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hf. J. Radmion Oncology Biol Phys, Vol. in the U.S.A. All rights reserved. F’rinted 17, pp. 747-753 Copyright 0360-3016/89 $3.00 + .oO 0 1989 Pergamon Pr.5s.s plc ??Original Contribution LATE COSMETIC OUTCOME AFTER CONSERVATIVE SURGERY AND RADIOTHERAPY: ANALYSIS OF CAUSES OF COSMETIC FAILURE Ivo M.D.,’ MARY ANN ROSE, M.D.,2 ROBERT T. OSTEEN, M.D.,3 SUSAN LOVE, M.D.,4 BLAKE CADY, M.D.,’ BARBARA SILVER, B.A.,2 A. OLIVOTTO, ABRAM RECHT, M.D.2 AND JAY R. HARRIS, M.D.2 ‘Division of Radiation Oncology, Cancer Control Agency of British Columbia and University of B.C., Vancouver, B.C., Canada; ‘Joint Center for Radiation Therapy, and Department of Radiation Therapy, Harvard Medical School (HMS); 3Department of Surgery, Brigham and Women’s Hospital, HMS: 4Department of Surgery, Beth Israel Hospital, HMS (present address: Faulkner Hospital); and ‘Department of Surgery, New England Deaconess Hospital, HMS. Boston, MA Although the majority of patients with early breast cancer treated with conservative surgery and radiotherapy have acceptable cosmetic outcomes, the specific causes of a less-than-acceptable result are not well known. To assess the technical factors associated with late cosmetic failure, we reviewed the records of 593 patients treated with conservative surgery and radiotherapy at the Joint Center for Radiation Therapy, Boston, between 1968 and 1981. Median follow-up was 76 months with a range of 37-186 months. Using a 4-point scoring system (excellent, good, fair, poor) patients were noted to have cosmetic “failure” if scored as either fair or poor. Cosmetic results were similar at 3, 5, and 7 years with excellent or good scores seen in 88%, 90%, and 78% of patients, respectively. Three technical factors were associated with a significant worsening of the cosmetic results. The resection of 70 cm3 or more of breast tissue was more common among the failed patients than among matched patients with good or excellent results (p = 0.03). Eighty-nine percent of patients treated with a tangent pair t; echnique had excellent results at 5 years compared to 69% of patients treated with a three-field technique (p = 0.004). The use of a larger volume implant was associated with a greater risk of a fair or poor cosmetic result compared to the use of a smaller volume implant. We conclude that overall cosmesis has been acceptable in this series, but there are technical (surgery and radiotherapy) factors which can be modified to optimize the cosmetic result without compromising local tumor control. Breast cancer, Radiotherapy, Cosmesis, Failure analysis. INTRODUmION Conservative surgery followed by radiotherapy is being used increasingly as definitive treatment for early stage breast cancer in preference to modified radical mastectomy. Retrospective ( 1,6,7,9, 19,2 1,23) and prospective randomized trials (12,25,29) have demonstrated excellent local control rates with this breast-conserving approach and survival equivalent to treatment by mastectomy. The motivation to pursue breast conservation is to maintain the patient’s body image and reduce the psychological morbidity associated with mastectomy. Much of this advantage may be lost unless attention is applied to optimizing those technical factors which contribute to the late cosmetic outcome. Presented in part at the 30th Annual Meeting of the American Society of Therapeutic Radiology and Oncology, New Orleans, LA, October 11, 1988. Reprint requests to: Jay R. Harris, M.D., at Joint Center for Radiation Therapy. 50 Binney St., Boston, MA 02 115. Previous reports from the Joint Center for Radiation Therapy (4) and other centers (8, 20, 22) have demonstrated that the majority of patients achieve a good-toexcellent cosmetic outcome, but most of these studies have relatively short follow-up. We have recently updated our results with a large group of patients followed for a longer time and have confirmed our previously reported high likelihood of achieving an acceptable outcome (24). We have also demonstrated the stability of these results at least to 7 years post treatment (24). We have previously described our findings on the impact of adjuvant chemotherapy on the cosmetic outcome (3, 15) and this will not be addressed in detail. In this report we address the question of which technical factors contribute to cosmetic failure and recommend This work was supported in part by the Shane Fellowship, CCABC, while IA0 was on a Clinical Fellowship at JCRT, Boston, MA. Accepted for publication 13 April 1989. 748 1. J. Radiation Oncology 0 Biology 0 Physics modifications to certain surgical and radiotherapeutic techniques to optimize the late cosmetic outcome after conservative surgery and radiotherapy, without compromising local tumor control. METHODS AND MATERIALS Seven hundred thirty-three women with UICC-AJCC clinical Stage I or II invasive breast carcinoma were treated with conservative surgery and radiation therapy at the Joint Center for Radiation Therapy between July 1968 and December 198 1. Fourteen women had bilateral tumors treated during that period for a total of 747 treated breasts. One hundred and fifty-four patients were excluded from the analysis because cosmetic follow-up was not undertaken at this institution. A total of 593 breasts were therefore evaluable for the analysis of cosmetic outcome. Follow-up was generally performed at approximately 6-month intervals after completion of treatment. Patients were censored from cosmetic follow-up at the time of local, distant, or opposite breast recurrence. The range of follow-up was 37 to 186 months, with a median of 76 months. The presence and severity of breast edema, retraction, fibrosis, telangiectasia and arm edema were noted and a score of none, minimal, moderate, or severe was assigned by the physician for each parameter on a standard follow-up form ( 16). The overall cosmetic result was classified by the physician as excellent, good, fair, or poor. An excellent score was assigned when the treated breast looked essentially the same as the opposite breast. A good cosmetic score was used to describe minimal but identifiable effects of radiation on the treated breast. A fair cosmetic score was given when significant effects of radiation on the breast were noted. A poor cosmetic score was used to describe severe normal tissue sequelae. Results were plotted graphically by grouping observations into 6-month time intervals. Not all patients were evaluated during every 6-month interval. If more than one observation was made per patient per time interval, the worst score was used. The midpoint of each time interval was used in all curves, thus individual observations ranged up to 3 months on either side of each time point. Analysis of results and comparisons between subgroups at specific time points of 3, 5, and 7 years were also undertaken. These time points were selected because: (a) we have previously reported that cosmetic results tend to stabilize at 3 years, (b) 5 years is a “benchmark” in oncology for reporting of results and comparison between series, and (c) 7 years is the longest time at which sufficient numbers of patients were available for valid statistical analysis. The entire group of 593 patients was subdivided and analyzed by the following parameters: (a) whole breast radiotherapy technique, (b) boost technique, (c) tumor size, and (d) use of adjuvant chemotherapy. The application of external beam radiotherapy underwent consid- October 1989, Volume 17, Number 4 erable evolution during the years of this study, both in terms of the technical aspects of matching fields and in philosophy concerning the necessity of treating regional nodes. In the earlier part of the study period, all patients received radiotherapy to the axillary and supraclavicular areas even if the findings on axillary dissection were negative. During the latter part of the study period, patients with negative nodes on axillary dissection received radiotherapy to the breast alone. A description of our “standard” three-field technique and the techniques used to minimize overlap at the matchline have been previously reported (27). In this group of 593 breasts, 473 were treated with a three-field technique, including tangents, the supraclavicular area, and the full axilla; 44 patients were treated to tangential fields and the supraclavicular area, but not the full axilla; and 76 patients received radiation to tangential fields only. The dose to the breast and draining nodes (when treated) was generally 4600 to 5000 cGy in 4.5 to 5 weeks. Five hundred and fifty of 593 evaluable breasts (93%) received a boost to the primary tumor area, generally bringing the total dose to 6000 cGy or greater. In 497 patients this was accomplished with an Iridium-192 interstitial implant. For each patient, the number of seeds, the total activity, and the average activity per seed were analyzed. Thirty-six patients received an electron boost to the primary site. Electron energies used ranged from 7 to 11 MeV, and were selected so that the 80% isodose curve would encompass the boost volume. Boost doses from either implant or electron beam ranged from 1000 to 2700 cGy, so that the total dose to the primary tumor area was 6000 to 7500 cGy. Axillary dissection was performed in 4 19 patients. In general, the dissections were limited to Level I and II lymph nodes to determine the need for adjuvant chemotherapy. “Complete” axillary dissections, including stripping of the axillary vein, were rarely performed in these patients. Of the 593 patients, 340 had tumors measuring 2 cm or less (Tl) and 253 had tumors between 2 cm and 5 cm (T2). Of the 238 patients with Tl tumors who underwent dissection, metastases were found in 64 (27%). Of the 18 1 patients with T2 tumors who underwent dissection, metastases were found in 8 1 (45%). One hundred thirty-four patients received some form of adjuvant chemotherapy, a factor previously reported to influence cosmetic outcome (3, 11, 18,24). In 77 cases radiation was completed before initiation of chemotherapy, in 49 cases radiation and chemotherapy were delivered concurrently, seven patients received “sandwich” chemotherapy-radiotherapy-chemotherapy, and one patient completed her chemotherapy before beginning radiotherapy. The effect of sequencing of radiation therapy and adjuvant chemotherapy has been the subject of a separate report from our institution ( 15). A detailed analysis was conducted on patients who were classified as having fair or poor scores and a minimum Cosmetic outcome after conservativetreatment 0 I. A.OLIVOTTO etal. follow-up of 3 years. Seventy such patients were identified, of whom 66 were considered evaluable and are the “cases” in a subsequent case:control analysis. (Three charts were irretrievable; review of the fourth showed that the deteriorating cosmesis was due to recurrent tumor rather than treatment effect. This patient was excluded from further cosmetic analysis.) To explore the effects of the extent of surgical resection and radiotherapy technique on the cosmetic outcome in greater detail, a case:control analysis was conducted. This approach was used to reduce possible confounding of variables which can occur in a retrospective analysis such as this. For each of the 66 “cases” identified above, a single “control” was selected on the basis of the best possible match from the computerized data bank of the larger pool of patients with excellent or good outcomes. Factors which were matched in the selection of the controls were: whether or not adjuvant chemotherapy was given; use of an Iridium-192 implant as a boost to the primary site; external beam technique (tangents vs three-field); T stage; and, as closely as possible, duration of follow-up. The volume of the primary site excision was determined by multiplying the length by the width by the depth as recorded in the original gross pathology report. If more than one specimen had been received, the volumes were calculated separately and then summated. Approximately 85% of patients had volume information recorded. Details of the radiotherapy including number of fields, tangent separation, machine energy, and implant factors such as dose, dose-rate, number of seeds, number of strands, total activity, and duration of implant were recorded for each of the cases and controls. Statistical comparisons between groups and proportions were calculated at fixed time points using the Fisher exact test. Tests for trend across tabulated data were calculated using the method of Breslow and Day (5) (equation 4.43) within a statistical package* for epidemiology and clinical trials. P-values of 0.05 or less were considered statistically significant. RESULTS The overall cosmetic results for the entire study population are summarized in Table 1. The overall cosmetic results, the degree of breast retraction, and the amount of telangiectasia evolved over the first 3 years following treatment and then remained relatively stable. The percentage of patients with good or excellent results was 88% at 3 years, 90% at 5 years and 78% at 7 years. Patients with a less than excellent or good result were considered a cosmetic “failure”. The percentage of patients with a cosmetic failure was 12% at 3 years, 10% at 5 years and 22% at 7 years (p = N.S.). * Epilog plus, Epicenter Software, Pasadena, CA. 749 Table 1. Overall cosmetic results: 1968-198 1 Years postradiotherapy No. pts. assessed Excellent % Good % Fair % Poor % 3 5 7 302 179 54 62 65 54 26 25 24 9 7 15 3 3 7 Surgical contribution to cosmetic outcome We attempted to assess the relationship between the volume of excision at the primary site and the overall cosmetic results by the use of a case:control analysis. Among the 66 evaluable cases with fair or poor scores at 3 years, information on excision volume was available for 55. The excision volume was known in 56 of the 66 controls. Larger volumes of excision were associated with a greater risk of fair or poor outcome. Forty-five percent (25/55) of the fair-poor cases had a primary excision volume 270 cm3 (3.5 X 4 X 5 cm) as opposed to 13/56 (23%) of the good-excellent controls (p = 0.03). Table 2 shows the relative risk of a fair or poor result in patients with known excision volume from this case:control analysis. There is a significant trend (p = 0.03) toward a greater risk of cosmetic “failure” as larger volumes of breast tissue are excised. A number of other potentially important surgical factors, such as length and placement of scars, use of drains, and closure technique, could not be assessed from this data set. Radiotherapy factors contributing to the cosmetic outcome The use of a three-field technique is associated with a significantly worse cosmetic outcome compared with a tangent pair alone (Fig. 1). At 3 years, only 59% of patients treated with a three-field technique (which included the full axilla) had an excellent result compared with 79% of patients treated with tangents only (p = 0.03). The results were similar at 5 years, with 59% of those treated with three-fields judged as having excellent results cotipared with 89% of those treated with tangents only (Q = 0.004). Similar results were observed when the comparison was restricted to patients who did not receive adjuvant chemotherapy. At 5 years, only 66% of evaluable patients treated with three-fields without chemotherapy had excellent results compared with 92% of patients treated with tangents only without chemotherapy (p = 0.01). There was also an increased proportion of fair or poor results. With three-field treatment at 3 years, 36/243 patients ( 15%) were scored as having a fair or poor result compared with O/38 patients treated with tangents only (p = 0.007). This trend persisted at 5 years (14% vs O%, p = 0.04) and similar results were seen when the comparison was restricted to patients who did not receive adjuvant che- I. J. Radiation Oncology 0 Biology 0 Physics 750 Table 2. Case: control analysis: relative risk of a fair or poor score with increasing primary excision volume Cosmetic Volume excised (cm3) Fair/poor (cases) <20 20-69.9 70-99.9 2100 October 1989, Volume 17, Number 4 Overall Cosmesis by Boost Technique outcome Relative risk of fair/poor Excellent/good (controls) 18 25 5 8 12 18 9 16 1.0 1.08 2.70 3.00 a = 0.03 (for trend) motherapy (10% vs. 0% at 5 years, p = NS). Among patients who were treated with a three-field technique, there was no significant difference in cosmetic outcome between those who received treatment to the supraclavicular area only and those treated to both the supraclavicular area and the full axilla. The use of an interstitial implant as a boost was associated with a significantly worse cosmetic result compared to either no boost or an electron beam boost (Fig. 2). However, this comparison is limited by possible selection bias, different follow-up times in the various groups, and the relatively small number of patient who did not receive an interstitial implant. At 3 years, only 58% of patients who received an implant were scored as excellent com- 0 m No boost H Electron boost 36pts M Implant 1 2 43pts 497 pts 3 4 5 6 7 a Years Fig. 2. Comparison of cosmetic results by boost technique. Note that the numbers of patients who received no boost or an electron beam boost are small. Overall Cosmesis by Number of Fields 1c Excellent 60 0 M Tangents only 76pts C-O 3-field technique 1 2 3 4 517pts 5 6 7 a Fig. 1. Comparison of cosmetic results for patients treated with a three-field technique and those treated with tangential fields only. The number of patients at risk at 3, 5, and 7 years was 38, 26, and 4, respectively, for tangents only and 264. 153. and 50, respectively, for three-field treatment. pared with 85% of patients who had an electron or photon boost (p = 0.03) and 85% of those who did not receive a boost (p = 0.01). Similarly, at 5 years 60% of patients treated with an implant had excellent results compared with 100% of those receiving an electron or photon boost (p = 0.03) and 93% of those not receiving a boost (p = 0.02). When the comparison was restricted to patients who did not receive adjuvant chemotherapy, similar results were observed. We attempted to determine which aspects of the use of an implant were associated with the cosmetic result. This analysis was limited by the fact that during the time of this study the technique of the Iridium implant was quite uniform and the dose range very narrow. The doses recorded were generally “minimum tumor doses.” The volume of the implant, as measured by the number of iridium seeds used. was the factor most significantly associated with an increased risk of a fair or poor result (Table 3). As the volume of the implant increased, the likelihood of a fair or poor cosmetic result increased. In particular, patients with implants containing less than 70 seeds had a 15% risk of a fair or poor result compared to a 38% risk for patients with implants containing 100 or more seeds (p < 0.01). This association may be confounded by the extent of surgical resection since smaller volume implants were more commonly used to treat Tl lesions (83% of implants with ~40 seeds, 62% of implants Cosmetic outcome after conservative treatment 0 I. A. OLIVOTTOet al. risk of a fair or poor result related to volume of the implant Table 3. Relative Cosmetic outcome (no. seeds) Fair/ poor Excellent/ good <40 40-69 70-99 2100 11 (13%) 32 (16%) 39 (27%) 24 (38%) 77 166 104 39 Volume Relative risk of fair/poor 1.0 1.35 2.62 4.31 p = <0.0001 (for trend) with 40-69 seeds, 47% of implants with 70-99 seeds and 25% of implants with 2 100 seeds were used to treat Tl lesions). We examined the effect of dose and dose rate in the case:control analysis. Of the 66 evaluable patients with fair or poor scores at 3 years, 58/66 (85%) of the pairs had received an implant as part of their primary therapy. Within the narrow range of doses and dose-rates prescribed, there were trends toward a worse outcome with the highest doses and dose-rates assessed, but these trends were not significant. The doses of the Iridium implants as recorded on the original physics plan were grouped into three dose levels: < 1900 cGy, 1900-2 199 cGy, and 22200 cGy. In a comparison where the relative risk (R.R.) of a fair or poor cosmetic result from a prescribed dose of < 1900 cGy was 1.O, the R.R. of a prescribed dose of 1900-2 199 cGy was 1.47 and the R.R. of a prescribed dose of 22200 cGy was 2.92 (p = N.S. for trend). Similarly, three groupings of prescribed dose-rate were assessed, <40,40-45, and ~45 cGy/hr. The R.R. of a fair or poor cosmetic result for these dose-rate groups were 1.O, 1.08, and 2.51, respectively (p = N.S. for trend). DISCUSSION The results of this study with more patients and longer follow-up corroborate the earlier reports from our institution that SO-90% of patients treated with conservative surgery and primary radiation therapy have a good or excellent cosmetic outcome (4, 24). Moreover, we have not observed detectable deterioration of the cosmetic outcome over time (24). In this analysis we did not intend to focus on the impact of chemotherapy on the cosmetic results since we have described this in detail elsewhere (3, 15). Our results continue to show that the use of adjuvant chemotherapy has a significant adverse effect on the cosmetic outcome, but this is primarily true when the two treatment modalities are used simultaneously ( 15). Since adjuvant chemotherapy can have a major effect, especially when administered concurrently with radiation, we have attempted to adjust for it in this analysis to focus on important aspects of the surgery and radiotherapy. In a companion paper, we have shown that the cosmetic results are adversely affected by 751 larger tumor size, but not by tumor location or patient age (24). Axillary dissection significantly increases the amount of breast edema and as a result significantly decreases the percentage of patients with excellent scores, but only in the first 18 months. After this, the edema has resolved in the majority of cases and the subsequent longterm cosmetic result is identical whether or not an axillary dissection was performed (24). In the present study, we have identified three technical factors that have an adverse influence on the cosmetic outcome: (a) the extent of surgery for the resection of the primary tumor, (b) the size of an Iridium- 192 implant used as a boost, and (c) the use of three fields rather than tangential fields to the breast alone. The extent of surgical excision plays a major role in the cosmetic outcome for the patient. Others have reported a significant worsening in cosmesis when an extensive surgical resection of the primary tumor was used (8, 20, 22). The data presented in the current study indicate that a volume of excision 270 cm3 (3.5 X 4 X 5 cm) is significantly correlated with a fair or poor cosmetic result (p = 0.03). These results stress the importance of minimizing the volume of excision to optimize the cosmetic outcome whenever this is consistent with ensuring local tumor control. This cosmetic analysis was performed over a time period when tumors generally were excised grossly, but microscopic margins of resection were not evaluated. Retrospective analysis of pathologic characteristics of the tumors of our patients has shown that only those with an extensive intraductal component (EIC), defined as intraductal carcinoma comprising 25% or more of the area within the infiltrating borders of the tumor and also present beyond the edge of the invasive cancer in grossly normal adjacent tissue, are at high risk for local failure in this setting (26). As a result, we insist on obtaining microscopically negative margins only in these high-risk patients. The large majority of patients who do not have an EIC are adequately treated with a gross excision of the tumor and radiotherapy including a boost to the primary site. An assessment for an extensive intraductal component can therefore be used to minimize the extent of surgery required prior to radiotherapy. The use of a boost to the primary site in the conservative management of breast cancer is controversial. The need for a boost must be considered in light of the extent of the resection of the primary tumor. In the National Surgical Adjuvant Breast Project (NSABP) Trial B-06, patients who underwent segmental mastectomy and received 5000 cGy of whole breast radiation without a boost had a 7% local recurrence rate at 5 years (14). However, note that all of these patients had negative margins of resection. Obtaining microscopically negative margins may seriously compromise the cosmetic outcome. In our experience, the use of a limited excision and radiotherapy including a boost to the primary tumor site has also resulted in a 7% rate of local recurrence at 5 years for patients with 152 1.J. Radiation Oncology 0 Biology 0 Physics Stage I and II breast cancer, even in the absence of known negative margins (23). Given the adverse cosmetic effects of extensive breast surgery, we believe it is generally preferable to limit the extent of breast surgery and use a boost to optimize local tumor control. However, the results shown here and also suggested by others (22) indicate that the use of an implant to deliver the boost, particularly if large, may reduce significantly the percentage of patients with excellent results. It is possible that an alteration in the technique or dose by implant may eliminate the deleterious cosmetic effect observed here. Over the time period of this study, the range of doses and dose-rates used for the Iridium- 192 implants was very narrow. Additionally, physician latitude in selecting which isodose to use in prescribing the dose makes it difficult to show any direct relationship between the prescribed dose or dose-rate and the cosmetic outcome. A significant detrimental effect was observed, however, when larger volumes (as measured by the number of seeds) were implanted. The diminished cosmetic result associated with a large implant is likely related to inhomogeneity of dose distribution with resultant areas of fat necrosis and fibrosis (28). In this analysis, it was difficult to compare the relative effects of implant and electron beam given the potential for bias and the small number of patients who received electron beam. It appears that the cosmetic results following boosts by electron beam and smaller volume implants are comparable. Our current approach is to use an external beam boost (typically electrons) in nearly all patients, given its greater convenience. Longer follow-up and larger numbers of patients treated in this manner are necessary to establish both its long-term effect on the cosmetic results and its impact on local tumor control. We are currently studying the issue of electron boosts versus implants in greater detail in such an expanded population. The preliminary results shown here, however, suggest that the cosmetic results using an election beam boost are satisfactory. The use of a three-field external beam technique was associated with a significantly lower percentage of good and excellent outcomes when compared with the use of tangents alone (p = 0.004). Note that this effect was observed not only among patients treated with our old technique, which allowed some overlap of radiation fields, but also among patients treated with our current technique which is designed to achieve a near perfect match (27). The use of a third field must also be evaluated in terms of its effect on survival. Long-term results of treatment of regional nodes are now available from two major randomized trials. Both in the NSABP B-04 trial, in which patients with clinically negative nodes were randomized to radical mastectomy or to total mastectomy plus nodal radiotherapy or to total mastectomy alone, and in the October 1989, Volume 17, Number 4 Cancer Research Campaign trial, in which patients with clinically negative or positive nodes were randomized to total mastectomy followed by nodal irradiation or to no nodal treatment, no difference in long-term survival was seen (2, 13). The utility of treating regional nodes after an axillary dissection is even more questionable. The overview or meta-analysis performed by Cuzick and colleagues of all the evaluable randomized trials testing the use of postoperative radiotherapy suggests that patients treated with prophylactic postoperative radiotherapy to the regional nodes are at an increased risk of dying between 10 and 20 years after treatment compared with patients treated with radical mastectomy alone (10). The reason for this increased mortality is not evident in the analysis of the data but was most apparent in patients with negative nodes treated in the kilovoltage era. It is likely that suboptimal technique and unselective patient entry criteria may have contributed to the outcome. Nevertheless, the results fail to indicate a survival benefit associated with such treatment. Furthermore, given that the use of nodal radiotherapy may also be associated with an increased risk of arm edema following axillary dissection ( 17) and a decrease in the likelihood of excellent cosmetic scores as shown here, the routine use of regional nodal irradiation must be strongly questioned. Clearly such treatment can decrease nodal recurrence and it is reasonable to use it in treating patients at very high risk of regional recurrence such as those in whom 50% or more of the nodes are positive or patients with prominent extranodal extension. However, for nearly all patients, irradiation of the breast alone seems to us the most appropriate. The results presented here and elsewhere (24) provide support for the use of breast-conserving treatment by demonstrating satisfactory cosmetic results that appear to remain stable over time. They also indicate opportunities to improve the cosmetic outcome further by making adjustments in the techniques of surgery and radiotherapy. While efforts to improve the cosmetic results are important, we do wish to stress that such considerations are valid only insofar as high levels of local tumor control are achieved. Taken together with the local tumor control results of this treatment approach discussed above, at the present time we recommend: (a) using pathologic features of the tumor to minimize the extent of breast surgery; (b) restricting radiotherapy to the breast alone in nearly all patients; and (c) restricting the volume of an implant boost or using an external beam boost to the primary site as a means of maintaining optimal local tumor control without compromising the cosmetic outcome. We will continue to monitor our patients treated according to these precepts to ensure that we continue to achieve optimal cosmetic outcomes. REFERENCES 1. Amahic, R.; Santamaria, F. R.; Robert, F.; Seigle. J.; Altshuler, C.; Pietra, J. C.; Amalric, F.; Kurtz, J. M.; Spitalier, J. M.; Brandone, H.; Ayme, Y.; Pollet, J. 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