin toxicity. The CTC grading system for acute radiation dermatitis is not sensitive when applied to modem breast cancer treatment because of its dependence of subjective rating of erythema and inability to gauge variations in desquamation. Further study of patient symptoms, quality of life, and cosmesis is needed to evaluate the benefit of IMRT for breast cancer.

Intensity modulated radiation therapy (IMRT) decreases acute skin toxicity for women receiving radiation for breast cancer.

Background. To quantify the risk of soft tissue and bone sarcomas after breast cancer according to the doses and technical modalities of irradiation. Methods. We followed a cohort of 6597 breast-cancer patients for 8.3 years on average. The number of soft tissue and bone sarcomas was compared to the expected number based on the incidence rates in the general French population. We also estimated the risk of sarcoma according to the radiation dose received at site of the sarcoma in a nested case control study of 14 breast-cancer patients who subsequently developed a sarcoma and 98 controls matched for age at diagnosis of breast cancer, period of initial treatment and length of follow-up. Results. In the cohort-study, 12 women who had initially received radiotherapy treatment developed a bone or soft tissue sarcoma during the follow-up period. The expected number of cases during this period was 1.7 (SIR=7.0, 95% CI: 3.7–11.7) and the mean annual excess incidence during the same period was 21 per 100,000 person-years. The 15-year cumulative incidence of sarcoma was 0.28% (95% CI: 0.10–0.45%). In the case–control study, all the 14 cases had received at least 11.8 Gray at the site of the sarcoma, which was always located in the irradiated field or in the upper ipsilateral extremity of the arm. A dose–effect relationship was observed (p < 0.001). The best fit was obtained for a quadratic dose–response relationship, without a negative exponential term for cell killing at high doses. The risk of sarcoma was 30.6 higher for doses of more than 44 Gray than for doses of less than 15 Gray. Conclusions. High doses of radiation strongly increase the risk of bone and soft tissue sarcoma.

Radiation dose and risk of soft tissue and bone sarcoma after breast cancer treatment.

Scarring is considered a major medical problem that leads to cosmetic and functional sequelae. Scar tissue is clinically distinguished from normal skin by an aberrant color, rough surface texture, increased thickness (hypertrophy), occurrence of contraction, and firmness. Marked histologic differences are the change in dermal architecture and the presence of cells such as the myofibroblast. Many assessment tools are available for analysis of pathologic conditions of the skin; however, there is no general agreement as to the most appropriate tools for evaluation of scar tissue. This review critically discusses currently available objective measurement tools, subjective assessment tools, and potential devices that may be available in the future for scar assessment.

Scar assessment tools: implications for current research.

Purpose: To evaluate the long-term toxicity after breast-conserving therapy in women with early-stage breast cancer. Methods and Materials: Late toxicity according to the late effects of normal tissue–subjective, objective, management, and analytic (LENT-SOMA) criteria and cosmetic outcome (graded by physicians) were evaluated in 590 of 2943 women with early-stage breast cancer who were irradiated between 1983 and 1995 using the following fractionation schedules: group A, 1983–1987, 2.5 Gy 4x/wk to 60 Gy; group B, 1988 –1993, 2.5 Gy 4x/wk to 55 Gy, group C, 1994 –1995, 2.0 Gy 5x/wk to 55 Gy. Results: LENT-SOMA Grade 3-4 toxicity was observed as follows: group A (median follow-up 171 months; range 154 –222 months), fibrosis 16% (7 of 45), telangiectasia 18% (8 of 45), and atrophy 4% (2 of 45); group B (median follow-up 113 months; range 78 –164 months), pain 2% (8 of 345), fibrosis 10% (34 of 345), telangiectasia 10% (33 of 345), arm edema 1% (2 of 345), and atrophy 8% (27 of 345); and group C (median follow-up 75 months, range 51–96 months, n 200), occurrence of Grade 3-4 late morbidity <2%. The cosmetic outcome was very good to acceptable in 78% (35 of 45) of patients in group A, 83% (286 of 345) in group B, and 94% (187 of 200) in group C. Conclusion: In our population, the long-term side effects after breast-conserving therapy were not rare, but were mainly asymptomatic. The LENT-SOMA breast module is a practical tool to assess radiation-induced long-term toxicity. © 2003 Elsevier Science Inc. Breast cancer, Radiotherapy, Late toxicity, Cosmesis, LENT-SOMA.

Long-term radiation sequelae after breast-conserving therapy in women with early-stage breast cancer: an observational study using the LENT-SOMA scoring system.

Male versus female skin: What dermatologists and cosmeticians should know.

Purpose: Late radiation-induced skin effects were studied in a multicenter project using our new sensitive noninvasive viscoelasticity skin analyzer (VESA). Methods and Materials: Skin viscoelasticity and anisotropy were examined quantitatively in symmetric areas of both breasts in healthy women and in 110 breast cancer patients who underwent lumpectomy and radiotherapy. These parameters were evaluated by the VESA measurement of the speed of elastic wave propagation in the skin; higher VESA readings correspond to higher skin stiffness. Effect of radiation was estimated by comparison of the data recorded in the irradiated versus nonirradiated breast of the same patient. Results: Skin viscoelasticity and anisotropy were similar in contralateral areas of the breasts in healthy controls as well as in the nonirradiated breasts of the patients. With age, skin viscoelasticity decreased and anisotropy increased similarly in both breasts. Radiotherapy, by a total radiation dose in the range of 45–50 Gy given with 1.8 Gy/fraction (fx) resulted in a similar minor, but still statistically significant, increase of skin stiffness relative to control. The effect was more pronounced when a dose of 50 Gy was given in a higher dose/fraction of 2.5 Gy. Conclusion: We found that the increase in dose of radiation per fraction had much more impact on the development of late skin effects than elevation in the total dose given.

Late effects of dose fractionation on the mechanical properties of breast skin following post-lumpectomy radiotherapy

PURPOSE
Late radiation-induced skin effects were studied in a multicenter project using our new sensitive noninvasive viscoelasticity skin analyzer (VESA).


METHODS AND MATERIALS
Skin viscoelasticity and anisotropy were examined quantitatively in symmetric areas of both breasts in healthy women and in 110 breast cancer patients who underwent lumpectomy and radiotherapy. These parameters were evaluated by the VESA measurement of the speed of elastic wave propagation in the skin; higher VESA readings correspond to higher skin stiffness. Effect of radiation was estimated by comparison of the data recorded in the irradiated versus nonirradiated breast of the same patient.


RESULTS
Skin viscoelasticity and anisotropy were similar in contralateral areas of the breasts in healthy controls as well as in the nonirradiated breasts of the patients. With age, skin viscoelasticity decreased and anisotropy increased similarly in both breasts. Radiotherapy, by a total radiation dose in the range of 45-50 Gy given with 1.8 Gy/fraction (fx) resulted in a similar minor, but still statistically significant, increase of skin stiffness relative to control. The effect was more pronounced when a dose of 50 Gy was given in a higher dose/fraction of 2.5 Gy.


CONCLUSION
We found that the increase in dose of radiation per fraction had much more impact on the development of late skin effects than elevation in the total dose given.

Late effects of dose fractionation on the mechanical properties of breast skin following post-lumpectomy radiotherapy (vol 45, pg 893, 1999)

A probe for examining viscoelasticity and anisotrophy of an area of an external layer of a living or artificial tissue, comprises an assembly ( 34 ) including at least one group of piezoelectric spaced-apart transducers ( 78,80,82 ), each having a surface contact making edge, wherein one of said transducers operates as a transmitter and at least one other transducer operates as a receiver, and wherein said assembly is movable both axially, as well as angularly; means for effecting the controlled axial movement ( 22,24 ) of said assembly; means for controlling the contact pressure ( 24 ) to be exerted by the transducers on the surface of an area of a tissue to be examined, and means for effecting angular movement of said assembly ( 18,20 ) at a selected axial displacement.

Device for examining viscoelasticity of a living of artificial tissue

Evaluation of Skin Viscoelasticity and Anisotropy by Measurement of Speed of Shear Wave Propagation With Viscoelasticity Skin Analyzer1

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Late effects of dose fractionation on the mechanical properties of breast skin following post-lumpectomy radiotherapy

Late effects of dose fractionation on the mechanical properties of breast skin following post-lumpectomy radiotherapy (vol 45, pg 893, 1999)

Device for examining viscoelasticity of a living of artificial tissue

Evaluation of Skin Viscoelasticity and Anisotropy by Measurement of Speed of Shear Wave Propagation With Viscoelasticity Skin Analyzer1