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The physician reported a poor outcome only in two patients and fair results in Figure 3 Examples of objective cosmetic results arms up and arms down : A excellent cosmeses, B good cosmeses, C fair cosmeses and D poor cosmeses. Full size image Discussion The delivery of daily doses higher than 1.

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The HF-WBI has been used in several institutions for decades and tested in randomized trials[ 1819 ]. There are three randomized trials performed in the last years that have compared hypofractionation with conventional radiotherapy for whole breast irradiation. In the Canadian trial 1, women with early-breast cancer were randomized after breast conserving surgery to accelerated HF-WBI Both trials showed similar outcomes with respect to local recurrence and adverse cosmesis for patients treated with hypofractionated regimens compared with standard treatment.

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Despite the uniformity of the results, there are several differences in patient selection, length of follow-up and use of systemic therapy and radiation boost among the three trials. In the Canadian study no patient received boost irradiation and only Furthermore, women with large breast were excluded because of an increase in adverse cosmesis observed when such patients were treated with standard fractionation[ 2122 ].

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The late toxicity and adverse cosmetic results were measured and reported differently in these three trials, as well. The most common change in breast appearance after radiotherapy is shrinkage, edema, retraction and teleangectasia. The tissue induration persistent many years after radiotherapy usually is due to an underlying fibrosis, but in the early years the fat necrosis and breast edema can contribute to induration scores.

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The adverse effects will appear for as long as patients are alive and the median follow-up times of the hypofractionated trials varied from 5. The critical question, as emphasized by Yarnold and colleagues[ 24 ], is whether the fractionation sensitivity of responses developing at the time of reporting are representative of those developing over entire life span of a patient.

Curran et al. On the basis of these considerations and uncertainties, nowadays may be unjustified to consider follow-up a factor limiting the interpretation of current hypofractionation trials[ 27 ].

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In literature, some authors used age as a selection criteria[ 12 ] as well as breast binary options woodes cc or large chest wall separation. In addition, the published trials of HF-WBI consisted of mostly lower-risk patients, therefore the applicability and safety of hypofractionation in women treated with adjuvant chemotherapy is not well known.

In the past, the worsening effect of chemotherapy on long-term fibrosis and cosmetic outcome was reported[ 2829 ].

The impact of the modern anthracycline- and taxane-based regimens in patients treated with HF-WBI is unknown.

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Anyway, the rate of high grade scores remained low. In prospective randomized trials the use of a tumor bed boost after whole breast irradiation reduced the risk of local recurrence even in patients with negative margins[ 3031 binary options woodes cc.

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The prospective trials of HF-WBI or never used a boost or used it at the discretion of the treating physician or department policy. Recent phase I-II trials investigated the role of concomitant boost in HF-WBI showing the safety and short-term efficacy of this approach for early-breast cancer.

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Freedman et al. All breast sizes and chemotherapy administration were permitted.

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No excess of acute skin toxicity was found. So far, neither the optimal HF-WBI regimen to use when a boost is planned nor the optimal tumor bed boost dose fractionation have been determined.

As concerns breast volume as a relevant factor related to skin toxicity contradictory data are available in the literature. In addition to acute toxicity, breast volume seems to increase the risk of late effects, too[ 37 ].

On the contrary, Corbin et al. Vicini et al. In this report, as in our study, the authors measured breast volume manually contouring of breast target volume.

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The average breast volume in our patients were smaller In our experience, compliance with this treatment was excellent thanks to short treatment duration. This was expected as it has been already reported that patients tend to evaluate the esthetic outcomes more positively than health care providers. The recent UK FAST trial reported that, after adjusting for breast size and surgical deficits, there was no evidence that the risk of late adverse effects of HF-WBI was associated with dose inhomogeneity[ 41 ].

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Special focus should be given to dose inhomogeneity which do not correlate with skin reaction, because it may be related to other types of side effects which have not yet been investigated and reported in the aferomentioned randomized trials, such as late subcutaneous toxicity. Our study showed an increase of late subcutaneous and skin effects in the patients who received additional binary options woodes cc.

These proceedings were reproduced using the manuscripts supplied by the authors ofthe different papers.

Then, the number of toxicity events is so low that no firm conclusion can be drawn from our data regarding the oncological safety of this procedure in patients needing of the additional boost.

References 1. Lancet