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Obeng-Gyasi S, Coles CE, Jones J, Sacks R, Lightowlers S, Bliss JM, Brunt AM, Haviland JS, Kirby AM, Kalinsky K. When the World Throws You a Curve Ball: Lessons Learned in Breast Cancer Management. Am Soc Clin Oncol Educ Book 2021; 41:1-11. [PMID: 33956493 DOI: 10.1200/edbk_320691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the care of patients with operable breast cancer, there has been a shift toward increasing use of neoadjuvant therapy. There are benefits to neoadjuvant therapy, such as monitoring for response, as well as an increased rate of breast conservation and reduction of potential morbidity associated with breast surgery, including axillary management. Among patients with highly proliferative tumors, such as HER2-positive or triple-negative breast cancer, those with residual disease are at higher risk of recurrence, which informs the recommended systemic therapy in the adjuvant setting. For instance, in patients with residual disease after neoadjuvant chemotherapy and HER2-targeted therapy, there is a role for adjuvant trastuzumab emtansine for those with residual disease at the time of surgery. The same holds true regarding the role of adjuvant capecitabine in patients with residual disease after neoadjuvant chemotherapy. With the added complexities of treating patients in the era of the COVID-19 outbreak, additional considerations are critical, including initiation of surgery within an appropriate time from completion of neoadjuvant therapy. National consensus guidelines on time to surgery must be developed to improve measurement and comparison across systems. In addition, there is emerging radiation treatment management research addressing a number of factors, including hypofractionation, role of proton beam therapy, safe omission of radiotherapy, and preoperative radiotherapy with or without drug combination. In this article, the multidisciplinary approach of treating patients with operable breast cancer is highlighted, with updates and future considerations described.
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Affiliation(s)
- Samilia Obeng-Gyasi
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Jade Jones
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Ruth Sacks
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Sara Lightowlers
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Judith M Bliss
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - A Murray Brunt
- School of Medicine, University of Keele, Keele, United Kingdom
| | - Joanne S Haviland
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, United Kingdom
| | - Anna M Kirby
- Department of Radiotherapy, Royal Marsden National Health Service Foundation Trust and The Institute of Cancer Research, London, United Kingdom
| | - Kevin Kalinsky
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
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Klaassen L, Petoukhova AL, Habraken SJM, Jacobs J, Sattler MGA, Verhoeven K, Klaver YLB. Effect of breathing motion on robustness of proton therapy plans for left-sided breast cancer patients with indication for locoregional irradiation. Acta Oncol 2021; 60:222-228. [PMID: 33269958 DOI: 10.1080/0284186x.2020.1825800] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate the dosimetric impact of breathing motion on robustly optimized proton therapy treatment plans for left-sided breast cancer patients with an indication for locoregional irradiation. MATERIALS AND METHODS Clinical Target Volumes (CTVs) (left-sided breast, level 1 to 4 axillary lymph nodes, interpectoral and internal mammary lymph node regions) and organs at risk were delineated on 4 D-CTs of ten female patients. After treatment planning to a prescribed dose of 40.05 Gy(RBE) in 15 fractions on the time-averaged CT, the dose was calculated on all ten phases of the breathing cycle. Robustness to setup (5 mm) and range errors (3%) was evaluated for those ten phases. Correlations were evaluated between the phases of the breathing cycle and the D98% of the CTV and the Dmean of the heart. RESULTS Correlations coefficients were between -0.12 and 0.29. At the most extreme values of the 28 robustness scenarios, the clinical goals were met for all but two patients. The mean heart dose was 0.41 Gy(RBE) with a standard deviation of 0.31 Gy(RBE) of proton therapy plans. CONCLUSION The effect of breathing motion on the robustness of proton therapy treatment plans for this patient group is minor and not of clinical significance. Based on this patient group, a deep-inspiration breath hold seems to be unnecessary to improve robustness for these patients.
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Affiliation(s)
- L. Klaassen
- HollandPTC, The Netherlands
- Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, The Netherlands
| | - A. L. Petoukhova
- HollandPTC, The Netherlands
- Haaglanden Medical Center, Department of Medical Physics, Burgemeester Banninglaan 1, Leidschendam, BA, The Netherlands
| | - S. J. M. Habraken
- HollandPTC, The Netherlands
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - M. G. A. Sattler
- HollandPTC, The Netherlands
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - K. Verhoeven
- Department of Radiation Oncology, MAASTRO, Maastricht, The Netherlands
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Assessing the Need for Adjusted Organ-at-Risk Planning Goals for Patients Undergoing Adjuvant Radiation Therapy for Locally Advanced Breast Cancer with Proton Radiation. Pract Radiat Oncol 2020; 11:108-118. [PMID: 33109494 DOI: 10.1016/j.prro.2020.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/25/2020] [Accepted: 09/04/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Locally advanced breast cancer requires surgical management via lumpectomy or mastectomy with or without systemic therapy followed by chest wall or breast (CW) and comprehensive nodal irradiation (CNI). Radiation (RT) dose constraints for the heart and ipsilateral lung have been developed based on photon RT. Proton therapy (PBT) can deliver significantly lower doses of RT to these organs-at-risk (OARs) and may warrant adjustments to OAR planning goals. METHODS AND MATERIALS The RT plans of consecutive patients undergoing adjuvant CW-CNI RT with PBT within a single center were reviewed. A inital treatment volume, comprised of CW/intact breast + CNI (CTV_init) structure, including the CW and CNI but excluding any boost plans was analyzed. Frequency distributions were generated based on doses received by the heart, lungs, and esophagus for validated dosimetric parameters. Frequency distributions were generated and then stratified by laterality and compared using the Kruskal-Wallis H test. The 75th, 85th, and 95th percentiles for each dosimetric parameter were calculated, overall and by laterality. The 75th percentile (Q3), was used as a suggested primary goal, and the 95th percentile was used as a suggested secondary goal. RESULTS One hundred and seventy-two plans were analyzed. Forty-nine plans were right-sided, 107 were left-sided, and 16 were bilateral. The overall Q3 of the mean and V25 of the heart were 1.5 Gy and 1.7%, respectively. The mean and V25 to the heart differed significantly by laterality. Pulmonary values were similar to current recommendations. For all lateralites, the median volume of the esophagus receiving 70% prescription dose was ≤1 cm3. CONCLUSIONS We present the first dosimetric study providing complete OAR dose-volume histograms data for patients undergoing adjuvant pencil-beam scanning-PBT for locally advanced breast cancer, with detailed information on central tendencies, ranges and distributions of data. We have provided suggested planning goals and metrics for the lungs, heart, and esophagus; the latter 2 differing significantly from current Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) constraints and classical photon goals.
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Proton pencil beam scanning reduces secondary cancer risk in breast cancer patients with internal mammary chain involvement compared to photon radiotherapy. Radiat Oncol 2020; 15:228. [PMID: 33008412 PMCID: PMC7532613 DOI: 10.1186/s13014-020-01671-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 09/24/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose Proton pencil beam scanning (PBS) represents an interesting option for the treatment of breast cancer (BC) patients with nodal involvement. Here we compare tangential 3D-CRT and VMAT to PBS proton therapy (PT) in terms of secondary cancer risk (SCR) for the lungs and for contralateral breast. Methods Five BC patients including supraclavicular (SVC) nodes in the target (Group 1) and five including SVC plus internal-mammary-nodes (IMNs, Group 2) were considered. The Group 1 patients were planned by PT versus tangential 3D-CRT in free-breathing (FB). The Group 2 patients were planned by PT versus VMAT considering both FB and deep-inspiration breath hold (DIBH) irradiation. The prescription dose to the target volume was 50 Gy (2 Gy/fraction). A constant RBE = 1.1 was assumed for PT. The SCR was evaluated with the excess absolute risk (EAR) formalism, considering also the age dependence. A cumulative EAR was finally computed. Results According to the linear, linear-exponential and linear-plateau dose response model, the cumulative EAR for Group 1 patients after PT was equal to 45 ± 10, 17 ± 3 and 15 ± 3, respectively. The corresponding relative increase for tangential 3D-CRT was equal to a factor 2.1 ± 0.5, 2.1 ± 0.4 and 2.3 ± 0.4. Group 2 patients showed a cumulative EAR after PT in FB equal to 65 ± 3, 21 ± 1 and 20 ± 1, according to the different models; the relative risk obtained with VMAT increased by a factor 3.5 ± 0.2, 5.2 ± 0.3 and 5.1 ± 0.3. Similar values emerge from DIBH plans. Contrary to photon radiotherapy, PT appears to be not sensitive to the age dependence due to the very low delivered dose. Conclusions PBS PT is associated to significant SCR reduction in BC patients compared to photon radiotherapy. The benefits are maximized for young patients with both SVC and IMNs involvement. When combined with the improved sparing of the heart, this might contribute to the establishment of effective patient-selection criteria for proton BC treatments.
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Borm KJ, Simonetto C, Kundrát P, Eidemüller M, Oechsner M, Düsberg M, Combs SE. Toxicity of internal mammary irradiation in breast cancer. Are concerns still justified in times of modern treatment techniques? Acta Oncol 2020; 59:1201-1209. [PMID: 32619381 DOI: 10.1080/0284186x.2020.1787509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to estimate the additional risk of side effects attributed to internal mammary node irradiation (IMNI) as part of regional lymph node irradiation (RNI) in breast cancer patients and to compare it with estimated overall survival (OS) benefit from IMNI. MATERIAL AND METHODS Treatment plans (n = 80) with volumetric modulated arc therapy (VMAT) were calculated for 20 patients (4 plans per patient) with left-sided breast cancer from the prospective GATTUM trial in free breathing (FB) and in deep inspiration breath hold (DIBH). We assessed doses to organs at risk ((OARs) lung, contralateral breast and heart) during RNI with and without additional IMNI. Based on the OAR doses, the additional absolute risks of 10-year cardiac mortality, pneumonitis, and secondary lung and breast cancer were estimated using normal tissue complication probability (NTCP) and risk models assuming different age and risk levels. RESULTS IMNI notably increased the mean OAR doses. The mean heart dose increased upon IMNI by 0.2-3.4 Gy (median: 1.9 Gy) in FB and 0.0-1.5 Gy (median 0.4 Gy) in DIBH. However, the estimated absolute additional 10-year cardiac mortality caused by IMNI was <0.5% for all patients studied except 70-year-old high risk patients (0.2-2.4% in FB and 0.0-1.1% in DIBH). In comparison to this, the published oncological benefit of IMNI ranges between 3.3% and 4.7%. The estimated additional 10-year risk of secondary cancer of the lung or contralateral breast ranged from 0-1.5% and 0-2.8%, respectively, depending on age and risk levels. IMNI increased the pneumonitis risk in all groups (0-2.2%). CONCLUSION According to our analyses, the published oncological benefit of IMNI outweighs the estimated risk of cardiac mortality even in case of (e.g., cardiac) risk factors during VMAT. The estimated risk of secondary cancer or pneumonitis attributed to IMNI is low. DIBH reduces the estimated additional risk of IMNI even further and should be strongly considered especially in patients with a high baseline risk.
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Affiliation(s)
- Kai Joachim Borm
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | | | - Pavel Kundrát
- Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany
- Department of Radiation Dosimetry, Nuclear Physics Institute of the Czech Academy of Sciences, Prague, Czech Republic
| | - Markus Eidemüller
- Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
- Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung, (DKTK)-Partner Site Munich, München, Germany
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Lee HL, Lim LH, Master Z, Wong SMM. The role of breath hold intensity modulated proton therapy for a case of left-sided breast cancer with IMN involvement. How protons compare with other conformal techniques? Tech Innov Patient Support Radiat Oncol 2020; 15:1-5. [PMID: 32490219 PMCID: PMC7256639 DOI: 10.1016/j.tipsro.2020.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose To evaluate the dosimetric impact of four different radiotherapy techniques for a case of left-sided breast cancer with Internal Mammary lymph Nodes (IMN) involvement. Materials and methods To identify the best radiotherapy technique for this patient, four methods were compared: 3D Conformal Radiotherapy (3D-CRT), Volumetric Modulated Arc Therapy (VMAT), Tomotherapy (TOMO) and Intensity Modulated Proton Therapy (IMPT). Patient was treated using deep inspiration breath-hold (DIBH) technique. Prescribed dose was 40.05y in 15 fractions. Plan evaluation was performed on target coverage and dose to the organs-at-risk (OARs) using 3D-CRT as a baseline. Results TOMO has the most ideal Conformity Index (CI) at 1.139, followed by IMPT at 1.158, VMAT at 0.765, and 3D-CRT at 0.685. Using 3D-CRT as a baseline, VMAT, TOMO and IMPT all showed improved dose coverage. IMPT has the best dose coverage. TOMO has the most ideal homogeneity index (HI) and Conformity Number (CN). Mean heart dose (MHD) is lowest for IMPT at 0.55 Gy and highest for VMAT at 4.79 Gy. V20Gy of left lung is the lowest for IMPT at 11.11%, compared to 17.53% for TOMO, 18.19% for VMAT and 33.33% for 3D-CRT. V5Gy for the contralateral breast ranges from 0.01% in IMPT to 72.32% in TOMO. Conclusion 3D-CRT compromising target coverage but achieving good OAR sparing for the contralateral right breast, left lung and right lung. Overall, IMPT performed best in terms of target coverage and OAR-sparing. Protons delivered superior target dose coverage and sparing of normal structures for this patient. As dose value parameters are expected to correlate with acute and chronic toxicities, proton therapy should be given due consideration as the preferred technique for the treatment of left-sided breast cancers with IMN involvement. Further studies with more patients can be done to evaluate the effectiveness of proton therapy on acute and chronic toxicities.
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Affiliation(s)
- H L Lee
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore
| | - L H Lim
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Zubin Master
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Sharon M M Wong
- Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore.,Division of Radiation Oncology, National Cancer Centre Singapore, Singapore.,College of Allied Health, SingHealth Academy, Singapore
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Settatree S, Brand D, Ranger A, Dunlop A, Harris E, Gulliford S, Kirby A. Estimating Contralateral Breast Cancer Risk from Photons versus Protons in Patients Undergoing Internal Mammary Nodal Breast Cancer Radiotherapy. Clin Oncol (R Coll Radiol) 2020; 32:342. [PMID: 31948769 DOI: 10.1016/j.clon.2019.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 12/13/2019] [Indexed: 11/22/2022]
Affiliation(s)
- S Settatree
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - D Brand
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - A Ranger
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - A Dunlop
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
| | - E Harris
- The Institute Cancer Research, London, UK
| | - S Gulliford
- University College London Hospital, London, UK
| | - A Kirby
- The Royal Marsden Hospital, London, UK; The Institute Cancer Research, London, UK
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Thorpe CS, Niska JR, Anderson JD, Girardo ME, McGee LA, Hartsell WF, Larson GL, Tsai HK, Rossi CJ, Rosen LR, Vargas CE. Acute toxicities after proton beam therapy following breast-conserving surgery for breast cancer: Multi-institutional prospective PCG registry analysis. Breast J 2020; 26:1760-1764. [PMID: 32297453 DOI: 10.1111/tbj.13812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 11/29/2022]
Abstract
We investigated adverse events (AEs) and clinical outcomes for proton beam therapy (PBT) after breast-conserving surgery (BCS) for breast cancer. From 2012 to 2016, 82 patients received PBT in the prospective multi-institutional Proton Collaborative Group registry. AEs were recorded prospectively at each institution. Median follow-up was 8.1 months. Median dose was 50.4 Gy in 28 fractions. Most patients received a lumpectomy bed boost (90%) and regional nodal irradiation (RNI)(83%). Six patients (7.3%) experienced grade 3 AEs (5 with dermatitis, 5 with breast pain). Body mass index (BMI) was associated with grade 3 dermatitis (P = .015). Fifty-eight patients (70.7%) experienced grade ≥2 dermatitis. PBT including RNI after BCS is well-tolerated. Elevated BMI is associated with grade 3 dermatitis.
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Affiliation(s)
| | - Joshua R Niska
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Marlene E Girardo
- Health Sciences Research, Division of Biostatistics, Mayo Clinic, Scottsdale, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Gary L Larson
- ProCure Proton Therapy Center, Oklahoma City, Oklahoma
| | - Henry K Tsai
- ProCure Proton Therapy Center, Somerset, New Jersey
| | - Carl J Rossi
- Scripps Proton Therapy Center, San Diego, California
| | - Lane R Rosen
- Willis-Knighton Proton Therapy Center, Shreveport, Louisiana
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Yang K, Kim H, Choi DH, Park W, Noh JM, Cho WK. Optimal radiotherapy for patients with internal mammary lymph node metastasis from breast cancer. Radiat Oncol 2020; 15:16. [PMID: 32122399 PMCID: PMC7052982 DOI: 10.1186/s13014-020-1464-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 01/09/2020] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to determine the optimal radiotherapy (RT) regimen for patients with clinical metastasis to the internal mammary lymph node (cIMN+) from breast cancer. Methods We retrospectively reviewed the medical records of 84 patients with cIMN+ breast cancer treated with curative surgery, taxane-based chemotherapy, and postoperative RT between January 2009 and December 2014. Postoperative RT was administered to the whole breast or chest wall using 50 Gy in 2 Gy fractions. Boost RT to the internal mammary lymph node (IMN) was administered at the physician’s discretion. We categorized patients into two groups according to the IMN dose as follows: low-dose IMN RT (50.0–63.5 Gy) and high-dose IMN RT (63.6–70.4 Gy). Results After a median follow-up of 58 months (range, 12–111 months), IMN recurrence was observed in 2 patients (2.4%), and all IMN recurrences developed simultaneously with distant metastases. The 5-year locoregional recurrence-free survival, disease-free survival (DFS), and overall survival rates were 89.1, 72.0, and 81.2%, respectively. The triple-negative subtype, IMN size ≥1.0 cm, old age, and low-dose IMN were significantly associated with poor DFS. Among the patients with IMN size ≥1.0 cm, the 5-year DFS was significantly higher in those treated with high-dose IMN RT than in those treated with low-dose IMN RT (69.3% vs. 33.3%, p = 0.019). Conclusions IMN RT without IMN dissection resulted in favorable outcomes in cIMN+ breast cancer. For patients with a large IMN, a higher IMN radiation dose might be needed for disease control.
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Affiliation(s)
- Kyungmi Yang
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, South Korea
| | - Haeyoung Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea, 06351.
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea, 06351
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea, 06351
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea, 06351
| | - Won Kyung Cho
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, Republic of Korea, 06351
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Variability in lymph node irradiation in patients with breast cancer-results from a multi-center survey in German-speaking countries. Strahlenther Onkol 2019; 196:15-22. [PMID: 31722060 DOI: 10.1007/s00066-019-01537-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Lymph node irradiation in breast cancer has gained complexity due to recently published studies and technical innovations which then led to changes in international guidelines. We sought to determine real-time variability in lymph node irradiation in clinical practice in German-speaking countries. METHODS The Department of Radiation Oncology, Technical University of Munich (TUM), developed an online-based questionnaire focusing on the indication, target definition, and treatment technique of lymph node irradiation in patients with breast cancer. The invitation to participate in the survey was sent to members of the German Society of Radiation Oncology (DEGRO) by e‑mail. The results of the survey were exported from the online platform into SPSS for a detailed analysis. RESULTS In total, 100 physicians completed the questionnaire between 05/2019 and 06/2019. Despite the existence of several treatment and contouring guidelines, we observed large variability of lymph node irradiation: The guideline recommendation for internal mammary irradiation is not consistently implemented in clinical practice and irradiation of the axilla after positive SLNB (sentinel lymph node biopsy) or ALND (axillary lymph node dissection) is handled very differently. Furthermore, in most clinics, the ESTRO (European Society for Therapeutic Radiology and Oncology) contouring consensus is not used, and PTV (planning target volume) definitions and margins vary considerably. CONCLUSION Further clinical studies should be performed with a particular focus on radiotherapy for lymphatic drainage to support and amend the existing guidelines. These studies should establish a more standardized treatment of the lymph node regions in clinical practice. Quality assurance should enforce broad implementation of consensus recommendations.
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Jimenez RB, Hickey S, DePauw N, Yeap BY, Batin E, Gadd MA, Specht M, Isakoff SJ, Smith BL, Liao EC, Colwell AS, Ho A, Januzzi JL, Passeri J, Neilan TG, Taghian AG, Lu HM, MacDonald SM. Phase II Study of Proton Beam Radiation Therapy for Patients With Breast Cancer Requiring Regional Nodal Irradiation. J Clin Oncol 2019; 37:2778-2785. [PMID: 31449469 PMCID: PMC7351324 DOI: 10.1200/jco.18.02366] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of proton beam radiation therapy (RT) for patients with breast cancer who require regional nodal irradiation. METHODS Patients with nonmetastatic breast cancer who required postoperative RT to the breast/chest wall and regional lymphatics and who were considered suboptimal candidates for conventional RT were eligible. The primary end point was the incidence of grade 3 or higher radiation pneumonitis (RP) or any grade 4 toxicity within 3 months of RT. Secondary end points were 5-year locoregional failure, overall survival, and acute and late toxicities per Common Terminology Criteria for Adverse Events (version 4.0). Strain echocardiography and cardiac biomarkers were obtained before and after RT to assess early cardiac changes. RESULTS Seventy patients completed RT between 2011 and 2016. Median follow-up was 55 months (range, 17 to 82 months). Of 69 evaluable patients, median age was 45 years (range, 24 to 70 years). Sixty-three patients (91%) had left-sided breast cancer, two had bilateral breast cancer, and five had right-sided breast cancer. Sixty-five (94%) had stage II to III breast cancer. Sixty-eight (99%) received systemic chemotherapy. Fifty (72%) underwent immediate reconstruction. Median dose to the chest wall/breast was 49.7 Gy (relative biological effectiveness) and to the internal mammary nodes, 48.8 Gy (relative biological effectiveness), which indicates comprehensive coverage. Among 62 surviving patients, the 5-year rates for locoregional failure and overall survival were 1.5% and 91%, respectively. One patient developed grade 2 RP, and none developed grade 3 RP. No grade 4 toxicities occurred. The unplanned surgical re-intervention rate at 5 years was 33%. No significant changes in echocardiography or cardiac biomarkers after RT were found. CONCLUSION Proton beam RT for breast cancer has low toxicity rates and similar rates of disease control compared with historical data of conventional RT. No early cardiac changes were observed, which paves the way for randomized studies to compare proton beam RT with standard RT.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Alice Ho
- Massachusetts General Hospital, Boston, MA
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De Rose F, Cozzi L, Meattini I, Fogliata A, Franceschini D, Franzese C, Tomatis S, Becherini C, Livi L, Scorsetti M. The Potential Role of Intensity-modulated Proton Therapy in the Regional Nodal Irradiation of Breast Cancer: A Treatment Planning Study. Clin Oncol (R Coll Radiol) 2019; 32:26-34. [PMID: 31377082 DOI: 10.1016/j.clon.2019.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/13/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
AIMS To investigate the role of intensity-modulated proton therapy (IMPT) for regional nodal irradiation in patients with breast carcinoma in comparison with volumetric-modulated arc therapy (VMAT). MATERIALS AND METHODS A cohort of 20 patients (10 in the breast-conserving surgery group and 10 post-mastectomy patients with tissue expander implants) was investigated. Proton plans were also computed using robust optimisation methods. Plan quality was assessed by means of dose-volume histograms and scored with conventional metrics. Estimates of the risk of secondary cancer induction (excess absolute risk, EAR) were carried out, taking into account fractionation, repopulation and repair. RESULTS Concerning target coverage, the data proved a substantial equivalence of VMAT and IMPT: for example, coverage for the 50 Gy target, expressed in terms of V98%, was 47.8 ± 0.4, 47.6 ± 0.4, 47.3 ± 0.8, consistent with the objective of 47.5 Gy, for post-mastectomy patients for the three groups of patients. Also, the conformality of the dose distributions was similar for the two techniques, about 1.1, without statistically significant differences. Organ at risk planning aims were achieved for all structures for both techniques. The mean dose to the ipsilateral lung was 10.8 ± 1.1, 6.2 ± 0.8, 7.2 ± 1.0; for the contralateral lung was 3.2 ± 0.7, 0.3 ± 0.2, 0.4 ± 0.2; for the contralateral breast was: 3.1 ± 0.7, 0.3 ± 0.3 and 0.3 ± 0.3, whereas it was 3.9 ± 0.9, 0.4 ± 0.3 and 0.5 ± 0.5, respectively, for the heart for VMAT, IMPT and robust IMPT plans over the whole group of patients. Robust optimisation affected the near-to-maximum dose values for contralateral lung and breast, the mean dose for the heart and ipsilateral lung, with a deterioration ranging from 20 to 40% of the nominal value of IMPT plans (e.g. from 8.1 ± 6.4 to 11.4 ± 8.8 for the heart compared with 16.2 ± 5.2 for the VMAT plans). The numerical values of EAR per 10 000 patient-years were about one order of magnitude higher for VMAT than for IMPT for contralateral structures: 11.66 ± 2.01, 0.89 ± 0.80, 0.98 ± 0.77 for the contralateral breast and the three groups of plans, respectively; 14.31 ± 2.75, 1.42 ± 0.80, 1.78 ± 0.87 for the contralateral lung; and 34.86 ± 2.64, 18.85 ± 2.15, 20.98 ± 2.35 for the ipsilateral lung. CONCLUSION IMPT with or without robust optimisation seems to be a potentially promising approach for the radiation treatment of breast cancer when nodal volumes should be irradiated. This was measured in terms of dosimetric advantage and predicted clinical benefit. In fact, the significant reduction in estimated EAR could add further clinical value to the dosimetric sparing of the organs at risk achievable with IMPT.
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Affiliation(s)
- F De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - L Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy.
| | - I Meattini
- Department of Biomedical Experimental and Clinical Sciences, University of Florence, Florence, Italy; Radiation Oncology Unit, Az. Osp. Careggi, Florence, Italy
| | - A Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - D Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - C Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - S Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - C Becherini
- Department of Biomedical Experimental and Clinical Sciences, University of Florence, Florence, Italy; Radiation Oncology Unit, Az. Osp. Careggi, Florence, Italy
| | - L Livi
- Department of Biomedical Experimental and Clinical Sciences, University of Florence, Florence, Italy; Radiation Oncology Unit, Az. Osp. Careggi, Florence, Italy
| | - M Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
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Duane FK, McGale P, Teoh S, Mortimer C, Broggio J, Darby SC, Dodwell D, Lavery B, Oliveros S, Vallis KA, Taylor CW. International Variation in Criteria for Internal Mammary Chain Radiotherapy. Clin Oncol (R Coll Radiol) 2019; 31:453-461. [PMID: 31060973 PMCID: PMC6575151 DOI: 10.1016/j.clon.2019.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 03/08/2019] [Accepted: 03/16/2019] [Indexed: 11/29/2022]
Abstract
AIMS Evidence has emerged that internal mammary chain (IMC) radiotherapy reduces breast cancer mortality, leading to changes in treatment guidelines. This study investigated current IMC radiotherapy criteria and the percentages of patients irradiated for breast cancer in England who fulfilled them. MATERIALS AND METHODS A systematic search was undertaken for national guidelines published in English during 2013-2018 presenting criteria for 'consideration of' or 'recommendation for' IMC radiotherapy. Patient and tumour variables were collected for patients who received breast cancer radiotherapy in England during 2012-2016. The percentages of patients fulfilling criteria stipulated in each set of guidelines were calculated. RESULTS In total, 111 729 women were recorded as receiving adjuvant breast cancer radiotherapy in England during 2012-2016 and full data were available on 48 095 of them. Percentages of patients fulfilling IMC radiotherapy criteria in various national guidelines were: UK Royal College of Radiologists 13% (6035/48 095), UK National Institute for Health and Care Excellence 18% (8816/48 095), Germany 32% (15 646/48 095), Ireland 56% (26 846/48 095) and USA 59% (28 373/48 095). Differences between countries occurred because in Ireland and the USA, treatment may be considered in some node-negative patients, whereas in the UK, treatment is considered if at least four axillary nodes are involved or for high-risk patients with one to three positive nodes. In Germany, treatment may be considered for all node-positive patients. CONCLUSIONS There is substantial variability between countries in criteria for consideration of IMC radiotherapy, despite guidelines being based on the same evidence. This will probably lead to large variations in practice and resource needs worldwide.
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Affiliation(s)
- F K Duane
- St Luke's Radiation Oncology Network, St. James's Hospital, Dublin, Ireland.
| | - P McGale
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - S Teoh
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - C Mortimer
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - J Broggio
- Public Health England, Birmingham, UK
| | - S C Darby
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - D Dodwell
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - B Lavery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Oliveros
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - K A Vallis
- CRUK/MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, UK
| | - C W Taylor
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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64
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Fellin F, Iacco M, D'Avino V, Tommasino F, Farace P, Palma G, Conson M, Giacomelli I, Zucchetti C, Falcinelli L, Amichetti M, Aristei C, Cella L. Potential skin morbidity reduction with intensity-modulated proton therapy for breast cancer with nodal involvement. Acta Oncol 2019; 58:934-942. [PMID: 30938217 DOI: 10.1080/0284186x.2019.1591638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Different modern radiation therapy treatment solutions for breast cancer (BC) and regional nodal irradiation (RNI) have been proposed. In this study, we evaluate the potential reduction in radiation-induced skin morbidity obtained by intensity modulated proton therapy (IMPT) compared with intensity modulated photon therapy (IMXT) for left-side BC and RNI. Material and Methods: Using CT scans from 10 left-side BC patients, treatment plans were generated using IMXT and IMPT techniques. A dose of 50 Gy (or Gy [RBE] for IMPT) was prescribed to the target volume (involved breast, the internal mammary, supraclavicular, and infraclavicular nodes). Two single filed optimization IMPT (IMPT1 and IMPT2) plans were calculated without and with skin optimization. For each technique, skin dose-metrics were extracted and normal tissue complication probability (NTCP) models from the literature were employed to estimate the risk of radiation-induced skin morbidity. NTCPs for relevant organs-at-risk (OARs) were also considered for reference. The non-parametric Anova (Friedman matched-pairs signed-rank test) was used for comparative analyses. Results: IMPT improved target coverage and dose homogeneity even if the skin was included into optimization strategy (HIIMPT2 = 0.11 vs. HIIMXT = 0.22 and CIIMPT2 = 0.96 vs. CIIMXT = 0.82, p < .05). A significant relative skin risk reduction (RR = NTCPIMPT/NTCPIMXT) was obtained with IMPT2 including the skin in the optimization with a RR reduction ranging from 0.3 to 0.9 depending on the analyzed skin toxicity endpoint/model. Both IMPT plans attained significant OARs dose sparing compared with IMXT. As expected, the heart and lung doses were significantly reduced using IMPT. Accordingly, IMPT always provided lower NTCP values. Conclusions: IMPT guarantees optimal target coverage, OARs sparing, and simultaneously minimizes the risk of skin morbidity. The applied model-based approach supports the potential clinical relevance of IMPT for left-side BC and RNI and might be relevant for the setup of cost-effectiveness evaluation strategies based on NTCP predictions, as well as for establishing patient selection criteria.
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Affiliation(s)
- Francesco Fellin
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Martina Iacco
- Perugia General Hospital, Medical Physics Unit, Perugia, Italy
| | - Vittoria D'Avino
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Francesco Tommasino
- Department of Physics, University of Trento, Povo, Italy
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics (INFN), Povo, Italy
| | - Paolo Farace
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Irene Giacomelli
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | | | | | - Maurizio Amichetti
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
- Department of Surgical and Biomedical Science, University of Perugia, Perugia, Italy
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- National Institute for Nuclear Physics (INFN), Naples, Italy
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Dunlop A, Colgan R, Kirby A, Ranger A, Blasiak-Wal I. Evaluation of organ motion-based robust optimisation for VMAT planning for breast and internal mammary chain radiotherapy. Clin Transl Radiat Oncol 2019; 16:60-66. [PMID: 31032432 PMCID: PMC6479013 DOI: 10.1016/j.ctro.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 11/23/2022] Open
Abstract
AIMS In patients undergoing locoregional radiotherapy (RT) for breast cancer including the internal mammary chain (IMC), VMAT has been shown to be superior to tangential-field radiotherapy in terms of target coverage and minimising dose to heart and lungs. In this study we describe and validate organ motion-based robust optimisation for generating breast and locoregional lymph node VMAT plans that are robust to inter-fractional changes. MATERIALS AND METHODS In this retrospective study of five patients with left-sided breast cancer requiring locoregional breast radiotherapy including the IMC, non-robust plans were generated in the nominal scenario (planning-CT) and corresponding robust plans were created by optimising over a range of simulated CTs representing worst-case scenario shape changes to the breast. Both plans were re-calculated on CBCT images (n = 67) acquired prior to RT to generate estimates of delivered fractional dose. Plan robustness to inter-fractional changes was assessed in terms of the estimated target coverage and OAR dose. RESULTS Organ motion-based robust optimisation was able to generate clinically acceptable treatment plans in the nominal scenario on the planning CT with no significant differences to OAR dose between the robust and non-robust planning techniques. All plans (robust and non-robust) achieved the mandatory target coverage requirements. Estimates of delivered dose demonstrated a significant improvement in breast target coverage for the robust plans compared to non-robust plans. For the breast CTV, 92% of the robust plans achieved the optimal D98% > 95% clinical goal as compared to 71% of the non-robust plans (p < 0.01). 94% of robust plans achieved acceptable superficial breast coverage, as compared to 55% for the non-robust technique. CONCLUSIONS Organ motion-based robust optimisation VMAT is able to produce clinically acceptable organ-at-risk sparing plans for locoregional breast radiotherapy (including the IMC) that are robust to inter-fractional changes, therefore reducing the likelihood of reactive adaptive re-planning.
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Affiliation(s)
- Alex Dunlop
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Rd, Sutton SM2 5PT, UK
| | - Ruth Colgan
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Rd, Sutton SM2 5PT, UK
| | - Anna Kirby
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Alison Ranger
- The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research, London, UK
| | - Irena Blasiak-Wal
- The Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden Hospital, Downs Rd, Sutton SM2 5PT, UK
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66
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De Rose F, Fogliata A, Franceschini D, Cozzi S, Iftode C, Stravato A, Tomatis S, Masci G, Torrisi R, Testori A, Tinterri C, Lisa AVE, Maione L, Vinci V, Klinger M, Santoro A, Scorsetti M. Postmastectomy radiation therapy using VMAT technique for breast cancer patients with expander reconstruction. Med Oncol 2019; 36:48. [PMID: 31028487 DOI: 10.1007/s12032-019-1275-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 04/19/2019] [Indexed: 11/28/2022]
Abstract
Postmastectomy radiotherapy (PMRT) following immediate breast reconstruction is increasingly adopted in the management of breast cancer patients. We retrospectively evaluate the complication rates of PMRT using VMAT technique to immediate tissue expander-based reconstructions and the possible impact of tissue expander volume on radiotherapy planning. We reviewed the data of patients who underwent immediate expander breast reconstruction and received PMRT with VMAT (50 Gy in 25 fractions) on the reconstructed breast and axillary levels III-IV. Neoadjuvant or adjuvant systemic therapy was administered in most of the patients. Autologous fat grafting was routinely performed at the time of second-stage reconstruction. Between 2015 and 2017, PMRT was delivered to 46 consecutive patients (median age 50 years) with expander reconstruction. Median follow-up was 27 months (range 10-41). Two patients (4.3%) had a reconstruction failure, as expander rupture and infection, following the first- and the second-stage reconstruction, respectively. In most cases expanders were completely inflated before PMRT (65.2%). Median expander volume before PMRT was 425 cm3 (range 150-700 cm3). The amount of expander inflation did not significantly affect dosimetry, except for skin dose, with a surface receiving more than 30 Gy of 36.6 ± 0.9 cm2 and 47.0 ± 2.5 cm2 for a volume expander below or above the median, respectively. However, this variable was not predictor for complications. Disease progression was recorded in 15.2% of patients. PMRT using VMAT technique for breast cancer patients with expander reconstruction is associated with a very low complication rate. The expander volume before PMRT does not significantly compromise radiotherapy dose distribution.
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Affiliation(s)
- Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy.
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Salvatore Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Cristina Iftode
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Antonella Stravato
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Giovanna Masci
- Medical Oncology Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Rosalba Torrisi
- Medical Oncology Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Alberto Testori
- Breast Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Corrado Tinterri
- Breast Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Andrea V E Lisa
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Luca Maione
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Valeriano Vinci
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Marco Klinger
- Plastic Surgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy
| | - Armando Santoro
- Medical Oncology Department, Humanitas Research Hospital, Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Milan, Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Rozzano, Italy
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67
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Chowdhary M, Lee A, Gao S, Wang D, Barry PN, Diaz R, Bagadiya NR, Park HS, Yu JB, Wilson LD, Moran MS, Higgins SA, Knowlton CA, Patel KR. Is Proton Therapy a "Pro" for Breast Cancer? A Comparison of Proton vs. Non-proton Radiotherapy Using the National Cancer Database. Front Oncol 2019; 8:678. [PMID: 30693271 PMCID: PMC6339938 DOI: 10.3389/fonc.2018.00678] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/21/2018] [Indexed: 12/25/2022] Open
Abstract
Background: Limited data exists demonstrating the clinical benefit of proton radiotherapy (PRT) in breast cancer. Using the National Cancer Database, we evaluated predictors associated with PRT use for patients with breast cancer. An exploratory analysis also investigates the impact of PRT on overall survival (OS). Methods: Patients with non-metastatic breast cancer treated with adjuvant radiotherapy from 2004 to 2014 were identified. Patients were stratified based on receipt of PRT or non-PRT (i.e., photons ± electrons). A logistic regression model was used to determine predictors for PRT utilization. For OS, Multivariable analysis (MVA) was performed using Cox proportional hazard model. Results: A total of 724,492 patients were identified: 871 received PRT and 723,621 received non-PRT. 58.3% of the PRT patients were group stage 0–1. Median follow-up time was 62.2 months. On multivariate logistic analysis, the following factors were found to be significant for receipt of PRT (all p < 0.05): academic facility (odds ratio [OR] = 2.50), South (OR = 2.01) and West location (OR = 12.43), left-sided (OR = 1.21), ER-positive (OR = 1.59), and mastectomy (OR = 1.47); pT2-T4 disease predicted for decrease use (OR = 0.79). PRT was not associated with OS on MVA for all patients: Hazard Ratio: 0.85, p = 0.168. PRT remained not significant on MVA after stratifying for subsets likely associated with higher heart radiation doses, including: left-sided (p = 0.140), inner-quadrant (p = 0.173), mastectomy (p = 0.095), node positivity (p = 0.680), N2-N3 disease (p = 0.880), and lymph node irradiation (LNI) (p = 0.767). Conclusions: Receipt of PRT was associated with left-sided, ER+ tumors, mastectomy, South and West location, and academic facilities, but not higher group stages or LNI. PRT was not associated with OS, including in subsets likely at risk for higher heart doses. Further studies are required to determine non-OS benefits of PRT. In the interim, given the high cost of protons, only well-selected patients should receive PRT unless enrolled on a clinical trial.
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Affiliation(s)
- Mudit Chowdhary
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, United States
| | - Anna Lee
- Department of Radiation Oncology, SUNY Downstate Medical Center, Brooklyn, NY, United States
| | - Sarah Gao
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Dian Wang
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, United States
| | - Parul N Barry
- Department of Radiation Oncology, Rush University Medical Center, Chicago, IL, United States
| | - Roberto Diaz
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL, United States
| | - Neeti R Bagadiya
- Department of Radiology, Emory University School of Medicine, Atlanta, GA, United States
| | - Henry S Park
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - James B Yu
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Lynn D Wilson
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Meena S Moran
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Susan A Higgins
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Christin A Knowlton
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Smilow Cancer Center, Yale University School of Medicine, New Haven, CT, United States
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Xu Y, Wang J, Hu Z, Tian Y, Ma P, Li S, Dai J, Wang S. Locoregional irradiation including internal mammary nodal region for left-sided breast cancer after breast conserving surgery: Dosimetric evaluation of 4 techniques. Med Dosim 2019; 44:e13-e18. [DOI: 10.1016/j.meddos.2018.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 08/30/2018] [Accepted: 09/24/2018] [Indexed: 12/18/2022]
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69
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Li WH, Zhang ZG, Huang ZR, Zhang W, Li ZB, Qi ZQ. No association between tumor laterality and cardiac-related mortality in breast cancer patients after radiotherapy: a population-based study. Cancer Manag Res 2018; 10:3649-3656. [PMID: 30271213 PMCID: PMC6152604 DOI: 10.2147/cmar.s172595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction To assess the effect of tumor laterality to cardiac-related deaths of breast cancer in the current radiation practices using a large modern population-based study. Methods Women diagnosed with breast cancer from 2000 to 2008 were included using the current Surveillance, Epidemiology, and End Results database. The primary outcome of this study was the cardiac-related mortality. Multivariate analysis was performed using the Cox proportional hazards model to analyze the cardiac-related mortality including demographic, clinicopathologic, and treatment factors. Results We identified 168,761 breast cancer patients, including 85,006 (50.4%) patients with left-sided tumors and 83,755 (49.6%) patients with right-sided tumors. The median follow-up period was 8.8 years. The 10-year cardiac-related mortality was 2.3% and 2.3% in left- and right-sided tumors, respectively (P=0.685). The results indicated that patients with older age, non-Hispanic Black, receipt of mastectomy, and married status were the independent adverse factors for cardiac-related mortality. However, left-sided tumors were not associated to a higher risk of cardiac-related mortality than right-sided tumors following postoperative radiotherapy (right vs left, hazard ratios 1.025, 95% CI 0.856–1.099, P=0.484). The risk of cardiac-related mortality in the entire cohort was increased with the extension of follow-up time. However, there was still not significantly different between left- and right-sided tumors. Subgroup analysis also found no association between tumor laterality and cardiac-related mortality after postoperative radiotherapy based on various demographics and treatment factors. Conclusion With a median follow-up of 8.8 years, no significant differences were found in cardiac-related mortality between left- and right-sided tumors under current radiation practices of breast cancer patients.
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Affiliation(s)
- Wei-Hua Li
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Zi-Guan Zhang
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Zheng-Rong Huang
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Wei Zhang
- Xiamen Institute of Cardiovascular Diseases, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China
| | - Zhi-Bin Li
- Epidemiology Research Unit, The First Affiliated Hospital of Xiamen University, Xiamen 361003, People's Republic of China,
| | - Zhong-Quan Qi
- Organ Transplantation Institute, Medical College, Xiamen University, Xiamen 361005, People's Republic of China,
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Qingqing H, Jian Z, Dayong Z, Ziyi F, Luming Z, Peng Z, Fang Y, Gaofeng N, Xuefeng D, Meng W, Dan W, Lei H, Xiaolei L, Tao Y. Robot-Assisted Internal Mammary Lymph Node Chain Dissection for Breast Cancer. Clin Breast Cancer 2018; 18:e441-e445. [PMID: 29752223 DOI: 10.1016/j.clbc.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/07/2018] [Accepted: 04/12/2018] [Indexed: 10/17/2022]
Affiliation(s)
- He Qingqing
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China.
| | - Zhu Jian
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Zhuang Dayong
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Fan Ziyi
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Zheng Luming
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Zhou Peng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Yu Fang
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Ni Gaofeng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Dong Xuefeng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Wang Meng
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Wang Dan
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Hou Lei
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Li Xiaolei
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
| | - Yue Tao
- Department of Thyroid and Breast Surgery, Jinan Military General Hospital of PLA, Jinan, China
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