Outcomes in Patients Treated with Post-mastectomy Chest Wall Radiotherapy without the Routine Use of Bolus

• Published in: Clinical oncology (Royal College of Radiologists (Great Britain)) Vol. 30; no. 7; pp. 427 - 432
• Main Authors: Yap, M.L., Tieu, M., Sappiatzer, J., Panzarella, T., Cuartero, J., McCready, D., Fyles, A.
• Format: Journal Article
• Language: English
• Published: England Elsevier Ltd 01.07.2018
• Subjects: Bolus; breast cancer; outcomes; post-mastectomy radiotherapy; radiotherapy; radiotherapy; breast cancer; Bolus; post-mastectomy radiotherapy; outcomes
• ISSN: 0936-6555; 1433-2981
• DOI: 10.1016/j.clon.2018.03.005

The use of bolus in post-mastectomy radiotherapy (PMRT) varies significantly between institutions. We report on chest wall recurrence and acute toxicity rates for PMRT patients treated with selective use of bolus. We analysed PMRT patients who received adjuvant chest wall radiotherapy for invasive breast cancer between 2004 and 2009. Patient, tumour and cancer outcomes were collected from a prospective database, with additional radiotherapy and acute toxicity details supplemented retrospectively. Chest wall bolus was reserved for patients considered at high risk of local recurrence. There were 314 patients suitable for analysis: 52 received bolus, 262 did not. The mean age was 53.2 years. The median follow-up was 4.2 years. The most common T stage was T2 (37%), followed by T3/T4 (33%). There were 229 patients (73%) who had N+ disease; 213 (68%) patients had grade 3 cancer. Oestrogen receptor was positive in 176 (56%) cases, progesterone receptor was positive in 134 (43%) and HER2 receptor was positive in 24 (8%). Lymphovascular space invasion was present in 146 patients (46%), dermal invasion in 30 patients (10%) and positive margin in 14 patients (4%). The 4 year chest wall recurrence rate was 14% (95% confidence interval 5.4–26.8%) in the bolus group and only 3.5% (95% confidence interval 1.6–6.4%) in the non-bolus group. On univariate analysis, use of bolus was associated with a significant difference in chest wall recurrence (hazard ratio 3.09; 1.15–8.33; P = 0.025). However, when taking into account margin status, this significance was lost (hazard ratio = 2.45; 95% confidence interval 0.80–7.50, P = 0.12). There was a higher rate of acute grade 2 skin toxicity in patients receiving bolus compared with those without, 40% versus 21% (P = 0.01). The selective use of bolus resulted in a small risk of chest wall recurrence rates for low-risk patients. This suggests that the routine use of bolus in PMRT patients may be unnecessary. •Four year chest wall recurrence rate (CWRR) in patients not receiving bolus was 3.5%.•On multivariable analysis, the use of bolus had no significant effect on CWRR.•Higher grade 2 skin toxicity in patients receiving bolus compared with no bolus.•The predominant site of failure in this locally advanced cohort was distant.