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Garsa AA, Ferraro DJ, Dewees T, Margenthaler JA, Naughton M, Aft R, Gillanders WE, Eberlein T, Matesa MA, Zoberi I. Analysis of fat necrosis after adjuvant high-dose-rate interstitial brachytherapy for early stage breast cancer. Brachytherapy 2012; 12:99-106. [PMID: 22726878 DOI: 10.1016/j.brachy.2012.04.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/16/2012] [Accepted: 04/16/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE To report the incidence and potential predictors of fat necrosis in women with early stage breast cancer treated with adjuvant high-dose-rate (HDR) multicatheter interstitial brachytherapy. METHODS AND MATERIALS Between 2003 and 2010, 238 treated breasts in 236 women were treated with accelerated partial breast irradiation using HDR interstitial brachytherapy. Selection criteria included patients with Tis-T2 tumors measuring ≤3cm, without nodal involvement, who underwent breast-conserving surgery. Ninety-nine percent of treatments were to a total dose of 34Gy. The presence and severity of fat necrosis were prospectively recorded during followup. Cosmesis was qualitatively scored in all patients. Cosmesis was quantitatively measured via the percentage breast retraction assessment in 151 cases. RESULTS Median followup was 56 months. The crude rate of fat necrosis was 17.6%. The rate of symptomatic fat necrosis was 10.1%. In univariate analysis, acute breast infection and anthracycline-based chemotherapy, number of catheters, volume encompassed by the prescription isodose, volume encompassed by the 150% isodose (V150), volume encompassed by the 200% isodose, and integrated reference air kerma were significantly associated with fat necrosis. There was significant collinearity between the brachytherapy-related factors; of these, V150 was most predictive. In multivariate analysis, only V150 was significantly associated with fat necrosis. At 3 years, patients with fat necrosis were more likely to have a fair or poor cosmetic outcome and a larger percentage breast retraction assessment. CONCLUSIONS Mammary fat necrosis is a common adverse event after breast-conserving surgery and HDR interstitial brachytherapy. Fat necrosis is associated with worse qualitative and quantitative cosmetic outcomes. Minimizing exposure volumes, such as V150, may decrease the incidence of fat necrosis and improve cosmesis.
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Affiliation(s)
- Adam A Garsa
- Department of Radiation Oncology, Siteman Cancer Center, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA
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Budrukkar A, Jagtap V, Kembhavi S, Munshi A, Jalali R, Seth T, Parmar V, Raj Upreti R, Badwe R, Sarin R. Fat necrosis in women with early-stage breast cancer treated with accelerated partial breast irradiation (APBI) using interstitial brachytherapy. Radiother Oncol 2012; 103:161-5. [DOI: 10.1016/j.radonc.2011.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 11/22/2011] [Accepted: 12/28/2011] [Indexed: 10/14/2022]
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Do structural changes in the tumour bed after intraoperative radiotherapy (IORT) of breast cancer complicate the evaluation of mammograms in a long-term follow-up? Eur J Radiol 2012; 81:e255-9. [DOI: 10.1016/j.ejrad.2011.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 02/02/2011] [Indexed: 11/19/2022]
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Mammographic findings after intraoperative radiotherapy of the breast. Radiol Res Pract 2012; 2012:758371. [PMID: 22550585 PMCID: PMC3328171 DOI: 10.1155/2012/758371] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 11/04/2011] [Accepted: 11/07/2011] [Indexed: 12/14/2022] Open
Abstract
Intraoperative Radiotherapy (IORT) is a form of accelerated partial breast radiation that has been shown to be equivalent to conventional whole breast external beam radiotherapy (EBRT) in terms of local cancer control. However, questions have been raised about the potential of f IORT to produce breast parenchymal changes that could interfere with mammographic surveillance of cancer recurrence. The purpose of this study was to identify, quantify, and compare the mammographic findings of patients who received IORT and EBRT in a prospective, randomized controlled clinical trial of women with early stage invasive breast cancer undergoing breast conserving therapy between July 2005 and December 2009. Treatment groups were compared with regard to the 1, 2 and 4-year incidence of 6 post-operative mammographic findings: architectural distortion, skin thickening, skin retraction, calcifications, fat necrosis, and mass density. Blinded review of 90 sets of mammograms of 15 IORT and 16 EBRT patients demonstrated a higher incidence of fat necrosis among IORT recipients at years 1, 2, and 4. However, none of the subjects were judged to have suspicious mammogram findings and fat necrosis did not interfere with mammographic interpretation.
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Falvo E, Strigari L, Citro G, Giordano C, Boboc G, Fabretti F, Bruzzaniti V, Bellesi L, Muti P, Blandino G, Pinnarò P. SNPs in DNA repair or oxidative stress genes and late subcutaneous fibrosis in patients following single shot partial breast irradiation. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2012; 31:7. [PMID: 22272830 PMCID: PMC3285050 DOI: 10.1186/1756-9966-31-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 01/24/2012] [Indexed: 11/10/2022]
Abstract
Background The aim of this study was to evaluate the potential association between single nucleotide polymorphisms related response to radiotherapy injury, such as genes related to DNA repair or enzymes involved in anti-oxidative activities. The paper aims to identify marker genes able to predict an increased risk of late toxicity studying our group of patients who underwent a Single Shot 3D-CRT PBI (SSPBI) after BCS (breast conserving surgery). Methods A total of 57 breast cancer patients who underwent SSPBI were genotyped for SNPs (single nucleotide polymorphisms) in XRCC1, XRCC3, GST and RAD51 by Pyrosequencing technology. Univariate analysis (ORs and 95% CI) was performed to correlate SNPs with the risk of developing ≥ G2 fibrosis or fat necrosis. Results A higher significant risk of developing ≥ G2 fibrosis or fat necrosis in patients with: polymorphic variant GSTP1 (Ile105Val) (OR = 2.9; 95%CI, 0.88-10.14, p = 0.047). Conclusions The presence of some SNPs involved in DNA repair or response to oxidative stress seem to be able to predict late toxicity. Trial Registration ClinicalTrials.gov: NCT01316328
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Affiliation(s)
- Elisabetta Falvo
- Laboratory of Pharmacokinetic/Pharmacogenomic, Regina Elena National Cancer Institute, Rome, Italy.
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Bourgier C, Pichenot C, Verstraet R, El Nemr M, Heymann S, Biron B, Delaloge S, Mathieu MC, Garbay JR, Bourhis J, Taghian AG, Marsiglia H. Early Side Effects of Three-Dimensional Conformal External Beam Accelerated Partial Breast Irradiation to a Total Dose of 40 Gy in One Week (A Phase II Trial). Int J Radiat Oncol Biol Phys 2011; 81:1228-35. [DOI: 10.1016/j.ijrobp.2010.07.040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 07/09/2010] [Accepted: 07/13/2010] [Indexed: 11/28/2022]
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Pinnarò P, Arcangeli S, Giordano C, Arcangeli G, Impiombato FA, Pinzi V, Iaccarino G, Soriani A, Landoni V, Strigari L. Toxicity and cosmesis outcomes after single fraction partial breast irradiation in early stage breast cancer. Radiat Oncol 2011; 6:155. [PMID: 22079051 PMCID: PMC3229442 DOI: 10.1186/1748-717x-6-155] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 11/11/2011] [Indexed: 01/30/2023] Open
Abstract
Background To report the clinical outcome after a Single Shot 3D-CRT PBI (SSPBI) in breast cancer patients after conservative surgery (ClinicalTrials.gov Identifier: NCT01316328). Methods A dose of 18Gy (in the first 4 patients) and 21Gy (in the remaining 60 patients) was prescribed in a single session and delivered to the index area (i.e. the area of breast including the primary tumor bed and the surrounding tissue) using 3D-CRT with patients in prone position. Acute and late toxicity was assessed using the National Cancer Institute's CTC for Adverse Events. Cosmesis was defined based on modified Harvard criteria. Differences between dosimetric or clinical parameters of patients with/without G2 or more late toxicity or unsatisfactory (poor or fair) cosmetic outcome were evaluated with the Mann-Whitney test. Odds ratios and 95% confidence interval were calculated for cosmesis and fibrosis. Univariate and multivariate analyses(UVA/MVA) were used to determine covariates associated with an increase in fibrosis or fat necrosis rate. Results Sixty four patients were enrolled. With a median follow-up of 3 years, G2 and G3 subcutaneous fibrosis was detected in 20(31%) and in 8(13%) patients, and ≥G2 fat necrosis was observed in 2(3%) patients. Good to excellent, fair and poor cosmesis was observed in 38(59%), 23(36%) and 3(5%) patients, respectively. Based on UVA, the breast volume receiving more than 21Gy (V21Gy) was found to be a predictor of the ≥G1 or ≥G2 fibrosis/fat necrosis. Based on MVA, V21Gy was confirmed as a predictor for ≥G1 fibrosis/fat necrosis, the results correlated as a trend for ≥G2. Cosmesis was correlated with whole breast (WB) mean dose (p = 0.030). Conclusion Our choice of a single dose of 21Gy significantly increased the treatment related toxicity. However, this should not discourage novel SSPBI approaches with lower equivalent doses.
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Affiliation(s)
- Paola Pinnarò
- Department of Radiation Oncology, Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy
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Shaitelman SF, Kim LH, Grills IS, Chen PY, Ye H, Kestin LL, Yan D, Vicini FA. Predictors of Long-Term Toxicity Using Three-Dimensional Conformal External Beam Radiotherapy to Deliver Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2011; 81:788-94. [DOI: 10.1016/j.ijrobp.2010.06.062] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 06/20/2010] [Indexed: 11/15/2022]
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Patel PS, Yan W, Trichter S, Sabbas A, Rosenblatt R, Drotman MB, Swistel A, Clifford Chao KS, Nori D, Hayes MK. Seroma is an Expected Consequence and not a Complication of MammoSite Brachytherapy. Breast J 2011; 17:498-502. [DOI: 10.1111/j.1524-4741.2011.01127.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mammary fat necrosis following radiotherapy in the conservative management of localized breast cancer: Does it matter? Radiother Oncol 2010; 97:92-4. [DOI: 10.1016/j.radonc.2010.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 02/17/2010] [Accepted: 02/23/2010] [Indexed: 11/23/2022]
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3-D Conformal Photon Boost in the Treatment of Early Stage Breast Cancer: Four Year Follow Up Results. Pathol Oncol Res 2010; 17:17-23. [DOI: 10.1007/s12253-010-9264-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
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Valachis A, Mauri D, Polyzos NP, Mavroudis D, Georgoulias V, Casazza G. Partial Breast Irradiation or Whole Breast Radiotherapy for Early Breast Cancer: A Meta-Analysis of Randomized Controlled Trials. Breast J 2010; 16:245-51. [PMID: 20210799 DOI: 10.1111/j.1524-4741.2010.00905.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Antonis Valachis
- Department of Medical Oncology, University General Hospital of Heraklion, Greece.
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Polgár C, Van Limbergen E, Pötter R, Kovács G, Polo A, Lyczek J, Hildebrandt G, Niehoff P, Guinot JL, Guedea F, Johansson B, Ott OJ, Major T, Strnad V. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiother Oncol 2010; 94:264-73. [PMID: 20181402 DOI: 10.1016/j.radonc.2010.01.014] [Citation(s) in RCA: 444] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 01/04/2010] [Accepted: 01/23/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE To give recommendations on patient selection criteria for the use of accelerated partial-breast irradiation (APBI) based on available clinical evidence complemented by expert opinion. METHODS AND MATERIALS Overall, 340 articles were identified by a systematic search of the PubMed database using the keywords "partial-breast irradiation" and "APBI". This search was complemented by searches of reference lists of articles and handsearching of relevant conference abstracts and book chapters. Of these, 3 randomized and 19 prospective non-randomized studies with a minimum median follow-up time of 4 years were identified. The authors reviewed the published clinical evidence on APBI, complemented by relevant clinical and pathological studies of standard breast-conserving therapy and, through a series of personal communications, formulated the recommendations presented in this article. RESULTS The GEC-ESTRO Breast Cancer Working Group recommends three categories guiding patient selection for APBI: (1) a low-risk group for whom APBI outside the context of a clinical trial is an acceptable treatment option; including patients ageing at least 50 years with unicentric, unifocal, pT1-2 (<or=30 mm) pN0, non-lobular invasive breast cancer without the presence of an extensive intraductal component (EIC) and lympho-vascular invasion (LVI) and with negative surgical margins of at least 2mm, (2) a high-risk group, for whom APBI is considered contraindicated; including patients ageing <or=40 years; having positive margins, and/or multicentric or large (>30 mm) tumours, and/or EIC positive or LVI positive tumours, and/or 4 or more positive lymph nodes or unknown axillary status (pNx), and (3) an intermediate-risk group, for whom APBI is considered acceptable only in the context of prospective clinical trials. CONCLUSIONS These recommendations will provide a clinical guidance regarding the use of APBI outside the context of a clinical trial before large-scale randomized clinical trial outcome data become available. Furthermore they should promote further clinical research focusing on controversial issues in the treatment of early-stage breast carcinoma.
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Affiliation(s)
- Csaba Polgár
- Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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Polgár C, Major T, Fodor J, Sulyok Z, Somogyi A, Lövey K, Németh G, Kásler M. Accelerated partial-breast irradiation using high-dose-rate interstitial brachytherapy: 12-year update of a prospective clinical study. Radiother Oncol 2010; 94:274-9. [PMID: 20181401 DOI: 10.1016/j.radonc.2010.01.019] [Citation(s) in RCA: 163] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Revised: 01/26/2010] [Accepted: 01/29/2010] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE To report the 12-year updated results of accelerated partial-breast irradiation (APBI) using multicatheter interstitial high-dose-rate (HDR) brachytherapy (BT). PATIENTS AND METHODS Forty-five prospectively selected patients with T1N0-N1mi, nonlobular breast cancer without the presence of an extensive intraductal component and with negative surgical margins were treated with APBI after breast-conserving surgery (BCS) using interstitial HDR BT. A total dose of 30.3 Gy (n=8) and 36.4 Gy (n=37) in seven fractions within 4 days was delivered to the tumour bed plus a 1-2 cm margin. The median follow-up time was 133 months for surviving patients. Local and regional control, disease-free (DFS), cancer-specific (CSS), and overall survival (OS), as well as late side effects, and cosmetic results were assessed. RESULTS Four (8.9%) ipsilateral breast tumour recurrences were observed, for a 5-, 10-, and 12-year actuarial rate of 4.4%, 9.3%, and 9.3%, respectively. A total of two regional nodal failures were observed for a 12-year actuarial rate of 4.4%. The 12-year DFS, CSS, and OS was 75.3%, 91.1%, and 88.9%, respectively. Grade 3 fibrosis was observed in one patient (2.2%). No patient developed grade 3 teleangiectasia. Fat necrosis requiring surgical intervention occurred in one woman (2.2%). Cosmetic results were rated excellent or good in 35 patients (77.8%). CONCLUSIONS Twelve-year results with APBI using HDR multicatheter interstitial implants continue to demonstrate excellent long-term local tumour control, survival, and cosmetic results with a low-rate of late side effects.
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Affiliation(s)
- Csaba Polgár
- Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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Tinterri C, Gatzemeier W, Zanini V, Regolo L, Pedrazzoli C, Rondini E, Amanti C, Gentile G, Taffurelli M, Fenaroli P, Tondini C, Sacchetto G, Sismondi P, Murgo R, Orlandi M, Cianchetti E, Andreoli C. Conservative surgery with and without radiotherapy in elderly patients with early-stage breast cancer: a prospective randomised multicentre trial. Breast 2009; 18:373-7. [PMID: 19910194 DOI: 10.1016/j.breast.2009.09.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 09/17/2009] [Indexed: 11/26/2022] Open
Abstract
Breast conserving therapy (BCT) including postoperative irradiation of the remaining breast tissue is generally accepted as the best treatment for the majority of patients with early-stage breast cancer. The question is whether there is a necessity for irradiating all patients. Between 2001 and 2005, 749 women aged 55-75 years with infiltrating breast carcinoma were randomly assigned to breast conservative surgery, with or without radiotherapy (RT), to evaluate the incidence of in-breast recurrence (IBR). After 5 years of median follow-up, the cumulative incidence of IBR was 2.5% in the surgery-only arm and 0.7% in the surgery plus RT arm. There are no differences in terms of overall survival and distant disease-free survival. The preliminary evaluation suggests that breast irradiation after conservative surgery can be avoided without exposing these patients to an increased risk of distant-disease recurrence. Prolonged follow-up will further clarify the possible risks and late sequelae potentially induced by breast RT.
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Affiliation(s)
- C Tinterri
- Breast Unit, Istituto Clinico Humanitas, via Manzoni 56, 20089 Rozzano, Milano, Italy
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Ruch M, Brade J, Schoeber C, Kraus-Tiefenbacher U, Schnitzer A, Engel D, Wenz F, Sütterlin M, Schoenberg S, Wasser K. Long-term follow-up-findings in mammography and ultrasound after intraoperative radiotherapy (IORT) for breast cancer. Breast 2009; 18:327-34. [DOI: 10.1016/j.breast.2009.09.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 09/09/2009] [Accepted: 09/11/2009] [Indexed: 10/20/2022] Open
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Recht A, Ancukiewicz M, Alm El-Din MA, Lu XQ, Martin C, Berman SM, Hirsch AE, Kachnic LA, Katz A, MacDonald S, Nedea EA, Stevenson MA, Powell SN, Taghian AG. Lung Dose-Volume Parameters and the Risk of Pneumonitis for Patients Treated With Accelerated Partial-Breast Irradiation Using Three-Dimensional Conformal Radiotherapy. J Clin Oncol 2009; 27:3887-93. [DOI: 10.1200/jco.2008.20.0121] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose There are no data on how complication rates after accelerated partial-breast irradiation delivered by three-dimensional conformal radiotherapy are affected by treatment technique. We therefore examined the risk of pneumonitis in relation to lung dose-volume parameters. Patients and Methods Our prospective dose-escalation trial enrolled 198 treated patients from 2003 to 2007. Patients received 32 or 36 Gy in 4-Gy fractions, given twice daily: 29 (14%) were treated with pure photons; 149 (77%) with mixed photons and electrons; and 20 (10%) with protons. Results There were four cases of pneumonitis at 4, 4, 7, and 9 months after treatment. All were in the 36-Gy cohort and were treated with pure photons. The risk of pneumonitis for the two cohorts combined was: 17% (four of 24) for an ipsilateral lung volume (ILV) receiving 20 Gy or higher (ILV, 20 Gy) of 3% or higher (P = .0002 for comparison to ILV 20 Gy < 3%, Fisher's exact test); 20% (four of 20) for an ILV 10 Gy of 10% or higher (P = .0001); and 15% (four of 26) for an ILV 5 Gy of 20% or higher (P = .0002). Conclusion The risk of pneumonitis appeared related to the ILV treated. This volume can be reduced by using mixed photons and electron when possible. We recommend that the ILV 20 Gy should be lower than 3%, the ILV 10 Gy lower than 10%, and the ILV 5 Gy lower than 20% when purely coplanar techniques are used.
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Affiliation(s)
- Abram Recht
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Marek Ancukiewicz
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Mohamed A. Alm El-Din
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Xing-Qi Lu
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Chrystalla Martin
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Stuart M. Berman
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Ariel E. Hirsch
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Lisa A. Kachnic
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Angela Katz
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Shannon MacDonald
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Elena A. Nedea
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Mary Ann Stevenson
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Simon N. Powell
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
| | - Alphonse G. Taghian
- From the Beth Israel Deaconess Medical Center; Massachusetts General Hospital; Boston Medical Center; the Harvard Medical School, Boston, MA; and the Department of Radiation Oncology, Tanta University Hospital, Tanta Faculty of Medicine, Egypt
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Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). Int J Radiat Oncol Biol Phys 2009; 74:987-1001. [PMID: 19545784 DOI: 10.1016/j.ijrobp.2009.02.031] [Citation(s) in RCA: 598] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 02/25/2009] [Indexed: 01/05/2023]
Abstract
PURPOSE To present guidance for patients and physicians regarding the use of accelerated partial-breast irradiation (APBI), based on current published evidence complemented by expert opinion. METHODS AND MATERIALS A systematic search of the National Library of Medicine's PubMed database yielded 645 candidate original research articles potentially applicable to APBI. Of these, 4 randomized trials and 38 prospective single-arm studies were identified. A Task Force composed of all authors synthesized the published evidence and, through a series of meetings, reached consensus regarding the recommendations contained herein. RESULTS The Task Force proposed three patient groups: (1) a "suitable" group, for whom APBI outside of a clinical trial is acceptable, (2) a "cautionary" group, for whom caution and concern should be applied when considering APBI outside of a clinical trial, and (3) an "unsuitable" group, for whom APBI outside of a clinical trial is not generally considered warranted. Patients who choose treatment with APBI should be informed that whole-breast irradiation (WBI) is an established treatment with a much longer track record that has documented long-term effectiveness and safety. CONCLUSION Accelerated partial-breast irradiation is a new technology that may ultimately demonstrate long-term effectiveness and safety comparable to that of WBI for selected patients with early breast cancer. This consensus statement is intended to provide guidance regarding the use of APBI outside of a clinical trial and to serve as a framework to promote additional clinical investigations into the optimal role of APBI in the treatment of breast cancer.
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van Esser S, Stapper G, van Diest PJ, van den Bosch MAAJ, Klaessens JHGM, Mali WPTM, Borel Rinkes IHM, van Hillegersberg R. Ultrasound-guided laser-induced thermal therapy for small palpable invasive breast carcinomas: a feasibility study. Ann Surg Oncol 2009; 16:2259-63. [PMID: 19506958 PMCID: PMC2711908 DOI: 10.1245/s10434-009-0544-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 05/18/2009] [Accepted: 05/18/2009] [Indexed: 12/19/2022]
Abstract
Background The next step in breast-conserving surgery for small breast carcinomas could be local ablation. In this study, the feasibility of ultrasound-guided laser-induced thermal therapy (LITT) is evaluated. Methods Patients with large-core needle biopsy-proven invasive, palpable breast carcinoma (clinically ≤2 cm) underwent ultrasound-guided LITT, followed by surgical excision. Completeness of ablation was determined by both hematoxylin and eosin staining and nicotinamide adenosine diaphorase staining. Results Fourteen patients completed the treatment. The mean histological tumor size was 17 mm (range, 8–37 mm); 6 of 14 tumors were histologically larger than the clinical entry threshold of 2 cm. The power applied in all patients was 7 W, and the mean treatment time was 21.4 min (range, 15–30 min). In one patient, a skin burn occurred, and one patient had a localized pneumothorax that could be treated conservatively. In 7 (50%) of 14 patients, the tumor was completely ablated, as confirmed by nicotinamide adenosine diaphorase staining. In 11 cases, extensive in-situ carcinoma was present. In one case, the in-situ carcinoma was also completely ablated. A total of seven (88%) of eight tumors <2 cm in size were completely ablated versus one (17%) of six tumors that were ≥2 cm in size (P = .026). Conclusions Successful LITT of invasive breast cancer seems to be feasible when confined to small (<2 cm) nonlobular carcinomas without surrounding extensive in-situ component and angioinvasion. However, to implement LITT in a curative setting, improvements in imaging to more reliably preoperatively assess tumor size and monitoring of fiber tip placement and treatment affect are essential.
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Affiliation(s)
- S van Esser
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Kásler M, Polgár C, Fodor J. Current status of treatment for early-stage invasive breast cancer. Orv Hetil 2009; 150:1013-21. [DOI: 10.1556/oh.2009.28615] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Az emlőrák a nők leggyakoribb rákos megbetegedése. Évente több mint egymillió nő betegszik meg emlőrákban. Az emlőrákos morbiditás meredeken emelkedett a fejlett ipari országokban az utóbbi pár évtizedben, de a mortalitási ráta mostanában csökken. Az utóbbi a szervezett lakossági szűréseknek, a korszerű sebészi és sugárterápiás beavatkozásoknak és a hatékonyabb szisztémás kezeléseknek köszönhető. A fejlődés egyik legizgalmasabb területe az új terápiás szerek bevezetése a klinikai gyakorlatba. A célzott terápia (tirozinkinázok gátlása) rohamosan fejlődik. Korai (0./I./II. stádium) emlőrákban a daganatot műtéttel eltávolítják, és ezt követi az adjuváns kezelés. Az adjuváns kezelés célja a lokoregionális és távoli mikroszkopikus daganatdepozitok elpusztítása. A daganatos kiújulás kockázatának megbecsülésére prognosztikai faktorokat használunk. Az optimális individualizált kezelés meghatározását a prediktív faktorok segítik. A dolgozatban a korai emlőrák kezelésének jelenlegi helyzetét tárgyaljuk, beleértve az emlőmegtartó kezelést, a mastectomia utáni sugárkezelést, a hormon- és kemoterápiát, valamint a humán epidermális növekedési faktor receptor-2- (HER-2-) pozitív daganatok trastuzumabkezelését.
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Affiliation(s)
- Miklós Kásler
- 1 Országos Onkológiai Intézet Budapest Ráth Gy. u. 7–9. 1122
| | - Csaba Polgár
- 1 Országos Onkológiai Intézet Budapest Ráth Gy. u. 7–9. 1122
| | - János Fodor
- 1 Országos Onkológiai Intézet Budapest Ráth Gy. u. 7–9. 1122
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Smith BD, Arthur DW, Buchholz TA, Haffty BG, Hahn CA, Hardenbergh PH, Julian TB, Marks LB, Todor DA, Vicini FA, Whelan TJ, White J, Wo JY, Harris JR. Accelerated partial breast irradiation consensus statement from the American Society for Radiation Oncology (ASTRO). J Am Coll Surg 2009; 209:269-77. [PMID: 19632605 DOI: 10.1016/j.jamcollsurg.2009.02.066] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 02/27/2009] [Indexed: 12/25/2022]
Affiliation(s)
- Benjamin D Smith
- Radiation Oncology Flight, Wilford Hall Medical Center, Lackland AFB, TX 78236, USA
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Toxicity of three-dimensional conformal radiotherapy for accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys 2009; 75:1290-6. [PMID: 19395195 DOI: 10.1016/j.ijrobp.2009.01.009] [Citation(s) in RCA: 158] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2008] [Revised: 01/12/2009] [Accepted: 01/13/2009] [Indexed: 12/24/2022]
Abstract
PURPOSE To assess the incidence and severity of late normal tissue toxicity using three-dimensional conformal radiotherapy to deliver accelerated partial breast irradiation. METHODS AND MATERIALS A total of 60 patients were treated with three-dimensional conformal radiotherapy for accelerated partial breast irradiation. Treatment planning and delivery were in strict accordance with the technique and specified dose-volume constraints of the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol. Late toxicity was evaluated according to the Radiation Therapy Oncology Group grading schema. The cosmetic outcome was scored using the Harvard criteria. Univariate logistic regression analysis was performed to evaluate the correlation of dosimetric variables with outcome. RESULTS At a median follow-up of 15 months, moderate-to-severe late toxicity developed in 10% of patients. The most pronounced late toxicity was subcutaneous fibrosis: 25% Grade 2-4 and 8.3% Grade 3-4. The modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5%, 20%, 50%, and 80% of the prescription dose to the whole breast volume, and maximal dose within the breast correlated with the development of fibrosis (p = .10, p = .03, p = .04, p = .06, p = .09, and p = .046, respectively). The overall cosmetic outcome was good to excellent in 81.7%, fair in 11.7%, and poor in 6.7%. The presence of subcutaneous fibrosis, modified planning tumor volume/whole breast volume ratio, ratio of the volume of breast tissue receiving 5% and 20% of the prescription dose to the whole breast volume, and pathologic specimen volume correlated with the risk of a fair/poor cosmetic outcome (p < .001, p = .02, p = .05, p = .04, p = .01, respectively). CONCLUSION The three-dimensional conformal radiotherapy technique for accelerated partial breast irradiation as specified in the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 protocol resulted in a remarkably high rate of moderate-to-severe late normal tissue effects, despite the relatively brief follow-up period. The toxic events correlated clearly with several dose-volume parameters.
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Fodor J. [Evidence-based radiotherapy in the treatment of early-stage invasive breast cancer: traditional clinical features and biomarkers]. Magy Onkol 2009; 53:7-14. [PMID: 19318321 DOI: 10.1556/monkol.53.2009.1.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Adjuvant radiotherapy after modified radical mastectomy and breast-conserving surgery for early-stage invasive breast cancer substantially reduces the risk of locoregional failure and is evidence-based. Using traditional clinical and pathological factors, patients can be classified into subgroups by the risk of locoregional recurrence. In the high-risk groups the absolute benefit of irradiation is larger. However, the patients are over-treated in every subgroup. Substantial proportion of the patients remains free of locoregional recurrence even in the absence of irradiation, and some patients develop locoregional recurrence despite postoperative irradiation. Molecular markers may provide sufficient information to allow accurate individual risk assessment to identify patients who might benefit from irradiation. Despite of hundreds of reports on tumor markers, results are controversial and the number of validated markers for clinical practice is small. Prognostic and predictive factors commonly used in radiotherapy practice are ER, PgR and HER-2. Adjuvant radiotherapy not only reduces locoregional recurrence rates but also improves cancer-specific survival in patients receiving systemic therapy. The highest mortality reduction is observed in mastectomy patients with good prognostic factors (<4 positive nodes, tumor size <2 cm, Grade 1 malignancy, ER- and PgR-positive, HER-2-negative). After mastectomy the chest wall, and after breast conserving surgery the ipsilateral breast are the sites at greatest risk of recurrence. The risk of axillary recurrence is low in patients undergoing axillary dissection. Axillary and supraclavicular recurrences generally forecast a grim prognosis, and they are indicators of distant dissemination. Improvement in survival resulting from the use of irradiation is more related to the prevention of local recurrences. Post-irradiation local recurrence increases the risk of mortality, but with good prognostic factors the 10-year survival is 80-90%. Patients with </=2 cm ipsilateral breast recurrence might receive a second conservative surgery. The radiation dose to the lung and heart can be significantly reduced by individualized CT-based treatment planning. The rate of Grade 3 atrophic dermatitis and fibrosis is 3-4%. The estimated incidence of ipsilateral breast angiosarcoma is less than 0.2%, but the mortality rate is high.
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Affiliation(s)
- János Fodor
- Országos Onkológiai Intézet 1122 Budapest Ráth György u. 7-9, Hungary.
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Current status and perspectives of brachytherapy for breast cancer. Int J Clin Oncol 2009; 14:7-24. [DOI: 10.1007/s10147-008-0867-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Indexed: 10/21/2022]
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Aristei C, Palumbo I, Cucciarelli F, Cavalli A, Tarducci R, Raymondi C, Perrucci E, Cavaliere A, Latini P, Rulli A. Partial breast irradiation with interstitial high-dose-rate brachytherapy in early breast cancer: Results of a phase II prospective study. Eur J Surg Oncol 2009; 35:144-50. [DOI: 10.1016/j.ejso.2008.06.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2008] [Revised: 05/22/2008] [Accepted: 06/02/2008] [Indexed: 10/21/2022] Open
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OECI Workshop on late side-effects of cancer treatments. Eur J Cancer 2009; 45:354-9. [DOI: 10.1016/j.ejca.2008.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/08/2008] [Indexed: 11/24/2022]
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Haley M, Beriwal S, Heron DE, Kim H, Falk J, Johnson R, Mogus R. MammoSite® accelerated partial breast irradiation: A single-institution outcomes analysis with 2 years of followup. Brachytherapy 2009; 8:9-13. [PMID: 18955020 DOI: 10.1016/j.brachy.2008.07.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 07/23/2008] [Accepted: 07/24/2008] [Indexed: 11/25/2022]
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Major T, Fröhlich G, Lövey K, Fodor J, Polgár C. Dosimetric experience with accelerated partial breast irradiation using image-guided interstitial brachytherapy. Radiother Oncol 2009; 90:48-55. [DOI: 10.1016/j.radonc.2007.10.027] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 08/29/2007] [Accepted: 10/18/2007] [Indexed: 11/16/2022]
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Offersen BV, Overgaard M, Kroman N, Overgaard J. Accelerated partial breast irradiation as part of breast conserving therapy of early breast carcinoma: a systematic review. Radiother Oncol 2008; 90:1-13. [PMID: 18783840 DOI: 10.1016/j.radonc.2008.08.005] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 08/08/2008] [Accepted: 08/13/2008] [Indexed: 12/24/2022]
Abstract
New strategies for adjuvant radiotherapy of early breast cancer are being investigated in several phase III randomised trials at the present time. Accelerated partial breast irradiation (APBI) is a way to offer an early breast cancer patient, who has had breast conservative surgery, an adjuvant radiotherapy of short duration aimed at the tumour bed with a certain margin. The rationale of this strategy is that most local recurrences appear close to the tumorectomy cavity and a wish to spare the patient late radiation morbidity. This review discusses the background for APBI, the different techniques, and we highlight possible pitfalls using these techniques. A systematic overview of all phase I and II studies is provided. Patient selection for this therapy is pivotal and based on evidence from previous studies on patient/tumour characteristics and pattern of local recurrences we propose inclusion criteria for patients in APBI protocols.
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