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Exposure of the Heart in Breast Cancer Radiation Therapy: A Systematic Review of Heart Doses Published During 2003 to 2013. Int J Radiat Oncol Biol Phys 2015; 93:845-53. [DOI: 10.1016/j.ijrobp.2015.07.2292] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/16/2015] [Accepted: 07/29/2015] [Indexed: 11/20/2022]
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Taylor C, Kirby A. Cardiac Side-effects From Breast Cancer Radiotherapy. Clin Oncol (R Coll Radiol) 2015; 27:621-9. [DOI: 10.1016/j.clon.2015.06.007] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 03/31/2015] [Accepted: 06/06/2015] [Indexed: 11/15/2022]
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Heggemann F, Grotz H, Welzel G, Dösch C, Hansmann J, Kraus-Tiefenbacher U, Attenberger U, Schönberg SO, Borggrefe M, Wenz F, Papavassiliu T, Lohr F. Cardiac Function After Multimodal Breast Cancer Therapy Assessed With Functional Magnetic Resonance Imaging and Echocardiography Imaging. Int J Radiat Oncol Biol Phys 2015; 93:836-44. [PMID: 26530752 DOI: 10.1016/j.ijrobp.2015.07.2287] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/13/2015] [Accepted: 07/29/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Breast intensity modulated radiation therapy (IMRT) reduces high-dose heart volumes but increases low-dose volumes. We prospectively assessed heart changes after 3D conformal RT (3DCRT) and IMRT for left-sided breast cancer. Heart dose was analyzed individually, 3DCRT patients were moderately exposed, and IMRT was performed only in patients with unacceptably high heart doses upon 3DCRT planning. METHODS AND MATERIALS In 49 patients (38 patients received 3DCRT; 11 patients received IMRT; and 20 patients received neoadjuvant or adjuvant chemotherapy) magnetic resonance imaging (MRI) and echocardiography were performed before and at 6, 12, and 24 months after treatment. RESULTS Mean heart dose for IMRT was 12.9 ± 3.9 Gy versus 4.5 ± 2.4 Gy for 3DCRT. Heart volumes receiving >40 Gy were 2.6% (3DCRT) versus 1.3% (IMRT); doses were >50 Gy only with 3DCRT. Temporary ejection fraction (EF) decrease was observed on MRI after 6 months (63%-59%, P=.005) resolving at 24 months. Only 3 patients had pronounced largely transient changes of EF and left ventricular enddiastolic diameter (LVEDD). Mitral (M) and tricuspid (T) annular plane systolic excursion (MAPSE and TAPSE) were reduced over the whole cohort (still within normal range). After 24 months left ventricular remodeling index decreased in patients receiving chemotherapy (0.80 vs 0.70, P=.028). Neither wall motion abnormalities nor late enhancements were found. On echocardiography, in addition to EF findings that were similar to those on MRI, global strain was unchanged over the whole cohort at 24 months after a transient decrease at 6 and 12 months. Longitudinal strain decreased in the whole cohort after 24 months in some segments, whereas it increased in others. CONCLUSIONS Until 24 months after risk-adapted modern multimodal adjuvant therapy, only subclinical cardiac changes were observed in both 3DCRT patients with inclusion of small to moderate amounts of heart volume in RT tangents and in the patients treated with IMRT and reduced high-dose heart exposure.
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Affiliation(s)
- Felix Heggemann
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany.
| | - Hanna Grotz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christina Dösch
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany
| | - Jan Hansmann
- Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Uta Kraus-Tiefenbacher
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ulrike Attenberger
- German Center for Cardiovascular Research, Mannheim, Germany; Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Stephan Oswald Schönberg
- German Center for Cardiovascular Research, Mannheim, Germany; Institute of Diagnostic Radiology and Nuclear Medicine, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theano Papavassiliu
- First Medical Department, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany; German Center for Cardiovascular Research, Mannheim, Germany
| | - Frank Lohr
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Meyersohn NNM, Pursnani A, Neilan TG. Detection of Cardiac Toxicity Due to Cancer Treatment: Role of Cardiac MRI. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:396. [PMID: 26134969 DOI: 10.1007/s11936-015-0396-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OPINION STATEMENT Common cancer treatments including anthracycline-based chemotherapy, tyrosine kinase inhibitors, and thoracic radiation therapy can result in short- and long-term cardiovascular complications with a significant impact on morbidity and mortality. Anthracycline-based chemotherapy and tyrosine kinase inhibitors are associated with left ventricular systolic dysfunction and heart failure. Radiation therapy is associated with restrictive cardiomyopathy, coronary artery disease, as well as pericardial and valvular disease. The current standard surveillance of oncology patients for cardiotoxicity involves echocardiography, radionuclide cardiac blood pool imaging, and cardiac magnetic resonance (CMR) imaging. CMR can be used to evaluate ventricular structure and function, which is important for management decisions to prevent further cardiac injury. In patients for whom standard surveillance imaging demonstrates a drop in systolic function with or without symptoms, the use of CMR is an appropriate next step for further evaluation due to the accuracy and reproducibility of measurements of function and volumes combined with the additive information provided by tissue characterization through imaging of myocardial edema and myocardial fibrosis, although the clinical applications of these latter are as yet unclear. Overall, detection of early cardiotoxicity is important since therapeutic response is improved with prompt initiation of medical treatment.
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Affiliation(s)
- Nandini Nina M Meyersohn
- Department of Radiology, Cardiac MR PET CT Program, Massachusetts General Hospital, Boston, MA, USA,
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Lin LL, Vennarini S, Dimofte A, Ravanelli D, Shillington K, Batra S, Tochner Z, Both S, Freedman G. Proton beam versus photon beam dose to the heart and left anterior descending artery for left-sided breast cancer. Acta Oncol 2015; 54:1032-9. [PMID: 25789715 DOI: 10.3109/0284186x.2015.1011756] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to compare the dose to heart, left anterior descending (LAD) artery and lung between proton and photon beam irradiation for left-sided early stage breast cancer. MATERIAL AND METHODS Ten women with early stage left-sided breast cancer were treated with breast conserving surgery and radiation. Whole breast radiation was delivered for actual treatment via a tangential technique with deep inspiration breath hold (DIBH) utilizing inverse planned intensity-modulated radiation therapy (IMRT). Each patient was replanned on an Institutional Review Board (IRB)-approved prospective study using en face proton beam radiation with both uniform scanning (US) and pencil beam scanning (PBS) techniques. RESULTS Both PBS (0.011 Gy) and US (0.009 Gy) proton plans resulted in a significantly lower mean heart dose compared to IMRT (1.612 Gy) (p < 0.05 for PBS vs. IMRT and US vs. IMRT). The Dmean, Dmin, Dmax, and D0.2cm(3) of the LAD with either proton technique were significantly lower (p = 0.005) compared to IMRT. Both US and PBS reduced the mean dose to the lungs compared to IMRT. The coverage of the breast planning target volume was comparable between photon and proton plans. CONCLUSIONS The dose to whole heart was relatively low in this study of patients treated under conditions of DIBH. However, proton beam radiation was associated with lower minimum, maximum, and dose to 0.2 cm(3) of the LAD, which is the critical structure for late radiation therapy effects, compared to even the most optimized photon beam plan with DIBH and IMRT.
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Affiliation(s)
- Lilie L. Lin
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sabina Vennarini
- Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Andreea Dimofte
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniele Ravanelli
- Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Katie Shillington
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sonny Batra
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Zelig Tochner
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan Both
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary Freedman
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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Beukema JC, Langendijk JA, Muijs CT. Cardiac toxicity in the radiation treatment of esophageal cancer: an emerging concern. Future Cardiol 2015; 11:367-9. [DOI: 10.2217/fca.15.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jannet C Beukema
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol 2015; 115:342-8. [DOI: 10.1016/j.radonc.2015.06.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 11/18/2022]
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L’irradiation des aires ganglionnaires (sus-claviculaire et mammaire interne) augmente-t-elle la toxicité de la radiothérapie adjuvante mammaire ? Cancer Radiother 2015; 19:261-4. [DOI: 10.1016/j.canrad.2015.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/04/2015] [Indexed: 11/23/2022]
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Lutz CM, Poulsen PR, Fledelius W, Offersen BV, Thomsen MS. Setup error and motion during deep inspiration breath-hold breast radiotherapy measured with continuous portal imaging. Acta Oncol 2015; 55:193-200. [PMID: 25984928 DOI: 10.3109/0284186x.2015.1045625] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The position and residual motion of the chest wall of breast cancer patients during treatment in deep inspiration breath-hold (DIBH) were investigated. MATERIAL AND METHODS The study included 58 left-sided breast cancer patients treated with DIBH three-dimensional (3D) conformal radiotherapy in 15 or 25 fractions. The DIBH levels were monitored using an external marker block placed on the chest, either shifted 5 cm to the right at the level of the xiphoid process (Group 1, 27 consecutive patients) or placed medially on the inferior part of the sternum (Group 2, 31 consecutive patients). At every third treatment fraction, continuous portal images were acquired. The time-resolved chest wall position during treatment was compared with the planned position to determine the inter-fraction setup errors and the intra-fraction motion of the chest wall. RESULTS The DIBH compliance was 95% during both recruitment periods. A tendency of smaller inter-fraction setup errors and intra-fraction motion was observed for group 2 (medial marker block position). However, apart from a significantly reduced inter-field random shift (σ = 1.7 mm vs. σ = 0.9 mm, p = 0.005), no statistically significant differences between the groups were found. In a combined analysis, the group mean inter-fraction setup error was M = - 0.1 mm, with random and systematic errors of σ = 1.7 mm and Σ = 1.4 mm. The group mean inter-field shift was M = 0.0 (σ = 1.3 mm and Σ = 1.1 mm) and the group mean standard deviation of the intra-field motion was 0.5 mm. The absolute setup error had a maximum of 16.3 mm, exceeding 5 mm in 2.2% of the imaged fields. CONCLUSION Compared to free breathing treatments, the primary benefit of the DIBH technique was the separation of the heart from the target rather than more accurate targeting. Despite a small gating window, occasional large errors in the chest wall position were observed for some patients, illustrating limitations of the external marker block as surrogate in a broad patient population.
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Affiliation(s)
| | - Per Rugaard Poulsen
- b Institute of Clinical Medicine, Aarhus University , Aarhus , Denmark
- c Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Walther Fledelius
- c Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
| | - Birgitte Vrou Offersen
- b Institute of Clinical Medicine, Aarhus University , Aarhus , Denmark
- c Department of Oncology , Aarhus University Hospital , Aarhus , Denmark
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Umezawa R, Takanami K, Kadoya N, Nakajima Y, Saito M, Ota H, Matsushita H, Sugawara T, Kubozono M, Yamamoto T, Ishikawa Y, Takeda K, Taki Y, Takase K, Jingu K. Assessment of myocardial metabolic disorder associated with mediastinal radiotherapy for esophageal cancer -a pilot study. Radiat Oncol 2015; 10:96. [PMID: 25896887 PMCID: PMC4407329 DOI: 10.1186/s13014-015-0410-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/15/2015] [Indexed: 12/25/2022] Open
Abstract
Background To evaluate the dose-effect relations for myocardial metabolic disorders after mediastinal radiotherapy (RT) by performing iodine-123 β-methyl-iodophenyl pentadecanoic acid (I-123 BMIPP) scintigraphy. Methods Between 2011 and 2012, we performed I-123 BMIPP scintigraphy for patients with esophageal cancer before and six months after curative mediastinal RT. Single photon emission computed tomography (SPECT) images of pre-RT and post-RT were registered into RT dose distributions. The myocardium was contoured, and the regional RT dose was calculated. Normalization is required to compare pre- and post-RT SPECT images because the uptake pattern is changed due to the breathing level. Normalization was applied on the mean of SPECT counts in regions of the myocardium receiving less than 5 Gy. Relative values in each dose region (interval of 5 Gy) were calculated on the basis of this normalization for each patient. The reduction in the percent of relative values was calculated. Results Five patients were enrolled in this study. None of the patients had a past history of cardiac disease. The left ventricle was partially involved in RT fields in all patients. The patients received RT with median total doses of 60-66 Gy for the primary tumor and metastatic lymph nodes. Concomitant chemotherapy consisting of cisplatin or nedaplatin and 5-fluorouracil with RT was performed in 4 patients. All patients had reduced uptake corresponding to RT fields. Dose-effect relations for reduced uptake tended to be observed at 6 months after RT with mean decreases of 8.96% in regions at 10-15 Gy, 12.6% in regions at 20-25 Gy, 15.6% in regions at 30-35 Gy, 19.0% in regions at 40-45 Gy and 16.0% in regions at 50-55 Gy. Conclusions Dose-effect relations for myocardial metabolic disorders tended to be observed. We may need to make an effort to reduce high-dose mediastinal RT to the myocardium in RT planning.
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Affiliation(s)
- Rei Umezawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Kentaro Takanami
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Noriyuki Kadoya
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Yujiro Nakajima
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Masahide Saito
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Haruo Matsushita
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Toshiyuki Sugawara
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Masaki Kubozono
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Takaya Yamamoto
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Yojiro Ishikawa
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Ken Takeda
- Department of Radiological Technology, School of Health Sciences, Faculty of Medicine, Tohoku University, Sendai, Japan.
| | - Yasuyuki Taki
- Department of Developmental Cognitive Neuroscience Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Sendai, Japan.
| | - Keiichi Jingu
- Department of Radiation Oncology, Tohoku University Graduate School of Medicine, Sendai, Japan.
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Hepp R, Ammerpohl M, Morgenstern C, Nielinger L, Erichsen P, Abdallah A, Galalae R. Deep inspiration breath-hold (DIBH) radiotherapy in left-sided breast cancer: Dosimetrical comparison and clinical feasibility in 20 patients. Strahlenther Onkol 2015; 191:710-6. [PMID: 25893323 DOI: 10.1007/s00066-015-0838-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 03/25/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Adjuvant radiotherapy after breast-conserving surgery (BCS) for breast cancer (BC) is a well-established indication. The risk of ischaemic heart disease after radiotherapy for BC increases linearly with the heart mean dose with no apparent threshold. Radiotherapy to the left breast in deep inspiration breath-hold (DIBH) reduces the dose to the heart. A new linac system with an integrated surface scanner (SS) for DIBH treatments was recently installed in our department. We tested it for potential benefits, safety, patients' acceptance/compliance and associated additional workload. MATERIALS AND METHODS Twenty consecutive patients following BCS for breast carcinoma of the left side were enrolled in our institutional DIBH protocol. We compared dose to the heart and ipsilateral lung (IL) between plans in DIBH and free breathing (FB) using standard defined parameters: mean dose, maximal dose to a volume of 2 cm(3) (D2 cm (3)), volume receiving ≥ 5 Gy (V5), 10 Gy (V10), 15 Gy (V15) and 20 Gy (V20). Comparison of median calculated dose values was performed using a two-tailed Wilcoxon signed rank test. RESULTS DIBH was associated with a statistically significant reduction (p < 0.001) in all studied parameters for the heart and the IL. In 16 of 20 patients the heart D2 cm (3) was less than 42 Gy in DIBH. In FB the heart D2 cm (3) was ≥ 42 Gy in 17 of 20 patients. The median daily treatment time was 9 min. CONCLUSION Radiotherapy of the left breast in DIBH using a SS could easily be incorporated into daily routine and is associated with significant dose reduction to the heart and IL.
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Affiliation(s)
- Rodrigo Hepp
- Klinik für Strahlentherapie und Radioonkologie, Evangelische Kliniken Gelsenkirchen, Munckelstraße 27, 45879, Gelsenkirchen, Deutschland,
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Edvardsson A, Nilsson MP, Amptoulach S, Ceberg S. Comparison of doses and NTCP to risk organs with enhanced inspiration gating and free breathing for left-sided breast cancer radiotherapy using the AAA algorithm. Radiat Oncol 2015; 10:84. [PMID: 25884950 PMCID: PMC4465142 DOI: 10.1186/s13014-015-0375-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 03/08/2015] [Indexed: 12/25/2022] Open
Abstract
Background The purpose of this study was to investigate the potential dose reduction to the heart, left anterior descending (LAD) coronary artery and the ipsilateral lung for patients treated with tangential and locoregional radiotherapy for left-sided breast cancer with enhanced inspiration gating (EIG) compared to free breathing (FB) using the AAA algorithm. The radiobiological implication of such dose sparing was also investigated. Methods Thirty-two patients, who received tangential or locoregional adjuvant radiotherapy with EIG for left-sided breast cancer, were retrospectively enrolled in this study. Each patient was CT-scanned during FB and EIG. Similar treatment plans, with comparable target coverage, were created in the two CT-sets using the AAA algorithm. Further, the probability of radiation induced cardiac mortality and pneumonitis were calculated using NTCP models. Results For tangential treatment, the median V25Gy for the heart and LAD was decreased for EIG from 2.2% to 0.2% and 40.2% to 0.1% (p < 0.001), respectively, whereas there was no significant difference in V20Gy for the ipsilateral lung (p = 0.109). For locoregional treatment, the median V25Gy for the heart and LAD was decreased for EIG from 3.3% to 0.2% and 51.4% to 5.1% (p < 0.001), respectively, and the median ipsilateral lung V20Gy decreased from 27.0% for FB to 21.5% (p = 0.020) for EIG. The median excess cardiac mortality probability decreased from 0.49% for FB to 0.02% for EIG (p < 0.001) for tangential treatment and from 0.75% to 0.02% (p < 0.001) for locoregional treatment. There was no significant difference in risk of radiation pneumonitis for tangential treatment (p = 0.179) whereas it decreased for locoregional treatment from 6.82% for FB to 3.17% for EIG (p = 0.004). Conclusions In this study the AAA algorithm was used for dose calculation to the heart, LAD and left lung when comparing the EIG and FB techniques for tangential and locoregional radiotherapy of breast cancer patients. The results support the dose and NTCP reductions reported in previous studies where dose calculations were performed using the pencil beam algorithm.
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Affiliation(s)
- Anneli Edvardsson
- Department of Medical Radiation Physics, Lund University, Lund, Sweden.
| | - Martin P Nilsson
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Sousana Amptoulach
- Department of Oncology and Radiation Physics, Skåne University Hospital, Malmö, Sweden.
| | - Sofie Ceberg
- Department of Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
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Wu S, Lai Y, He Z, Zhou Y, Chen S, Dai M, Zhou J, Lin Q, Chi F. Dosimetric comparison of the simultaneous integrated boost in whole-breast irradiation after breast-conserving surgery: IMRT, IMRT plus an electron boost and VMAT. PLoS One 2015; 10:e0120811. [PMID: 25781183 PMCID: PMC4363530 DOI: 10.1371/journal.pone.0120811] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 02/06/2015] [Indexed: 12/25/2022] Open
Abstract
Objectives To compare the target volume coverage and doses to organs at risks (OARs) using three techniques that simultaneous integrated boost (SIB) in whole-breast irradiation (WBI) after breast-conserving surgery, including intensity-modulated radiation therapy (IMRT), IMRT plus an electron boost (IMRT-EB), and volumetric-modulated arc therapy (VMAT). Methods A total of 10 patients with early-stage left-sided breast cancer after breast-conserving surgery were included in this study. IMRT, IMRT-EB and VMAT plans were generated for each patient. Results The conformity index (CI) of the planning target volumes evaluation (PTV-Eval) of VMAT was significantly superior to those of IMRT and IMRT-EB (P < 0.05). The CI of the PTV Eval-boost of VMAT was better than that of IMRT (P = 0.018) and IMRT-EB (P < 0.001), while the CI of the PTV Eval-boost of IMRT was better than that of IMRT-EB (P = 0.002). The V5, V10 and Dmean in ipsilateral lung with VMAT were significantly higher than IMRT (P < 0.05) and IMRT-EB (P < 0.05). The Dmean, V5 and V10 in heart with VMAT were significantly greater than those of IMRT and IMRT-EB (P < 0.05). There was no significant difference in the OARs between IMRT and IMRT-EB (P > 0.05). Conclusions Considered the target volume coverage and radiation dose delivered to the OARs (especially the heart and lung), IMRT may be more suitable for the SIB in WBI than IMRT-EB and VMAT. Additional clinical studies with a larger sample size will be needed to assess the long-term feasibility and efficacy of SIB using different radiotherapy techniques.
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Affiliation(s)
- Sangang Wu
- Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Youqun Lai
- Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Zhenyu He
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Department of Radiation Oncology, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People’s Republic of China
| | - Yuan Zhou
- Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Shanyu Chen
- Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Mingming Dai
- Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Juan Zhou
- Xiamen Cancer Center, Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
| | - Qin Lin
- Xiamen Cancer Center, Department of Radiation Oncology, the First Affiliated Hospital of Xiamen University, Xiamen, People’s Republic of China
- * E-mail: (QL); (FC)
| | - Feng Chi
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Department of Radiation Oncology, Collaborative Innovation Center of Cancer Medicine, Guangzhou, People’s Republic of China
- * E-mail: (QL); (FC)
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Garg AK, Buchholz TA. Influence of Neoadjuvant Chemotherapy on Radiotherapy for Breast Cancer. Ann Surg Oncol 2015; 22:1434-40. [DOI: 10.1245/s10434-015-4402-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Indexed: 11/18/2022]
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Cutter DJ, Schaapveld M, Darby SC, Hauptmann M, van Nimwegen FA, Krol ADG, Janus CPM, van Leeuwen FE, Aleman BMP. Risk of valvular heart disease after treatment for Hodgkin lymphoma. J Natl Cancer Inst 2015; 107:djv008. [PMID: 25713164 PMCID: PMC4394894 DOI: 10.1093/jnci/djv008] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hodgkin lymphoma (HL) survivors are at increased risk of developing valvular heart disease (VHD). We evaluated the determinants of the risk and the radiation dose-response. METHODS A case-control study was nested in a cohort of 1852 five-year HL survivors diagnosed at ages 15 to 41 years and treated between 1965 and 1995. Case patients had VHD of at least moderate severity as their first cardiovascular diagnosis following HL treatment. Control patients were matched to case patients for age, gender, and HL diagnosis date. Treatment and follow-up data were abstracted from medical records. Radiation doses to heart valves were estimated by reconstruction of individual treatments on representative computed tomography datasets. All statistical tests were two-sided. RESULTS Eighty-nine case patients with VHD were identified (66 severe or life-threatening) and 200 control patients. Aortic (n = 63) and mitral valves (n = 42) were most frequently affected. Risks increased more than linearly with radiation dose. For doses to the affected valve(s) of less than or equal to 30, 31-35, 36-40, and more than 40 Gy, VHD rates increased by factors of 1.4, 3.1, 5.4, and 11.8, respectively (P trend < .001). Approximate 30-year cumulative risks were 3.0%, 6.4%, 9.3%, and 12.4% for the same dose categories. VHD rate increased with splenectomy by a factor of 2.3 (P = .02). CONCLUSIONS Radiation dose to the heart valves can increase the risk of clinically significant VHD, especially at doses above 30 Gy. However, for patients with mediastinal involvement treated today with 20 or 30 Gy, the 30-year risk will be increased by only about 1.4%. These findings may be useful for patients and doctors both before treatment and during follow-up.
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Affiliation(s)
- David J Cutter
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Michael Schaapveld
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Sarah C Darby
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Michael Hauptmann
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Frederika A van Nimwegen
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Augustinus D G Krol
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Cecile P M Janus
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Flora E van Leeuwen
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA)
| | - Berthe M P Aleman
- Clinical Trial Service Unit, University of Oxford, Oxford, UK (DJC, SCD); Department of Psychosocial Research, Epidemiology and Biostatistics, the Netherlands Cancer Institute, Amsterdam, the Netherlands (MS, MH, FAvN, FEvL); Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands (ADGK); Department of Radiation Oncology, Erasmus Medical Center/Daniel den Hoed Clinic, Rotterdam, the Netherlands (CPMJ); Department of Radiation Oncology, the Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands (BMPA).
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Chan EK, Woods R, Virani S, Speers C, Wai ES, Nichol A, McBride ML, Tyldesley S. Long-term mortality from cardiac causes after adjuvant hypofractionated vs. conventional radiotherapy for localized left-sided breast cancer. Radiother Oncol 2015; 114:73-8. [DOI: 10.1016/j.radonc.2014.08.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 07/02/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
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Offersen BV, Boersma LJ, Kirkove C, Hol S, Aznar MC, Biete Sola A, Kirova YM, Pignol JP, Remouchamps V, Verhoeven K, Weltens C, Arenas M, Gabrys D, Kopek N, Krause M, Lundstedt D, Marinko T, Montero A, Yarnold J, Poortmans P. ESTRO consensus guideline on target volume delineation for elective radiation therapy of early stage breast cancer. Radiother Oncol 2015; 114:3-10. [PMID: 25630428 DOI: 10.1016/j.radonc.2014.11.030] [Citation(s) in RCA: 408] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 11/15/2014] [Accepted: 11/15/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Delineation of clinical target volumes (CTVs) is a weak link in radiation therapy (RT), and large inter-observer variation is seen in breast cancer patients. Several guidelines have been proposed, but most result in larger CTVs than based on conventional simulator-based RT. The aim was to develop a delineation guideline obtained by consensus between a broad European group of radiation oncologists. MATERIAL AND METHODS During ESTRO teaching courses on breast cancer, teachers sought consensus on delineation of CTV through dialogue based on cases. One teacher delineated CTV on CT scans of 2 patients, followed by discussion and adaptation of the delineation. The consensus established between teachers was sent to other teams working in the same field, both locally and on a national level, for their input. This was followed by developing a broad consensus based on discussions. RESULTS Borders of the CTV encompassing a 5mm margin around the large veins, running through the regional lymph node levels were agreed, and for the breast/thoracic wall other vessels were pointed out to guide delineation, with comments on margins for patients with advanced breast cancer. CONCLUSION The ESTRO consensus on CTV for elective RT of breast cancer, endorsed by a broad base of the radiation oncology community, is presented to improve consistency.
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Affiliation(s)
| | - Liesbeth J Boersma
- Department of Radiation Oncology, Maastricht University Medical Centre - GROW (MAASTRO), The Netherlands
| | - Carine Kirkove
- Department of Radiation Oncology, Catholic University of Louvain, Belgium
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, The Netherlands
| | | | - Albert Biete Sola
- Department of Radiation Oncology, Hospital Clinic i Provincial, Barcelona, Spain
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Jean-Philippe Pignol
- Department of Radiation Oncology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Vincent Remouchamps
- Department of Radiation Oncology, Clinique Sainte Elisabeth (AMPR), Namur, Belgium
| | - Karolien Verhoeven
- Department of Radiation Oncology, University Hospitals Leuven, KU Leuven, Belgium
| | - Caroline Weltens
- Department of Radiation Oncology, University Hospitals Leuven, KU Leuven, Belgium
| | - Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan, Reus, Spain
| | - Dorota Gabrys
- Department of Radiation Oncology, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice, Poland
| | - Neil Kopek
- Department of Oncology, Division of Radiation Oncology, McGill University, Montréal, Canada
| | - Mechthild Krause
- German Cancer Consortium (DKTK) Dresden and German Cancer Research Center (DKFZ) Heidelberg, Dept. of Radiation Oncology and OncoRay, University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Dan Lundstedt
- Department of Oncology, Sahlgrenska Universitetssjukhuset, Gothenborg, Sweden
| | - Tanja Marinko
- Department of Radiation Oncology, Institute of Oncology, Ljubljana, Slovenia
| | - Angel Montero
- Department of Radiation Oncology, Centro Integral Oncológico Clara Campal, Hospital Universitario Sanchinarro, Madrid, Spain
| | - John Yarnold
- Division of Radiotherapy and Imaging, Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, Sutton, UK
| | - Philip Poortmans
- Department of Radiation Oncology, Radboud university medical centre, The Netherlands
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268
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Beukema JC, van Luijk P, Widder J, Langendijk JA, Muijs CT. Is cardiac toxicity a relevant issue in the radiation treatment of esophageal cancer? Radiother Oncol 2014; 114:85-90. [PMID: 25554226 DOI: 10.1016/j.radonc.2014.11.037] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 11/04/2014] [Accepted: 11/23/2014] [Indexed: 01/22/2023]
Abstract
PURPOSE In recent years several papers have been published on radiation-induced cardiac toxicity, especially in breast cancer patients. However, in esophageal cancer patients the radiation dose to the heart is usually markedly higher. To determine whether radiation-induced cardiac toxicity is also a relevant issue for this group, we conducted a review of the current literature. METHODS A literature search was performed in Medline for papers concerning cardiac toxicity in esophageal cancer patients treated with radiotherapy with or without chemotherapy. RESULTS The overall crude incidence of symptomatic cardiac toxicity was as high as 10.8%. Toxicities corresponded with several dose-volume parameters of the heart. The most frequently reported complications were pericardial effusion, ischemic heart disease and heart failure. CONCLUSION Cardiac toxicity is a relevant issue in the treatment of esophageal cancer. However, valid Normal Tissue Complication Probability models for esophageal cancer are not available at present.
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Affiliation(s)
- Jannet C Beukema
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Peter van Luijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joachim Widder
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Johannes A Langendijk
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christina T Muijs
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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269
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Number of negative lymph nodes can predict survival of breast cancer patients with four or more positive lymph nodes after postmastectomy radiotherapy. Radiat Oncol 2014; 9:284. [PMID: 25511525 PMCID: PMC4278342 DOI: 10.1186/s13014-014-0284-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/02/2014] [Indexed: 12/03/2022] Open
Abstract
Background This study was conducted to assess the prognostic value of the number of negative lymph nodes (NLNs) in breast cancer patients with four or more positive lymph nodes after postmastectomy radiotherapy (PMRT). Methods This retrospective study examined 605 breast cancer patients with four or more positive lymph nodes who underwent mastectomy. A total of 371 patients underwent PMRT. The prognostic value of the NLN count in patients with and without PMRT was analyzed. The log-rank test was used to compare survival curves, and Cox regression analysis was performed to identify prognostic factors. Results The median follow-up was 54 months, and the overall 8-year locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) were 79.8%, 50.0%, 46.8%, and 57.9%, respectively. The optimal cut-off points for NLN count was 12. Univariate analysis showed that the number of NLNs, lymph node ratio (LNR) and pN stage predicted the LRFS of non-PMRT patients (p < 0.05 for all). Multivariate analysis showed that the number of NLNs was an independent prognostic factor affecting the LRFS, patients with a higher number of NLNs had a better LRFS (hazard ratio = 0.132, 95% confidence interval = 0.032-0.547, p =0.005). LNR and pN stage had no effect on LRFS. PMRT improved the LRFS (p < 0.001), DMFS (p = 0.018), DFS (p = 0.001), and OS (p = 0.008) of patients with 12 or fewer NLNs, but it did not any effect on survival of patients with more than 12 NLNs. PMRT improved the regional lymph node recurrence-free survival (p < 0.001) but not the chest wall recurrence-free survival (p = 0.221) in patients with 12 or fewer NLNs. Conclusions The number of NLNs can predict the survival of breast cancer patients with four or more positive lymph nodes after PMRT. Electronic supplementary material The online version of this article (doi:10.1186/s13014-014-0284-5) contains supplementary material, which is available to authorized users.
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270
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Beck RE, Kim L, Yue NJ, Haffty BG, Khan AJ, Goyal S. Treatment techniques to reduce cardiac irradiation for breast cancer patients treated with breast-conserving surgery and radiation therapy: a review. Front Oncol 2014; 4:327. [PMID: 25452938 PMCID: PMC4231838 DOI: 10.3389/fonc.2014.00327] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 10/30/2014] [Indexed: 12/25/2022] Open
Abstract
Thousands of women diagnosed with breast cancer each year receive breast-conserving surgery followed by adjuvant radiation therapy. For women with left-sided breast cancer, there is risk of potential cardiotoxicity from the radiation therapy. As data have become available to quantify the risk of cardiotoxicity from radiation, strategies have also developed to reduce the dose of radiation to the heart without compromising radiation dose to the breast. Several broad categories of techniques to reduce cardiac radiation doses include breath hold techniques, prone positioning, intensity-modulated radiation therapy, and accelerated partial breast irradiation, as well as many small techniques to improve traditional three-dimensional conformal radiation therapy. This review summarizes the published scientific literature on the various techniques to decrease cardiac irradiation in women treated to the left breast for breast cancer after breast-conserving surgery.
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Affiliation(s)
- Robert E Beck
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Leonard Kim
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Ning J Yue
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Atif J Khan
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
| | - Sharad Goyal
- Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, Rutgers Cancer Institute of New Jersey , New Brunswick, NJ , USA
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Swamy ST, Radha CA, Kathirvel M, Arun G, Subramanian S. Feasibility Study of Deep Inspiration Breath-Hold Based Volumetric Modulated Arc Therapy for Locally Advanced Left Sided Breast Cancer Patients. Asian Pac J Cancer Prev 2014; 15:9033-8. [DOI: 10.7314/apjcp.2014.15.20.9033] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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272
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[Towards an integrated approach to cardiovascular toxicities related to the treatments of breast cancer]. Bull Cancer 2014; 101:730-40. [PMID: 25091656 DOI: 10.1684/bdc.2014.1926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is an increasing number of therapeutic options in breast cancer management. While prognosis improves, the cardiac toxicity related to treatments remains a significant issue. This toxicity has several clinical presentations and can be explained by complex and diverse molecular mechanisms. Systemic treatments (anthracyclines, inhibitors of HER2 signaling pathway, hormone therapy, antiangiogenic agents) and radiotherapy have their own cardiac toxicity. However, the toxicities associated with these treatments may potentiate together and the existence of pre-existing cardiovascular risk factors should be taken into account. The assessment of cardiac hazard evolves toward a multifactorial approach. Several possibilities exist to minimize the incidence of cardiac complications. Those include pharmacological and technological innovations, but also a more accurate selection of patients and a growing involvement of practitioners in the field of cardiac toxicity, which is prerequisite for an early management of cardiac events.
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273
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Patties I, Haagen J, Dörr W, Hildebrandt G, Glasow A. Late inflammatory and thrombotic changes in irradiated hearts of C57BL/6 wild-type and atherosclerosis-prone ApoE-deficient mice. Strahlenther Onkol 2014; 191:172-9. [PMID: 25200359 DOI: 10.1007/s00066-014-0745-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/07/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Radiation-induced heart disease represents a late complication of thoracic radiotherapy. We investigated the inflammatory and thrombotic response after local heart irradiation in wild-type and atherosclerosis-prone mice. MATERIAL AND METHODS Atherosclerosis-prone ApoE(-/-) and C57BL/6 wild-type mice were sacrificed 20, 40, and 60 weeks after irradiation with 0.2, 2, 8, or 16 Gy. The expression of CD31, vascular cell adhesion molecule-1 (VCAM-1), thrombomodulin (TM), and CD45 were quantified by immunofluorescence staining of heart tissue sections. RESULTS Microvascular density decreased at 40 weeks after 16 Gy in C57BL/6 but not in ApoE(-/-) mice. CD31 expression declined in C57BL/6 mice at 40 weeks (8 Gy), but increased in ApoE(-/-) mice at 20 (2/8/16 Gy) and 60 weeks (16 Gy). Capillary area decreased in C57BL/6 at 40 weeks (8/16 Gy) but increased in ApoE(-/-) mice at 20 weeks (16 Gy). Endocardial VCAM-1 expression remained unchanged. TM-positive capillaries decreased at 40 weeks (8/16 Gy) in C57BL/6 and at 60 weeks (2/16 Gy) in ApoE(-/-) mice. Leukocyte infiltration transiently rose 40 weeks after 8 Gy (only ApoE(-/-)) and 16 Gy. After receiving a low irradiation dose of 0.2 Gy, no significant changes were observed in any of the mouse models. CONCLUSION This study demonstrated that local heart irradiation affects microvascular structure and induces inflammatory/thrombotic responses in mice in a dose- and time-dependent manner. Thereby, significant prothrombotic changes were found in both strains, although they were progressive in ApoE(-/-) mice only. Proinflammatory responses, like the increase of adhesion molecules and leukocyte infiltration, were more pronounced and occurred at lower doses in ApoE(-/-) vs. C57BL/6 mice. These findings indicate that metabolic risk factors, such as decreased ApoE lipoproteins, may lead to an enhanced proinflammatory and prothrombotic late response in locally irradiated hearts.
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Affiliation(s)
- I Patties
- Department of Radiation Therapy, University of Leipzig, Stephanstrasse 9a, 04103, Leipzig, Germany,
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274
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Tramm T, Mohammed H, Myhre S, Kyndi M, Alsner J, Børresen-Dale AL, Sørlie T, Frigessi A, Overgaard J. Development and validation of a gene profile predicting benefit of postmastectomy radiotherapy in patients with high-risk breast cancer: a study of gene expression in the DBCG82bc cohort. Clin Cancer Res 2014; 20:5272-80. [PMID: 25149560 DOI: 10.1158/1078-0432.ccr-14-0458] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To identify genes predicting benefit of radiotherapy in patients with high-risk breast cancer treated with systemic therapy and randomized to receive or not receive postmastectomy radiotherapy (PMRT). EXPERIMENTAL DESIGN The study was based on the Danish Breast Cancer Cooperative Group (DBCG82bc) cohort. Gene-expression analysis was performed in a training set of frozen tumor tissue from 191 patients. Genes were identified through the Lasso method with the endpoint being locoregional recurrence (LRR). A weighted gene-expression index (DBCG-RT profile) was calculated and transferred to quantitative real-time PCR (qRT-PCR) in corresponding formalin-fixed, paraffin-embedded (FFPE) samples, before validation in FFPE from 112 additional patients. RESULTS Seven genes were identified, and the derived DBCG-RT profile divided the 191 patients into "high LRR risk" and "low LRR risk" groups. PMRT significantly reduced risk of LRR in "high LRR risk" patients, whereas "low LRR risk" patients showed no additional reduction in LRR rate. Technical transfer of the DBCG-RT profile to FFPE/qRT-PCR was successful, and the predictive impact was successfully validated in another 112 patients. CONCLUSIONS A DBCG-RT gene profile was identified and validated, identifying patients with very low risk of LRR and no benefit from PMRT. The profile may provide a method to individualize treatment with PMRT.
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Affiliation(s)
- Trine Tramm
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Hayat Mohammed
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Simen Myhre
- Department of Genetics, Institute of Cancer Research, Oslo University Hospital, Radiumhospitalet, Norway. K-G. Jebsen Center for Breast Cancer Research, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway. Atlantis Medical University College, Oslo, Norway
| | - Marianne Kyndi
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Lise Børresen-Dale
- Department of Genetics, Institute of Cancer Research, Oslo University Hospital, Radiumhospitalet, Norway. K-G. Jebsen Center for Breast Cancer Research, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Therese Sørlie
- Department of Genetics, Institute of Cancer Research, Oslo University Hospital, Radiumhospitalet, Norway. K-G. Jebsen Center for Breast Cancer Research, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Arnoldo Frigessi
- Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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275
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Freeman JL, Weber GJ, Peterson SM, Nie LH. Embryonic ionizing radiation exposure results in expression alterations of genes associated with cardiovascular and neurological development, function, and disease and modified cardiovascular function in zebrafish. Front Genet 2014; 5:268. [PMID: 25147559 PMCID: PMC4124797 DOI: 10.3389/fgene.2014.00268] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 07/21/2014] [Indexed: 01/16/2023] Open
Abstract
The relationship between ionizing radiation (IR) and carcinogenesis is long established, but recently the association between IR and other diseases is starting to be recognized. Currently, there is limited information on the genetic mechanisms governing the role of IR in non-cancer related adverse health effects and in regards to an early developmental exposure. In this study, zebrafish embryos were exposed to a range of IR doses (0, 1, 2, 5, 10 Gy) at 26 h post fertilization (hpf). No significant increase in mortality or hatching rate was observed, but a significant decrease in total larval length, head length, and eye diameter was observed in the 10 Gy dose. Transcriptomic analysis was conducted at 120 hpf to compare gene expression profiles between the control and highest IR dose at which no significant differences were observed in morphological measurements (5 Gy). 253 genes with well-established function or orthology to human genes were significantly altered. Gene ontology and molecular network analysis revealed enrichment of genes associated with cardiovascular and neurological development, function, and disease. Expression of a subset of genetic targets with an emphasis on those associated with the cardiovascular system was assessed using Quantitative PCR (qPCR) to confirm altered expression at 5 Gy and then to investigate alterations at lower doses (1 and 2 Gy). Strong correlation between microarray and qPCR expression values was observed, but zebrafish exposed to 1 or 2 Gy resulted in a significant expression alteration in only one of these genes (LIN7B). Moreover, heart rate was analyzed through 120 hpf following IR dosing at 26 hpf. A significant decrease in heart rate was observed at 10 Gy, while a significant increase in heart rate was observed at 1, 2, and 5 Gy. Overall these findings indicate IR exposure at doses below those that induce gross morphological changes alters heart rate and expression of genes associated with cardiovascular and neurological functions.
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Affiliation(s)
| | - Gregory J Weber
- School of Health Sciences, Purdue University West Lafayette, IN, USA
| | - Samuel M Peterson
- School of Health Sciences, Purdue University West Lafayette, IN, USA
| | - Linda H Nie
- School of Health Sciences, Purdue University West Lafayette, IN, USA
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276
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Benderitter M, Caviggioli F, Chapel A, Coppes RP, Guha C, Klinger M, Malard O, Stewart F, Tamarat R, van Luijk P, Limoli CL. Stem cell therapies for the treatment of radiation-induced normal tissue side effects. Antioxid Redox Signal 2014; 21:338-55. [PMID: 24147585 PMCID: PMC4060814 DOI: 10.1089/ars.2013.5652] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
SIGNIFICANCE Targeted irradiation is an effective cancer therapy but damage inflicted to normal tissues surrounding the tumor may cause severe complications. While certain pharmacologic strategies can temper the adverse effects of irradiation, stem cell therapies provide unique opportunities for restoring functionality to the irradiated tissue bed. RECENT ADVANCES Preclinical studies presented in this review provide encouraging proof of concept regarding the therapeutic potential of stem cells for treating the adverse side effects associated with radiotherapy in different organs. Early-stage clinical data for radiation-induced lung, bone, and skin complications are promising and highlight the importance of selecting the appropriate stem cell type to stimulate tissue regeneration. CRITICAL ISSUES While therapeutic efficacy has been demonstrated in a variety of animal models and human trials, a range of additional concerns regarding stem cell transplantation for ameliorating radiation-induced normal tissue sequelae remain. Safety issues regarding teratoma formation, disease progression, and genomic stability along with technical issues impacting disease targeting, immunorejection, and clinical scale-up are factors bearing on the eventual translation of stem cell therapies into routine clinical practice. FUTURE DIRECTIONS Follow-up studies will need to identify the best possible stem cell types for the treatment of early and late radiation-induced normal tissue injury. Additional work should seek to optimize cellular dosing regimes, identify the best routes of administration, elucidate optimal transplantation windows for introducing cells into more receptive host tissues, and improve immune tolerance for longer-term engrafted cell survival into the irradiated microenvironment.
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Affiliation(s)
- Marc Benderitter
- 1 Laboratory of Radiopathology and Experimental Therapies, IRSN , PRP-HOM, SRBE, Fontenay-aux-Roses, France
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Sung K, Lee KC, Lee SH, Ahn SH, Lee SH, Choi J. Cardiac dose reduction with breathing adapted radiotherapy using self respiration monitoring system for left-sided breast cancer. Radiat Oncol J 2014; 32:84-94. [PMID: 25061577 PMCID: PMC4104224 DOI: 10.3857/roj.2014.32.2.84] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 04/09/2014] [Accepted: 05/15/2014] [Indexed: 12/25/2022] Open
Abstract
Purpose To quantify the cardiac dose reduction during breathing adapted radiotherapy using Real-time Position Management (RPM) system in the treatment of left-sided breast cancer. Materials and Methods Twenty-two patients with left-sided breast cancer underwent CT scans during breathing maneuvers including free breathing (FB), deep inspiration breath-hold (DIBH), and end inspiration breath-hold (EIBH). The RPM system was used to monitor respiratory motion, and the in-house self respiration monitoring (SRM) system was used for visual feedback. For each scan, treatment plans were generated and dosimetric parameters from DIBH and EIBH plans were compared to those of FB plans. Results All patients completed CT scans with different breathing maneuvers. When compared with FB plans, DIBH plans demonstrated significant reductions in irradiated heart volume and the heart V25, with the relative reduction of 71% and 70%, respectively (p < 0.001). EIBH plans also resulted in significantly smaller irradiated heart volume and lower heart V25 than FB plans, with the relative reduction of 39% and 37%, respectively (p = 0.002). Despite of significant expansion of lung volume using inspiration breath-hold, there were no significant differences in left lung V25 among the three plans. Conclusion In comparison with FB, both DIBH and EIBH plans demonstrated a significant reduction of radiation dose to the heart. In the training course, SRM system was useful and effective in terms of positional reproducibility and patient compliance.
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Affiliation(s)
- KiHoon Sung
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyu Chan Lee
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Seung Heon Lee
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - So Hyun Ahn
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Seok Ho Lee
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
| | - Jinho Choi
- Department of Radiation Oncology, Gachon University Gil Medical Center, Incheon, Korea
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278
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Killander F, Anderson H, Kjellén E, Malmström P. Increased cardio and cerebrovascular mortality in breast cancer patients treated with postmastectomy radiotherapy--25 year follow-up of a randomised trial from the South Sweden Breast Cancer Group. Eur J Cancer 2014; 50:2201-10. [PMID: 24951164 DOI: 10.1016/j.ejca.2014.04.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 03/27/2014] [Accepted: 04/23/2014] [Indexed: 11/15/2022]
Abstract
AIM OF THE STUDY To analyse late morbidity and mortality in pre and post-menopausal breast cancer patients treated with postmastectomy radiotherapy, with emphasis on side-effects from the heart, cerebrovascular and respiratory systems. METHODS Long term follow-up of two randomised, clinical trials with 1100 patients was carried out. Pre-menopausal women were allocated to radiotherapy (RT), RT+oral cyclophosphamide (RT+C) or cyclophosphamide only (C). Post-menopausal women were allocated to RT, RT+Tamoxifen for one year (RT+Tam) or tamoxifen only (Tam). Information on admission to hospital, mortality and causes of death was obtained from national registers. RESULTS After 25 years, adding RT to cyclophosphamide in pre-menopausal women raised the mortality from heart disease from zero to 0.8% (p=0.04). In post-menopausal women, adding RT to Tam raised the mortality from heart disease from 10.5% to 18.4% (p=0.005). In post-menopausal women mortality due to cerebrovascular disease increased from 3.4% to 8.7% by adding RT to Tam (p=0.015). The differences were not evident until in the second decade of follow-up. In spite of differences in specific causes of death, there were no significant differences between the treatment arms concerning morbidity or overall mortality. CONCLUSION Postmastectomy radiotherapy to the chest wall and loco-regional lymph nodes including the parasternal lymph nodes as delivered in the end of the seventies did not reduce overall mortality, but gave a significantly increased risk of death from heart and cerebrovascular disease, which appeared during the second decade after radiotherapy.
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Affiliation(s)
- Fredrika Killander
- Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden.
| | - Harald Anderson
- Department of Cancer Epidemiology, Lund University, Lund, Sweden
| | - Elisabeth Kjellén
- Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden
| | - Per Malmström
- Skåne Department of Oncology, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Division of Oncology, Lund University, Lund, Sweden
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279
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Nagykálnai T, Nagy AC, Landherr L. [Postoperative radiotherapy of breast cancer and cardiotoxicity]. Orv Hetil 2014; 155:897-902. [PMID: 24880968 DOI: 10.1556/oh.2014.29890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cardiac complications may present a particular problem following radiation treatment applied to the mediastinum and thoracic wall (and especially to the left breast). Exposure of the heart during radiotherapy increases the risk of ischemic heart disease occurring generally years after the treatment. The incidence of radiation cardiotoxicity depends on various factors related to oncological therapies and the patient (details of radiotherapy, age, gender, comorbidities, smoking habits, etc.). Until recently the majority of clinical studies reported increased cardiac morbidity in patients receiving radiation treatment of the chest wall and the breast. Due to modern methods, however, postoperative chest wall and left breast irradiation is much safer today than previously. In order to avoid cardiotoxicity, adherence to clinical practice guidelines for chemo- and targeted therapy of breast cancer, use of the most advanced irradiation procedures, regular monitoring of patients, and close cooperation between cardiologists and oncologists are all recommended.
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280
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Risk of second primary lung cancer in women after radiotherapy for breast cancer. Radiother Oncol 2014; 111:366-73. [DOI: 10.1016/j.radonc.2014.05.004] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/05/2014] [Accepted: 05/07/2014] [Indexed: 11/17/2022]
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281
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Rong Y, Walston S, Welliver MX, Chakravarti A, Quick AM. Improving intra-fractional target position accuracy using a 3D surface surrogate for left breast irradiation using the respiratory-gated deep-inspiration breath-hold technique. PLoS One 2014; 9:e97933. [PMID: 24853144 PMCID: PMC4031138 DOI: 10.1371/journal.pone.0097933] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 04/25/2014] [Indexed: 11/18/2022] Open
Abstract
Purpose To evaluate the use of 3D optical surface imaging as a surrogate for respiratory gated deep-inspiration breath-hold (DIBH) for left breast irradiation. Material and Methods Patients with left-sided breast cancer treated with lumpectomy or mastectomy were selected as candidates for DIBH treatment for their external beam radiation therapy. Treatment plans were created on both free breathing (FB) and DIBH computed tomography (CT) simulation scans to determine dosimetric benefits from DIBH. The Real-time Position Management (RPM) system was used to acquire patient's breathing trace during DIBH CT acquisition and treatment delivery. The reference 3D surface models from FB and DIBH CT scans were generated and transferred to the “AlignRT” system for patient positioning and real-time treatment monitoring. MV Cine images were acquired during treatment for each beam as quality assurance for intra-fractional position verification. The chest wall excursions measured on these images were used to define the actual target position during treatment, and to investigate the accuracy and reproducibility of RPM and AlignRT. Results Reduction in heart dose can be achieved using DIBH for left breast/chest wall radiation. RPM was shown to have inferior correlation with the actual target position, as determined by the MV Cine imaging. Therefore, RPM alone may not be an adequate surrogate in defining the breath-hold level. Alternatively, the AlignRT surface imaging demonstrated a superior correlation with the actual target positioning during DIBH. Both the vertical and magnitude real-time deltas (RTDs) reported by AlignRT can be used as the gating parameter, with a recommended threshold of ±3 mm and 5 mm, respectively. Conclusion The RPM system alone may not be sufficient for the required level of accuracy in left-sided breast/CW DIBH treatments. The 3D surface imaging can be used to ensure patient setup and monitor inter- and intra- fractional motions. Furthermore, the target position accuracy during DIBH treatment can be improved by AlignRT as a superior surrogate, in addition to the RPM system.
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Affiliation(s)
- Yi Rong
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, The James Cancer Hospital, Columbus, Ohio, United States of America
- * E-mail:
| | - Steve Walston
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, The James Cancer Hospital, Columbus, Ohio, United States of America
| | - Meng Xu Welliver
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, The James Cancer Hospital, Columbus, Ohio, United States of America
| | - Arnab Chakravarti
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, The James Cancer Hospital, Columbus, Ohio, United States of America
| | - Allison M. Quick
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, The James Cancer Hospital, Columbus, Ohio, United States of America
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282
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Mackenzie P, Fyles A, Wang W, Chung C. Advanced radiotherapy techniques for breast cancer to minimize cardiovascular risk. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
SUMMARY Radiotherapy plays an integral role in the management of breast cancer and has been demonstrated to reduce the risk of recurrence and improve overall survival. Recent reports in the literature have suggested a dose-dependent risk of cardiovascular disease following radiation treatment for breast cancer. This article highlights new advances in radiotherapy for breast cancer that may help minimize radiotherapy doses to the heart.
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Affiliation(s)
- Penny Mackenzie
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario, M5V 2V1, Canada
| | - Anthony Fyles
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario, M5V 2V1, Canada
| | - Wei Wang
- Westmead Cancer Centre, Sydney, Australia
| | - Caroline Chung
- Department of Radiation Oncology, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario, M5V 2V1, Canada
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283
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Hohenforst-Schmidt W, Zarogoulidis P, Oezkan F, Mahnkopf C, Grabenbauer G, Kreczy A, Bartunek R, Darwiche K, Freitag L, Li Q, Huang H, Vogl T, Lepilvert P, Tsiouda T, Tsakiridis K, Zarogoulidis K, Brachmann J. "Denervation" of autonomous nervous system in idiopathic pulmonary arterial hypertension by low-dose radiation: a case report with an unexpected outcome. Ther Clin Risk Manag 2014; 10:207-15. [PMID: 24707181 PMCID: PMC3972028 DOI: 10.2147/tcrm.s58705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Vasointestinal peptide metabolism plays a key physiological role in multimodular levels of vasodilatory, smooth muscle cell proliferative, parenchymal, and inflammatory lung reactions. In animal studies, vasointestinal peptide relaxes isolated pulmonary arterial segments from several mammalian species in vitro and neutralizes the pulmonary vasoconstrictor effect of endothelin. In some animal models, it reduces pulmonary vascular resistance in vivo and in monocrotaline-induced pulmonary hypertension. A 58-year-old woman presented with dyspnea and mild edema of the lower extremities. A bronchoscopy was performed without any suspicious findings suggesting a central tumor or other infiltrative disease. Endobronchial ultrasound revealed enlarged pulmonary arteries containing thrombi, a few enlarged lymph nodes, and enlarged mediastinal tissue anatomy with suspicion for mediastinal infiltration of a malignant process. We estimated that less than 10% of the peripheral vascular bed of the lung was involved in direct consolidated fibrosis as demonstrated in the left upper lobe apex. Further, direct involvement of fibrosis around the main stems of the pulmonary arteries was assumed to be low from positron emission tomography and magnetic resonance imaging scans. Assuming a positive influence of low-dose radiation, it was not expected that this could have reduced pulmonary vascular resistance by over two thirds of the initial result. However; it was noted that this patient had idiopathic pulmonary arterial hypertension mixed with “acute” (mediastinal) fibrosis which could have contributed to the unexpected success of reduction of pulmonary vascular resistance. To the best of our knowledge, this is the first report of successful treatment of idiopathic pulmonary arterial hypertension, probably as a result of low-dose radiation to the pulmonary arterial main stems. The patient continues to have no specific complaints concerning her idiopathic pulmonary arterial hypertension.
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Affiliation(s)
| | - Paul Zarogoulidis
- Pulmonary Department-oncology Unit, G Papanikolaou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Filiz Oezkan
- Department of Interventional Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Christian Mahnkopf
- II Medizinische Klinik, Klinik für Kardiologie, Angiologie, Pneumologie, Klinikum Coburg, Germany
| | | | - Alfons Kreczy
- Department of Pathology, Cytology and Molecular Diagnostics, University of Wüerzburg, Coburg, Germany
| | - Rudolf Bartunek
- Institute of Diagnostic and Interventional Radiology, Coburg Clinic, University of Wüerzburg, Coburg, Germany
| | - Kaid Darwiche
- Department of Interventional Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Lutz Freitag
- Department of Interventional Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital, University of Duisburg-Essen, Essen, Germany
| | - Qiang Li
- Department of Respiratory Diseases, Changhai Hospital/First Affiliated Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Haidong Huang
- Department of Respiratory Diseases, Changhai Hospital/First Affiliated Hospital of the Second Military Medical University, Shanghai, People's Republic of China
| | - Thomas Vogl
- Department of Diagnostic and Interventional Radiology, Goethe University of Frankfurt, Frankfurt, Germany
| | - Patrick Lepilvert
- Interventional Drug Delivery Systems and Strategies (ID2S2), Medical Cryogenics, Lakeland Court Jupiter, FL, USA
| | - Theodora Tsiouda
- Internal Medicine Unit, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - Kosmas Tsakiridis
- Cardiothoracic Surgery Department, Saint Luke Private Hospital, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- Pulmonary Department-oncology Unit, G Papanikolaou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Johannes Brachmann
- II Medical Clinic, Coburg Clinic, University of Würzburg, Coburg, Germany
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284
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Seemann I, te Poele JAM, Hoving S, Stewart FA. Mouse bone marrow-derived endothelial progenitor cells do not restore radiation-induced microvascular damage. ISRN CARDIOLOGY 2014; 2014:506348. [PMID: 25101181 PMCID: PMC4005028 DOI: 10.1155/2014/506348] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/06/2014] [Indexed: 11/24/2022]
Abstract
Background. Radiotherapy is commonly used to treat breast and thoracic cancers but it also causes delayed microvascular damage and increases the risk of cardiac mortality. Endothelial cell proliferation and revascularization are crucial to restore microvasculature damage and maintain function of the irradiated heart. We have therefore examined the potential of bone marrow-derived endothelial progenitor cells (BM-derived EPCs) for restoration of radiation-induced microvascular damage. Material & Methods. 16 Gy was delivered to the heart of adult C57BL/6 mice. Mice were injected with BM-derived EPCs, obtained from Eng(+/+) or Eng(+/-) mice, 16 weeks and 28 weeks after irradiation. Morphological damage was evaluated at 40 weeks in transplanted mice, relative to radiation only and age-matched controls. Results. Cardiac irradiation decreased microvascular density and increased endothelial damage in surviving capillaries (decrease alkaline phosphatase expression and increased von Willebrand factor). Microvascular damage was not diminished by treatment with BM-derived EPCs. However, BM-derived EPCs from both Eng(+/+) and Eng(+/-) mice diminished radiation-induced collagen deposition. Conclusion. Treatment with BM-derived EPCs did not restore radiation-induced microvascular damage but it did inhibit fibrosis. Endoglin deficiency did not impair this process.
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Affiliation(s)
- Ingar Seemann
- Division of Biological Stress Response (H3), The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Johannes A. M. te Poele
- Division of Biological Stress Response (H3), The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Saske Hoving
- Division of Biological Stress Response (H3), The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Fiona A. Stewart
- Division of Biological Stress Response (H3), The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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285
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Mistiaen WP. Cancer in heart disease patients: what are the limitations in the treatment strategy? Future Cardiol 2014; 9:535-47. [PMID: 23834694 DOI: 10.2217/fca.13.33] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Cardiovascular disease and cancer are leading causes of morbidity and mortality, and can both be present in one patient. In patients with simultaneous disease, the most threatening disease should be treated first. This is usually heart disease, but this can pose specific problems. If percutaneous coronary intervention is preferred, bleeding and thrombotic tendencies have to be taken into account in the subsequent treatment of the malignancy. With coronary artery bypass grafting, the advantages and disadvantages of one- or two-stage procedures, and the use of extracorporeal circulation have to be balanced. Development of heart disease after treatment of malignancy could be due to radiotherapy and chemotherapy. The effects of these cancer treatments have to be taken into account for the treatment options of the heart disease and the postoperative prognosis.
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Affiliation(s)
- Wilhelm P Mistiaen
- University of Antwerp, Faculty of Medicine & Health Sciences, Artesis-Plantijn University College Antwerp, J. De Boeckstr. 10, 2170 Antwerp, Belgium.
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286
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Adjuvant Hypofractionated Versus Conventional Whole Breast Radiation Therapy for Early-Stage Breast Cancer: Long-Term Hospital-Related Morbidity From Cardiac Causes. Int J Radiat Oncol Biol Phys 2014; 88:786-92. [DOI: 10.1016/j.ijrobp.2013.11.243] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 11/16/2022]
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287
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Irradiation of existing atherosclerotic lesions increased inflammation by favoring pro-inflammatory macrophages. Radiother Oncol 2014; 110:455-60. [DOI: 10.1016/j.radonc.2014.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 01/08/2014] [Accepted: 01/12/2014] [Indexed: 01/26/2023]
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288
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Varga Z, Cserháti A, Rárosi F, Boda K, Gulyás G, Együd Z, Kahán Z. Individualized positioning for maximum heart protection during breast irradiation. Acta Oncol 2014; 53:58-64. [PMID: 23544358 DOI: 10.3109/0284186x.2013.781674] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prone positioning has been found feasible and appropriate for the reduction of radiation exposure of the lungs, but its effects on the heart dose remain controversial. Individual anatomical features were sought for the selection of optimal treatment positioning. MATERIAL AND METHODS In 138 left-sided breast cancer cases awaiting postoperative whole-breast radiotherapy, conformal radiotherapy plans were generated in both prone and supine positions. RESULTS The radiation doses to the left anterior descending coronary artery (LAD) and heart in the two positions differed individually, and were strongly related to the body mass index (BMI). Image fusion of the CT scans revealed that prone positioning was detrimental if the heart was situated distant from the chest wall in the supine position, but moved to the chest wall in the prone position. For characterization of the geography of the heart and the breast, the median distance between the LAD and the chest wall (dmedian), and the heart area included in the radiation field on a single CT scan at the middle of the heart in the supine position (Aheart) proved most appropriate. CONCLUSION A validated statistical model, utilizing the BMI, dmedian and Aheart, permits individualized positioning for maximum heart protection.
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Affiliation(s)
- Zoltán Varga
- Department of Oncotherapy, University of Szeged , Szeged , Hungary
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289
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The feasibility of evaluating radiation dose to the heart by integrating kilovoltage-cone beam computed tomography in stereotactic body radiotherapy of early non-small-cell lung cancer patients. Radiat Oncol 2013; 8:295. [PMID: 24369788 PMCID: PMC3909334 DOI: 10.1186/1748-717x-8-295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 12/23/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the feasibility of contouring the planning risk organ volume (PRV) for the heart, and to determine the probability of evaluating radiation dose to the heart using kilovoltage-cone beam computed tomography (kV-CBCT) in early-stage non-small-cell lung cancer (NSCLC) patients, who received stereotactic body radiotherapy (SBRT). MATERIALS AND METHODS Seventeen NSCLC patients who received SBRT (5Gy/f × 10f dose) were enrolled and subjected to CBCT and CT imaging analyses to plan treatment. Sequential planning CBCT images of individual patient's hearts were analyzed for reproducibility of heart contouring and volume. Comparative analyses were made between the planning CT- and CBCT-detected heart margins and dose-volume indices for treatment. RESULTS The heart volume from planning CT images was significantly smaller than that from CBCT scans (p < 0.05), and the volumes based on the different series of CBCT images were similar (p > 0.05).The overlap of the heart region on the same anatomical section between the first series of CBCT scans and other scans reached 0.985 ± 0.020 without statistically significant differences (p > 0.05). The mean margins of the heart from planning CT and CBCT scans were 10.5 ± 2.8 mm in the left direction, 5.9 ± 2.8 mm in the right direction, 2.2 ± 1.6 mm in the direction of the head, 3.3 ± 2.2 mm in the direction of the foot, 6.7 ± 1.1 mm in the anterior direction, and 4.5 mm ± 2.5 mm in the posterior direction. All relative and absolute dose-volume indices obtained from CBCT images were significantly larger than those from planning CT scans (p < 0.05), with the exception of the volume in the 5Gy region. CONCLUSION The PRV of heart contouring based on kV-CBCT is feasible with good reproducibility. More accurate and objective dose-volume indices may be obtained for NSCLC patients by using kV-CBCT, instead of CT, to plan SBRT.
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290
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Bartlett F, Yarnold J, Donovan E, Evans P, Locke I, Kirby A. Multileaf Collimation Cardiac Shielding in Breast Radiotherapy: Cardiac Doses are Reduced, But at What Cost? Clin Oncol (R Coll Radiol) 2013; 25:690-6. [DOI: 10.1016/j.clon.2013.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 08/06/2013] [Accepted: 08/23/2013] [Indexed: 10/26/2022]
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291
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Takahashi I, Ohishi W, Mettler FA, Ozasa K, Jacob P, Ban N, Lipshultz SE, Stewart FA, Nabika T, Niwa Y, Takahashi N, Akahoshi M, Kodama K, Shore R. A report from the 2013 international workshop: radiation and cardiovascular disease, Hiroshima, Japan. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2013; 33:869-880. [PMID: 24190873 DOI: 10.1088/0952-4746/33/4/869] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Two longitudinal cohort studies of Japanese atomic bomb survivors-the life span study (LSS) and the adult health study (AHS)-from the Radiation Effects Research Foundation (RERF) indicate that total body irradiation doses less than 1 Gy are associated with an increased risk of cardiovascular disease (CVD), but several questions about this association remain.In particular, the diversity of heart disease subtypes and the high prevalence of other risk factors complicate the estimates of radiation effects. Subtype-specific analyses with more reliable diagnostic criteria and measurement techniques are needed. The radiation effects on CVD risk are probably tissue-reaction (deterministic) effects, so the dose-response relationships for various subtypes of CVD may be nonlinear and therefore should be explored with several types of statistical models.Subpopulations at high risk need to be identified because effects at lower radiation doses may occur primarily in these susceptible subpopulations. Whether other CVD risk factors modify radiation effects also needs to be determined. Finally, background rates for various subtypes of CVD have historically differed substantially between Japanese and Western populations, so the generalisability to other populations needs to be examined.Cardiovascular disease mechanisms and manifestations may differ between high-dose local irradiation and low-dose total body irradiation (TBI)-microvascular damage and altered metabolism from low-dose TBI, but coronary artery atherosclerosis and thrombotic myocardial infarcts at high localised doses. For TBI, doses to organs other than the heart may be important in pathogenesis of CVD, so data on renal and liver disorders, plaque instability, microvascular damage, metabolic disorders, hypertension and various CVD biomarkers and risk factors are needed. Epidemiological, clinical and experimental studies at doses of less than 1 Gy are necessary to clarify the effects of radiation on CVD risk.
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Affiliation(s)
- Ikuno Takahashi
- Department of Clinical Studies, Radiation Effects Research Foundation (RERF), Hiroshima, Japan
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Wondergem J, Boerma M, Kodama K, Stewart FA, Trott KR. Cardiovascular effects after low-dose exposure and radiotherapy: what research is needed? RADIATION AND ENVIRONMENTAL BIOPHYSICS 2013; 52:425-434. [PMID: 23999657 DOI: 10.1007/s00411-013-0489-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 08/19/2013] [Indexed: 06/02/2023]
Abstract
The authors of this report met at the Head Quarter of the International Atomic Energy Agency (IAEA) in Vienna, Austria, on 2-4 July 2012, for intensive discussions of an abundance of original publications on new epidemiological studies on cardiovascular effects after low-dose exposure and radiotherapy and radiobiological experiments as well as several comprehensive reviews that were published since the previous meeting by experts sponsored by the IAEA in June 2006. The data necessitated a re-evaluation of the situation with special emphasis on the consequences current experimental and clinical data may have for clinical oncology/radiotherapy and radiobiological research. The authors jointly arrived at the conclusions and recommendations presented here.
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Affiliation(s)
- Jan Wondergem
- Applied Radiation Biology and Radiotherapy Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Wagrammer Strasse 5, PO box 100, 1400, Vienna, Austria,
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293
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294
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Thorsen LBJ, Thomsen MS, Overgaard M, Overgaard J, Offersen BV. Quality assurance of conventional non-CT-based internal mammary lymph node irradiation in a prospective Danish Breast Cancer Cooperative Group trial: the DBCG-IMN study. Acta Oncol 2013; 52:1526-34. [PMID: 23957621 DOI: 10.3109/0284186x.2013.813643] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED In 2003, the Danish Breast Cancer Cooperative Group (DBCG) initiated DBCG-IMN, a prospective study on the effect of adjuvant internal mammary lymph node radiotherapy (IMN-RT) in patients with early lymph node positive breast cancer (BC). In the study, standard DBCG IMN-RT was provided only to patients with right-sided BC. We provide estimates of doses to IMNs and organs at risk (OARs) in patients treated with the non-CT-based RT techniques used during the DBCG-IMN study. MATERIAL AND METHODS Five DBCG RT regimens were simulated on planning CT scans from 50 consecutively scanned BC patients, 10 in each group. Intended target volumes were chest wall or breast and regional lymph nodes ± IMNs. Field planning was conducted in the Eclipse(TM) RT treatment planning system. Subsequently, IMN clinical target volumes (CTVs) and OARs were delineated. Estimates on doses to the IMN-CTV and OARs were made. RESULTS IMN dose coverage estimates were consistently higher in right-sided techniques where IMN treatment was intended (p < 0.0001). Estimated doses to cardiac structures were low regardless of whether IMNs were treated or not. Post-lumpectomy patients had the highest estimated lung doses. CONCLUSION Overall, simulator-based treatment using the DBCG RT techniques resulted in satisfactory coverage of IMNs and acceptable levels of OAR irradiation.
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Affiliation(s)
- Lise B J Thorsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital , Aarhus , Denmark
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295
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The role of adjuvant radiation treatment in older women with early breast cancer. J Geriatr Oncol 2013; 4:402-12. [DOI: 10.1016/j.jgo.2013.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/24/2013] [Accepted: 05/24/2013] [Indexed: 11/20/2022]
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296
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Blitzblau RC, Horton JK. Treatment planning technique in patients receiving postmastectomy radiation therapy. Pract Radiat Oncol 2013; 3:241-8. [PMID: 24674393 DOI: 10.1016/j.prro.2012.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 09/14/2012] [Accepted: 09/19/2012] [Indexed: 12/25/2022]
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297
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Park SH, Kim JC. Comparison of electron and x-ray beams for tumor bed boost irradiation in breast-conserving treatment. J Breast Cancer 2013; 16:300-7. [PMID: 24155759 PMCID: PMC3800726 DOI: 10.4048/jbc.2013.16.3.300] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 09/10/2013] [Indexed: 01/21/2023] Open
Abstract
Purpose This study aimed to compare the dosimetric profiles of electron beams (EB) and X-ray beams (XB) for boosting irradiation in breast cancer patients who underwent breast-conserving surgery and postoperative radiotherapy. Methods For 131 breast cancer patients who underwent breast-conserving surgery, we compared plans for EB and XB boost irradiation after whole-breast irradiation. The organs at risk (OAR) included the cardiac chambers, coronary arteries, ipsilateral lung, and skin. The conformity index (CI), inhomogeneity index (IHI), and dose-volume parameters for the planning target volume (PTV), and OAR were calculated. Postradiotherapy chest computed tomography scans were performed to detect radiation pneumonitis. Results XB plans showed a significantly better CI and IHI for the PTVs, compared to the EB plans. Regarding OAR sparing, the XB reduced the high-dose volume at the expense of an increased low-dose volume. In 33 patients whose radiation fields included nipples, IHI was higher in the EB plans, whereas the presence of a nipple in the radiation field did not interfere with the XB. EB-treated patients developed more subclinical radiation pneumonitis. Conclusion XB plans were superior to EB plans in terms of PTV coverage (homogeneity and conformity) and high-dose volume sparing in OAR when used as boost irradiation after breast-conserving surgery. A disadvantage of the XB plan was an increased low-dose volume in the OAR, but this was offset by the increased electron energy. Consequently, tailored plans with either XB or EB are necessary to adapt to patient anatomic variance and tumor bed geometric properties.
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Affiliation(s)
- Shin-Hyung Park
- Department of Radiation Oncology, Kyungpook National University School of Medicine, Daegu, Korea
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298
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Borghini A, Luca Gianicolo EA, Picano E, Andreassi MG. Ionizing radiation and atherosclerosis: Current knowledge and future challenges. Atherosclerosis 2013; 230:40-7. [DOI: 10.1016/j.atherosclerosis.2013.06.010] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 05/13/2013] [Accepted: 06/12/2013] [Indexed: 11/16/2022]
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299
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Chen JLY, Cheng JCH, Kuo SH, Chan HM, Huang YS, Chen YH. Prone breast forward intensity-modulated radiotherapy for Asian women with early left breast cancer: factors for cardiac sparing and clinical outcomes. JOURNAL OF RADIATION RESEARCH 2013; 54:899-908. [PMID: 23504450 PMCID: PMC3766291 DOI: 10.1093/jrr/rrt019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 01/25/2013] [Accepted: 02/17/2013] [Indexed: 05/29/2023]
Abstract
Since December 2009, after breast-conserving surgery for Stage 0-I cancer of the left breast, 21 women with relatively pendulous breasts underwent computed tomography prone and supine simulations. The adjuvant radiotherapy was 50 Gy in 25 fractions to the left breast alone. Four plans--conventional wedged tangents and forward intensity-modulated radiotherapy (fIMRT) in supine and prone positions--were generated. fIMRT generated better homogeneity in both positions. Prone position centralized the breast tissue by gravity and also shortened the breast width which led to better conformity in both planning techniques. Prone fIMRT significantly reduced doses to left lung, Level I and Level II axilla. The mean cardiac doses did not differ between positions. Among the four plans, prone fIMRT produced the best target dosimetry and normal organ sparing. In subgroup analysis, patients with absolute breast depth > 7 cm in the prone position or breast depth difference > 3 cm between positions had significant cardiac sparing with prone fIMRT. Sixteen patients with significant cardiac sparing in prone position were treated using prone fIMRT and the others using supine fIMRT. All patients received a supine electron tumor bed boost of 10 Gy in 5 fractions. No patients developed Grade 2 or worse acute or late toxicities. There was no difference in the number of segments or beams, monitor units, treatment time, or positioning reproducibility between prone and supine positions. At a median follow-up time of 26.8 months, no locoregional or distant recurrence or death was noted.
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Affiliation(s)
- Jenny Ling-Yu Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jason Chia-Hsien Cheng
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Oncology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Sung-Hsin Kuo
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
- Cancer Research Center, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsing-Min Chan
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Sen Huang
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Hsuan Chen
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
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300
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Chargari C, Riet F, Mazevet M, Morel E, Lepechoux C, Deutsch E. Complications of thoracic radiotherapy. Presse Med 2013; 42:e342-51. [PMID: 23972736 DOI: 10.1016/j.lpm.2013.06.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 06/12/2013] [Indexed: 12/25/2022] Open
Abstract
The issue of toxicity is a primary concern for chest irradiation, because it is a dose-limiting toxicity and because in some circumstances it can alleviate the survival benefit of radiation therapy. Potential acute and delayed side effects can compromise the patients' prognosis and generate significant morbidity. Here we review on chest complications of radiation therapy, with focus on cardiac and pulmonary radio-induced side effects. Most radiographic changes associated with thoracic irradiation are asymptomatic. However, chest irradiation generated by treatment of breast cancer, bronchopulmonary malignancies, or mediastinal lymphoma has been associated with a risk of acute radiation pneumonitis and late lung fibrosis. An increasing number of clinical studies suggest that some dosimetric factors (e.g. V20, V30, mean lung dose) should be considered for limiting the risk of lung toxicity. Improvements in radiation techniques as well as changes in indications, volumes and prescribed doses of radiation therapy should help to better spare lungs from irradiation and thus decreasing the risk of subsequent toxicity. Numerous other contributing factors should also be considered, such as chemotherapeutic agents, smoking, tumor topography, or intrinsic sensitivity. Cardiac toxicity is another clinically relevant issue in patients receiving radiation therapy for breast cancer or for lymphoma. This life threatening toxicity should be analyzed in the light of dosimetric factors (including low doses) but also associated systemic agents which almost carry a potential for additive toxicity toward myocardium or coronaries. A long-term follow-up of patients as well as an increasing knowledge of the underlying biological pathways involved in cardiac toxicity should help designing effective preventing strategies.
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Affiliation(s)
- Cyrus Chargari
- Université Paris-Sud, institut Gustave-Roussy, LabEx Lermit - DHU Torino, radiothérapie moléculaire, Inserm 1030, 94805 Villejuif, France
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