METHODS
A total of 65 patients who underwent at least 1 year of treatment for a diagnosis of early stage breast
cancer were included in the study. Whole breast irradiation cases were included in Group A (n=34), and
patients who underwent chemotherapy followed by WBI comprised Group B (n=31). Various details,
including cosmetic outcome and score according to Johansen"s scoring system were evaluated at postoperative
month 1, after first treatment, and at the conclusion of 1 year of treatment.
RESULTS
The mean age of the patients was 53.5 years (range: 38-74 years), and the mean follow-up period was 23
months (range: 12-39 months). The mean tumor diameter was 16.95 mm (range: 4-30 mm). The tumor
was located in the upper outer quadrant in 36 patients. It was determined that 14 patients had a comorbid
disease, 7 were premenopausal, 7 were cigarette smokers, 7 had a tumor of >2 cm and 11 had inner
quadrant localization. In 15 cases, the score was 9 or greater, indicating a poor cosmetic result. There were
7 patients with a poor cosmetic result in Group A, with a mean score of 10, and 8 patients from group
B, with a mean score of 10.3. An independent t-test did not reveal a statistically significant difference
between the groups (p>0.1).
CONCLUSION
The effects of radiotherapy and chemotherapy in addition to BCS and IOBRT in early breast cancer cases
were similar with respect to cosmetic results. Smoking, comorbid disease, the size of the tumor and quadrant
of localization may contribute to poor cosmetic outcome.
Keywords: Breast cancer; breast conserving surgery; chemotherapy; cosmetic outcome intraoperative radiotherapy; whole breast radiotherapy
One of the success criteria in breast cancer surgery, primarily for patients treated with BCS, is the cosmetic result. This result depends on the experience of the treating surgeon, surgical technique, characteristics of the patient and the tumor, and local treatment methods such as systemic chemotherapy (CT) and WBI, as well as brachytherapy, accelerated partial irradiation and intraoperative radiotherapy (IORT).
This topic has been investigated in many studies, and in some series, the cases treated with both local and systemic methods have been studied together or separately. In this study, we aimed to investigate the effect of the order of adjuvant treatment on the cosmetic results of patients with breast cancer treated with BCS and IO boost RT (IOBRT) at our clinic during the last 4 years.
Skin and tissue findings were recorded together with
age, comorbidities, smoking status, menopausal status,
tumor diameter, and location on the breast. The findings
were scored according to the modified scoring system
described by Johansen [
When the tumors and personal characteristics of the
patients with poor cosmetic results (n=15) were examined,
it was found that 4 were premenopausal and 11
were postmenopausal, similar the distribution of other
cases in the series. Ten (71%) of the patients with comorbidities
(n=14) and all smokers were in this group.
While 7 of the 10 patients with a tumor diameter of >2
cm were in this group, it was interesting to note that the
tumor was localized to the inner quadrant in 11 (73%)
patients. Tumor was located in the upper inner quadrant
in seven patients and lower inner quadrant in four.
Smokers with a localization in the inner quadrant and a
tumor diameter of >2 cm received higher scores (Table
The role of other treatment modalities on cosmetic
results after breast surgery has been addressed in many
studies. In some series, the effect of systemic treatment
on cosmetic results, in some cases radiotherapy techniques,
and in others both local and systemic treatments
have been discussed. While in early studies long-term
cosmetic results were solely based on visual evaluation,
it is reported in recent publications that the cases are examined
using different scales. The most detailed of these
is the Radiotherapy Oncology Group (RTOG) scale that
carries the same name. It is suitable for prospective studies
and especially studies on RT techniques. In our series,
because the patients were scored both in terms of
the order of RT and CT they received and by physician examinations, the scoring system described and used
by Johansen was preferred with the assumption that it
would be more objective.[
Recht reviewed prospective and retrospective studies
of patients treated with BSC+RT and systemic treatment
and concluded that although there was no consensus on
early and late effects, the predominant view was that cosmetic
results are not related to systemic treatment.[
In the article by Kelemen wherein 178 patients receiving
CT+RT after BCS were investigated, the outcomes
of patients at 1 and 5 years were evaluated according
to the RTOG scale and it was concluded that the
effect of RT on the breast was greatly diminished due
to new technologies. In this series, only 20 patients received
CT and the treatment did not make a difference
in terms of cosmetic results. In general, poor cosmetic
results were associated with age (>50 years), tumor size
(>2 cm), presence of comorbidities, tumor location in
the breast, and other factors of the patient (smoking and
N+ status).[
IOBRT has also been the subject of many studies in
terms of its relation to cosmetic results as an independent
factor. Boost RT is also remarkable because it requires
additional doses as well as it significantly reduces
the risk of local recurrence. As opposed to postoperative
boost RT, IOBRT is advantageous because it allows focusing
directly on the tumor bed and can be delivered
with less but more effective dose without skin toxicity
and has also been shown to be superior in terms of cosmetic
results and patient comfort.[
According to ESTRO 2016, 50 patients with breast
cancer undergoing IOBRT (10 Gy) using MOBETRON
between 2008 and 2011 were presented. These patients
additionally received 50 Gy WBI and those in whom
CT was indicated received postoperative CT followed by
WBI. In this study, which is similar to our series in terms
of treatment schedule, the observation period was 1.5?
5.5 years and cosmetic results were evaluated by EORTC
questionnaires (QLQ-C30 and QLQ-BR23) at 6 months,
1 year, 2 years, 3 years, and 4 years after the end of RT,
and it was found that the early (first year) local effects
of IORT were easily tolerated and its effect on cosmetic
results were not statistically significant (p=0.08).[
In another study investigating the effect of different
boost techniques on cosmetic results, it was reported
that IOBRT was better tolerated than postoperative
external boost RT, and it did not have any negative effects
on skin change.[
Because IOBRT is not present in all studies in the
literature investigating the effects of systemic and local
treatments, it is still debated whether this practice is an
independent factor of cosmetic results. The studies conducted
solely for this purpose are recent and limited, and
the existing studies generally indicate a positive effect.
All the patients presented in this study were selected
among those in whom IOBRT was performed during
BCS. Although the time elapsed since the first treatment
of all patients was 50 months, because we studied patients
with at least 1 year after the end of the adjuvant
treatment, the mean follow-up period of the scored patients
was 25 (13-39) months. Although ?23 months of
follow-up is sufficient to observe the late effects of both
systemic treatment and RT, whether IOBRT is an independent
factor for cosmetic results or not should be
evaluated in broader series.
Peer-review: Externally peer-reviewed.
Conflict of Interest: None declared.
Authorship contributions: Concept - S.G., Ö.K.; Design - S.G, A.A.; Supervision - S.G, Ö.K.; Materials - S.G, Ö.K., H.T.; Data collection &/or processing - H.T.; Analysis and/or interpretation - S.G., O.Y., A.A., Ö.K.; Literature search - S.G.; Writing - S.G.; Critical review - S.G., O.Y.
