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Gregucci F, Ciabattoni A. Challenges for breast radiotherapy with SIB: the IMPORT HIGH trial. Lancet 2024; 403:1751-1752. [PMID: 38704170 DOI: 10.1016/s0140-6736(24)00357-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/20/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA.
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2
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Sampadi B, Vermeulen S, Mišovic B, Boei JJ, Batth TS, Chang JG, Paulsen MT, Magnuson B, Schimmel J, Kool H, Olie CS, Everts B, Vertegaal ACO, Olsen JV, Ljungman M, Jeggo PA, Mullenders LHF, Vrieling H. Divergent Molecular and Cellular Responses to Low and High-Dose Ionizing Radiation. Cells 2022; 11:cells11233794. [PMID: 36497055 PMCID: PMC9739411 DOI: 10.3390/cells11233794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Cancer risk after ionizing radiation (IR) is assumed to be linear with the dose; however, for low doses, definite evidence is lacking. Here, using temporal multi-omic systems analyses after a low (LD; 0.1 Gy) or a high (HD; 1 Gy) dose of X-rays, we show that, although the DNA damage response (DDR) displayed dose proportionality, many other molecular and cellular responses did not. Phosphoproteomics uncovered a novel mode of phospho-signaling via S12-PPP1R7, and large-scale dephosphorylation events that regulate mitotic exit control in undamaged cells and the G2/M checkpoint upon IR in a dose-dependent manner. The phosphoproteomics of irradiated DNA double-strand breaks (DSBs) repair-deficient cells unveiled extended phospho-signaling duration in either a dose-dependent (DDR signaling) or independent (mTOR-ERK-MAPK signaling) manner without affecting signal magnitude. Nascent transcriptomics revealed the transcriptional activation of genes involved in NRF2-regulated antioxidant defense, redox-sensitive ERK-MAPK signaling, glycolysis and mitochondrial function after LD, suggesting a prominent role for reactive oxygen species (ROS) in molecular and cellular responses to LD exposure, whereas DDR genes were prominently activated after HD. However, how and to what extent the observed dose-dependent differences in molecular and cellular responses may impact cancer development remain unclear, as the induction of chromosomal damage was found to be dose-proportional (10-200 mGy).
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Affiliation(s)
- Bharath Sampadi
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
- Correspondence: (B.S.); (H.V.)
| | - Sylvia Vermeulen
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Branislav Mišovic
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Jan J. Boei
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Tanveer S. Batth
- Proteomics Program, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Jer-Gung Chang
- Department of Cell and Chemical Biology, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Michelle T. Paulsen
- Department of Radiation Oncology, Rogel Cancer Center and Center for RNA Biomedicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Brian Magnuson
- Department of Radiation Oncology, Rogel Cancer Center and Center for RNA Biomedicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Joost Schimmel
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Hanneke Kool
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Cyriel S. Olie
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Bart Everts
- Department of Parasitology, Leiden University Medical Center, 2333ZA Leiden, The Netherlands
| | - Alfred C. O. Vertegaal
- Department of Cell and Chemical Biology, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
| | - Jesper V. Olsen
- Proteomics Program, Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Science, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Mats Ljungman
- Department of Radiation Oncology, Rogel Cancer Center and Center for RNA Biomedicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Penny A. Jeggo
- Genome Damage and Stability Centre, School of Life Sciences, University of Sussex, Brighton BN1 9RQ, UK
| | - Leon H. F. Mullenders
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
- Department of Genetics, Research Institute of Environmental Medicine (RIeM), Nagoya University, Nagoya 464-8601, Japan
| | - Harry Vrieling
- Department of Human Genetics, Leiden University Medical Center, 2333ZC Leiden, The Netherlands
- Correspondence: (B.S.); (H.V.)
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Pazzaglia S, Eidemüller M, Lumniczky K, Mancuso M, Ramadan R, Stolarczyk L, Moertl S. Out-of-field effects: lessons learned from partial body exposure. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2022; 61:485-504. [PMID: 36001144 PMCID: PMC9722818 DOI: 10.1007/s00411-022-00988-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/03/2022] [Indexed: 05/27/2023]
Abstract
Partial body exposure and inhomogeneous dose delivery are features of the majority of medical and occupational exposure situations. However, mounting evidence indicates that the effects of partial body exposure are not limited to the irradiated area but also have systemic effects that are propagated outside the irradiated field. It was the aim of the "Partial body exposure" session within the MELODI workshop 2020 to discuss recent developments and insights into this field by covering clinical, epidemiological, dosimetric as well as mechanistic aspects. Especially the impact of out-of-field effects on dysfunctions of immune cells, cardiovascular diseases and effects on the brain were debated. The presentations at the workshop acknowledged the relevance of out-of-field effects as components of the cellular and organismal radiation response. Furthermore, their importance for the understanding of radiation-induced pathologies, for the discovery of early disease biomarkers and for the identification of high-risk organs after inhomogeneous exposure was emphasized. With the rapid advancement of clinical treatment modalities, including new dose rates and distributions a better understanding of individual health risk is urgently needed. To achieve this, a deeper mechanistic understanding of out-of-field effects in close connection to improved modelling was suggested as priorities for future research. This will support the amelioration of risk models and the personalization of risk assessments for cancer and non-cancer effects after partial body irradiation.
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Affiliation(s)
- S. Pazzaglia
- Laboratory of Biomedical Technologies, ENEA CR-Casaccia, Via Anguillarese 301, 00123 Rome, Italy
| | - M. Eidemüller
- Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - K. Lumniczky
- Department of Radiobiology and Radiohygiene, Unit of Radiation Medicine, National Public Health Centre, Albert Florian u. 2-6, 1097 Budapest, Hungary
| | - M. Mancuso
- Laboratory of Biomedical Technologies, ENEA CR-Casaccia, Via Anguillarese 301, 00123 Rome, Italy
| | - R. Ramadan
- Radiobiology Unit, Belgian Nuclear Research Centre (SCK CEN), Mol, Belgium
| | - L. Stolarczyk
- Danish Centre for Particle Therapy, Palle Juul-Jensens Boulevard 25, 8200 Aarhus N, Denmark
| | - S. Moertl
- Federal Office for Radiation Protection, Ingolstädter Landstr. 1, 85764 Oberschleißheim, Germany
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Kearney M, Keys M, Faivre-Finn C, Wang Z, Aznar MC, Duane F. Exposure of the heart in lung cancer radiation therapy: A systematic review of heart doses published during 2013 to 2020. Radiother Oncol 2022; 172:118-125. [PMID: 35577022 DOI: 10.1016/j.radonc.2022.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/26/2022] [Accepted: 05/08/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Lung cancer radiotherapy increases the risk of cardiotoxicity and heart radiation dose is an independent predictor of poor survival. This study describes heart doses and strategies aiming to reduce exposure. MATERIALS AND METHODS A systematic review of lung cancer dosimetry studies reporting heart doses published 2013-2020 was undertaken. Doses were compared according to laterality, region irradiated, treatment modality (stereotactic ablative body radiotherapy (SABR) and non-SABR), planning technique, and respiratory motion management. RESULTS For 392 non-SABR regimens in 105 studies, the average MHD was 10.3 Gy (0.0-48.4) and was not significantly different between left and right-sided tumours. It was similar between IMRT and 3DCRT (10.9 Gy versus 10.6 Gy) and lower with particle beam therapy (proton 7.0 Gy; carbon-ion 1.9 Gy). Active respiratory motion management reduced exposure (7.4 Gy versus 9.3 Gy). For 168 SABR regimens in 35 studies, MHD was 4.0 Gy (0.0-32.4). Exposure was higher in central and lower lobe lesions (6.3 and 5.8 Gy respectively). MHD was lowest for carbon ions (0.5 Gy) compared to other techniques. Active respiratory motion management reduced exposure (2.4 Gy versus 5.0 Gy). Delineation guidelines and Dose Volume Constraints for the heart varied substantially. CONCLUSIONS There is scope to reduce heart radiation dose in lung cancer radiotherapy. Consensus on planning objectives, contouring and DVCs for the heart may lead to reduced heart doses in the future. For IMRT, more stringent optimisation objectives may reduce heart dose. Active respiratory motion management or particle therapy may be considered in situations where cardiac dose is high.
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Affiliation(s)
- Maeve Kearney
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, Trinity College Dublin, Ireland.
| | - Maeve Keys
- St Luke's Radiation Oncology Network, St. Luke's Hospital, Dublin, Ireland; The Christie NHS Foundation Trust, University of Manchester, United Kingdom
| | | | - Zhe Wang
- Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Marianne C Aznar
- Nuffield Department of Population Health, University of Oxford, United Kingdom; Manchester Cancer Research Centre, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Frances Duane
- St Luke's Radiation Oncology Network, St. Luke's Hospital, Dublin, Ireland; School of Medicine, Trinity College Dublin, Ireland; Trinity St James's Cancer Institute, St. James's Hospital, Dublin, Ireland
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5
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Figlia V, Simonetto C, Eidemüller M, Naccarato S, Sicignano G, De Simone A, Ruggieri R, Mazzola R, Matuschek C, Bölke E, Pazos M, Niyazi M, Belka C, Alongi F, Corradini S. Mammary Chain Irradiation in Left-Sided Breast Cancer: Can We Reduce the Risk of Secondary Cancer and Ischaemic Heart Disease with Modern Intensity-Modulated Radiotherapy Techniques? Breast Care (Basel) 2021; 16:358-367. [PMID: 34602941 DOI: 10.1159/000509779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction The aim of the present study was to estimate the impact of the addition of internal mammary chain (IMC) irradiation in node-positive left-sided breast cancer (BC) patients undergoing regional nodal irradiation (RNI) and comparatively evaluate excess relative and absolute risks of radiation-induced lung cancer/BC and ischaemic heart disease for intensity-modulated radiotherapy (IMRT) versus 3D conformal radiotherapy (3D-CRT). Methods Four treatment plans were created (3D-CRT and IMRT -/+ IMC) for each of the 10 evaluated patients, and estimates of excess relative risk (ERR) and 10-year excess absolute risk (EAR) were calculated for radiation-induced lung cancer/BC and coronary events using linear, linear-exponential and plateau models. Results The addition of IMC irradiation to RNI significantly increased the dose exposure of the heart, lung and contralateral breast using both techniques, increasing ERR for secondary lung cancer (58 vs. 44%, p = 0.002), contralateral BC (49 vs. 31%, p = 0.002) and ischaemic heart disease (41 vs. 27%, p = 0.002, IMRT plans). IMRT significantly reduced the mean cardiac dose and mean lung dose as compared to 3D-CRT, decreasing ERR for major coronary events (64% 3D-CRT vs. 41% IMRT, p = 0.002) and ERR for secondary lung cancer (75 vs. 58%, p = 0.004) in IMC irradiation, without a significant impact on secondary contralateral BC risks. Conclusion Although IMC irradiation has been shown to increase survival rates in node-positive BC patients, it increased dose exposure of organs at risk in left-sided BC, resulting in significantly increased risks for secondary lung cancer/contralateral BC and ischaemic heart disease. In this setting, the adoption of IMRT seems advantageous when compared to 3D-CRT.
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Affiliation(s)
- Vanessa Figlia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | | | - Markus Eidemüller
- Institute of Radiation Medicine, Helmholtz Center Munich, Munich, Germany
| | - Stefania Naccarato
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Gianluisa Sicignano
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Antonio De Simone
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy.,University of Brescia, Brescia, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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Vakaet V, Van Hulle H, Vergotte M, Schoepen M, Deseyne P, Van Greveling A, Post G, Speleers B, Paelinck L, Monten C, De Neve W, Veldeman L. 5-Year Outcomes of a Randomized Trial Comparing Prone and Supine Whole Breast Irradiation in Large-Breasted Women. Int J Radiat Oncol Biol Phys 2021; 110:766-771. [PMID: 33508375 DOI: 10.1016/j.ijrobp.2021.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Prone position for whole breast irradiation (WBI) results in lower rates of toxicity and reduced ipsilateral mean lung and heart doses. No randomized trials comparing toxicity and cosmesis at 5 years with prone and supine positioning are available. METHODS AND MATERIALS In this phase 2 open-label trial, 100 patients with large breast size requiring WBI were randomized between prone and supine positioning. Physician-assessed toxicity (retraction, fibrosis, edema, telangiectasia, pigmentation changes) was scored yearly for a total of 5 years, and photographs were taken at 5 years to assess cosmesis. The data were analyzed longitudinally and cross-sectionally. RESULTS Longitudinal analysis shows lower grade 2 late toxicity with prone positioning. The results for at least grade 1 physician-assessed toxicity at 5 years are similar between supine and prone position, respectively, for retraction (56% vs 54%), fibrosis outside the tumor bed (33% vs 24%), tumor bed fibrosis (49% vs 46%), edema (11% vs 8%), telangiectasia (8% vs 3%), and breast pain (6% vs 8%) using cross-sectional analysis. However, the risk of pigmentation changes in prone position (0% vs 19%) 5 years after radiation therapy was significantly lower. Cosmesis was good or excellent in 92% and 75% of patients who used prone and supine positioning, respectively. The 5-year overall survival is 96% in both groups. CONCLUSION Prone positioning results in reduced rates of late toxicity.
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Affiliation(s)
- Vincent Vakaet
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium.
| | - Hans Van Hulle
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Marie Vergotte
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Industrial Systems Engineering and Product Design, Kortrijk, Belgium
| | - Pieter Deseyne
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Giselle Post
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Bruno Speleers
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Chris Monten
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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Shen L, Liu C, Jin J, Han C, Zhou Y, Zheng X, Gong C, Chen M, Xie C, Jin X. Association of lung and heart dose with survival in patients with non-small cell lung cancer underwent volumetric modulated arc therapy. Cancer Manag Res 2019; 11:6091-6098. [PMID: 31308747 PMCID: PMC6613608 DOI: 10.2147/cmar.s200837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/12/2019] [Indexed: 12/25/2022] Open
Abstract
Background Controversial conclusions had been reported in studies trying to confirm the impact of heart dose on overall survival (OS) reported in RTOG 0167 for non-small cell lung cancer (NSCLC) patients who underwent radiotherapy (RT). The purpose of this study is to investigate the association of lung and heart dosimetric parameters with OS in NSCLC patients treated by volumetric modulated arc therapy (VMAT). Methods Inoperable NSCLC patients treated by VMAT from March 2012 to December 2015 were retrospectively reviewed. OS and progression-free survival (PFS) were estimated with the Kaplan–Meier method. Univariate and multivariate analyses were conducted with Cox proportional hazards model. Multivariate model building was conducted using stepwise regression for variables with p-value smaller than 0.2 in the univariate analysis. Results There were 130 NSCLC patients enrolled in this study with a median age of 63 years (range from 34 to 82 y). The median prescription dose for these patients was 56 Gy (range 40–70 Gy) with a mean heart and lung dose of 14.8±8.5 Gy and 13.6±4.4 Gy, respectively. The rates of patients with above grade III radiation pneumonitis (RP) and fibrosis were 8.5% and 8.5%, respectively. The 2-year PFS and OS of these patients were 15.2% and 39.8%, with a median PFS and OS of 7.2 and 18.8 months, respectively. RP was correlated with OS (p=0.048) and lung V20 was associated with PFS (p=0.04) according to the univariate analysis. Multivariate analysis demonstrated that RP (HR 1.39, 95%CI 1.010–1.909, p=0.043) and heart V15 (HR 1.02, 95%CI 1.006–1.025 p=0.002) were progression factors of OS, and no factor was associated with PFS. Conclusions RP and heart V15 were associated with OS for patients with stage III NSCLC who underwent VMAT. Heart and lung dosimetric parameters were highly correlated with each other, sparing of heart and lung should be considered equally during the treatment planning.
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Affiliation(s)
- Lanxiao Shen
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Cong Liu
- Ningbo Institute of Technology, Zhejiang University, Ningbo 315100, People's Republic of China
| | - Juebin Jin
- Department of Medical Engineering, The 1st Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Ce Han
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Yongqiang Zhou
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Xiaomin Zheng
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Changfei Gong
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Mengfeng Chen
- Respiratory Department, Third People's Hospital of Yueqing, Wenzhou 325600, People's Republic of China
| | - Congying Xie
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
| | - Xiance Jin
- Radiation and Medical Oncology Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, People's Republic of China
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Fellin F, Iacco M, D'Avino V, Tommasino F, Farace P, Palma G, Conson M, Giacomelli I, Zucchetti C, Falcinelli L, Amichetti M, Aristei C, Cella L. Potential skin morbidity reduction with intensity-modulated proton therapy for breast cancer with nodal involvement. Acta Oncol 2019; 58:934-942. [PMID: 30938217 DOI: 10.1080/0284186x.2019.1591638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Different modern radiation therapy treatment solutions for breast cancer (BC) and regional nodal irradiation (RNI) have been proposed. In this study, we evaluate the potential reduction in radiation-induced skin morbidity obtained by intensity modulated proton therapy (IMPT) compared with intensity modulated photon therapy (IMXT) for left-side BC and RNI. Material and Methods: Using CT scans from 10 left-side BC patients, treatment plans were generated using IMXT and IMPT techniques. A dose of 50 Gy (or Gy [RBE] for IMPT) was prescribed to the target volume (involved breast, the internal mammary, supraclavicular, and infraclavicular nodes). Two single filed optimization IMPT (IMPT1 and IMPT2) plans were calculated without and with skin optimization. For each technique, skin dose-metrics were extracted and normal tissue complication probability (NTCP) models from the literature were employed to estimate the risk of radiation-induced skin morbidity. NTCPs for relevant organs-at-risk (OARs) were also considered for reference. The non-parametric Anova (Friedman matched-pairs signed-rank test) was used for comparative analyses. Results: IMPT improved target coverage and dose homogeneity even if the skin was included into optimization strategy (HIIMPT2 = 0.11 vs. HIIMXT = 0.22 and CIIMPT2 = 0.96 vs. CIIMXT = 0.82, p < .05). A significant relative skin risk reduction (RR = NTCPIMPT/NTCPIMXT) was obtained with IMPT2 including the skin in the optimization with a RR reduction ranging from 0.3 to 0.9 depending on the analyzed skin toxicity endpoint/model. Both IMPT plans attained significant OARs dose sparing compared with IMXT. As expected, the heart and lung doses were significantly reduced using IMPT. Accordingly, IMPT always provided lower NTCP values. Conclusions: IMPT guarantees optimal target coverage, OARs sparing, and simultaneously minimizes the risk of skin morbidity. The applied model-based approach supports the potential clinical relevance of IMPT for left-side BC and RNI and might be relevant for the setup of cost-effectiveness evaluation strategies based on NTCP predictions, as well as for establishing patient selection criteria.
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Affiliation(s)
- Francesco Fellin
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Martina Iacco
- Perugia General Hospital, Medical Physics Unit, Perugia, Italy
| | - Vittoria D'Avino
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Francesco Tommasino
- Department of Physics, University of Trento, Povo, Italy
- Trento Institute for Fundamental Physics and Applications (TIFPA), National Institute for Nuclear Physics (INFN), Povo, Italy
| | - Paolo Farace
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Irene Giacomelli
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | | | | | - Maurizio Amichetti
- Protontherapy Department, Azienda Provinciale per I Servizi Sanitari (APSS), Trento, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
- Department of Surgical and Biomedical Science, University of Perugia, Perugia, Italy
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
- National Institute for Nuclear Physics (INFN), Naples, Italy
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9
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Eidemüller M, Simonetto C, Kundrát P, Ulanowski A, Shemiakina E, Güthlin D, Rennau H, Remmele J, Hildebrandt G, Wolf U. LONG-TERM HEALTH RISK AFTER BREAST-CANCER RADIOTHERAPY: OVERVIEW OF PASSOS METHODOLOGY AND SOFTWARE. RADIATION PROTECTION DOSIMETRY 2019; 183:259-263. [PMID: 30520982 DOI: 10.1093/rpd/ncy219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Breast-cancer radiotherapy reduces the recurrence rates and improves patient survival. However, it also increases the incidence of second cancers and of heart disease. These radiation-induced long-term health risks become increasingly important with improved cure rates and prolonged patient survival. Radiation doses to nearby as well as distant organs strongly vary between different irradiation techniques and among individual patients. To provide personalized lifetime risk estimates, the German national project PASSOS combines individual anatomy, dosimetric estimates, organ-specific low- and high-dose risk models and personal risk factors such as smoking. A dedicated software tool is under development to assist clinical decision-making processes.
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Affiliation(s)
- Markus Eidemüller
- Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Cristoforo Simonetto
- Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Pavel Kundrát
- Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Alexander Ulanowski
- Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Elena Shemiakina
- Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Denise Güthlin
- Helmholtz Zentrum München GmbH, German Research Center for Environmental Health, Institute of Radiation Protection, Ingolstädter Landstr. 1, Neuherberg, Germany
| | - Hannes Rennau
- Klinik und Poliklinik für Strahlentherapie, Universitätsmedizin Rostock, Südring 75, Rostock, Germany
| | - Julia Remmele
- Klinik für Strahlentherapie, Universität Leipzig, Stephanstr. 9a, Leipzig, Germany
| | - Guido Hildebrandt
- Klinik und Poliklinik für Strahlentherapie, Universitätsmedizin Rostock, Südring 75, Rostock, Germany
| | - Ulrich Wolf
- Klinik für Strahlentherapie, Universität Leipzig, Stephanstr. 9a, Leipzig, Germany
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Kim J, Forouzannia A, Saini A, Hwang C. Hypofractionated whole-breast radiotherapy using a three-dimensional conformal technique: Toxicity comparison in different breast sizes. PRECISION RADIATION ONCOLOGY 2018. [DOI: 10.1002/pro6.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jae Kim
- University of Central Florida College of Medicine; Orlando Florida USA
| | | | - Amitpal Saini
- Florida Hospital, Department of Radiation Oncology; Orlando Florida USA
| | - Catherine Hwang
- Florida Hospital, Department of Radiation Oncology; Orlando Florida USA
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Does deep inspiration breath-hold prolong life? Individual risk estimates of ischaemic heart disease after breast cancer radiotherapy. Radiother Oncol 2018; 131:202-207. [PMID: 30097250 DOI: 10.1016/j.radonc.2018.07.024] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/13/2018] [Accepted: 07/23/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Aim of the current comparative modelling study was to estimate the individual radiation-induced risk for death of ischaemic heart disease (IHD) under free breathing (FB) and deep inspiration breath-hold (DIBH) in a real-world population. MATERIALS AND METHODS Eighty-nine patients with left-sided early breast cancer were enrolled in the prospective SAVE-HEART study. For each patient three-dimensional conformal treatment plans were created in FB and DIBH and corresponding radiation-induced risks of IHD mortality were estimated based on expected survival, individual IHD risk factors and the relative radiation-induced risk. RESULTS With the use of DIBH, mean heart doses were reduced by 35% (interquartile range: 23-46%) as compared to FB. Mean expected years of life lost (YLL) due to radiation-induced IHD mortality were 0.11 years in FB, and 0.07 years in DIBH. YLL were remarkably independent of age at treatment in patients with a favourable tumour prognosis. DIBH led to more pronounced reductions in YLL in patients with high baseline risk (0.08 years for upper vs 0.02 years for lower quartile), with favourable tumour prognosis (0.05 years for patients without vs 0.02 years for those with lymph-node involvement), and in patients with high mean heart doses in FB (0.09 years for doses >3 Gy vs 0.02 years for doses <1.5 Gy). CONCLUSION Ideally, the DIBH technique should be offered to all patients with left-sided breast cancer. However, highest benefits are expected for patients with a favourable tumour prognosis, high mean heart dose or high baseline IHD risk, independent of their age.
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Aerobic exercise and cardiopulmonary fitness in childhood cancer survivors treated with a cardiotoxic agent: a meta-analysis. Support Care Cancer 2018; 26:2113-2123. [PMID: 29671063 DOI: 10.1007/s00520-018-4208-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/09/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE The main purpose of this review was to synthesize evidence from existing childhood cancer survivor studies that report the effect of aerobic exercise on cardiopulmonary fitness (a marker of cardiovascular health), in survivors that were currently receiving or had been treated with a cardiotoxic agent. METHODS Studies were identified for this review by searching both electronic databases of peer-reviewed articles, as well as various sources of gray literature. Risk of bias was qualitatively assessed in these studies using the domains outlined in the Cochrane Handbook for Systematic Reviews of Interventions. Data was analyzed quantitatively using random-effects meta-analyses and subgroup analyses in RevMan Software. RESULTS Meta-analysis of pooled evidence from the nine included studies suggests that aerobic exercise has a statistically and clinically significant positive effect on cardiopulmonary fitness (effect estimate = 6.92%, p value = 0.02). Findings from subgroup analyses of clinical characteristics and exercise parameters were not significant. CONCLUSIONS The findings from this review, although not directly demonstrating a cardioprotective effect, are a preliminary step towards establishing the putative cardioprotective effect of aerobic exercise against the direct cardiotoxic impact of cancer treatments. The significant positive effect estimate in favor of aerobic exercise is a small but important advancement towards the standardization of aerobic exercise in childhood cancer survivors. Further studies are necessary.
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Johnson RP. Review of medical radiography and tomography with proton beams. REPORTS ON PROGRESS IN PHYSICS. PHYSICAL SOCIETY (GREAT BRITAIN) 2018; 81:016701. [PMID: 28884707 DOI: 10.1088/1361-6633/aa8b1d] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The use of hadron beams, especially proton beams, in cancer radiotherapy has expanded rapidly in the past two decades. To fully realize the advantages of hadron therapy over traditional x-ray and gamma-ray therapy requires accurate positioning of the Bragg peak throughout the tumor being treated. A half century ago, suggestions had already been made to use protons themselves to develop images of tumors and surrounding tissue, to be used for treatment planning. The recent global expansion of hadron therapy, coupled with modern advances in computation and particle detection, has led several collaborations around the world to develop prototype detector systems and associated reconstruction codes for proton computed tomography (pCT), as well as more simple proton radiography, with the ultimate intent to use such systems in clinical treatment planning and verification. Recent imaging results of phantoms in hospital proton beams are encouraging, but many technical and programmatic challenges remain to be overcome before pCT scanners will be introduced into clinics. This review introduces hadron therapy and the perceived advantages of pCT and proton radiography for treatment planning, reviews its historical development, and discusses the physics related to proton imaging, the associated experimental and computation issues, the technologies used to attack the problem, contemporary efforts in detector and computational development, and the current status and outlook.
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Affiliation(s)
- Robert P Johnson
- Department of Physics, University of California Santa Cruz, 1156 High St., Santa Cruz, CA 95064, United States of America
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14
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Corradini S, Ballhausen H, Weingandt H, Freislederer P, Schönecker S, Niyazi M, Simonetto C, Eidemüller M, Ganswindt U, Belka C. Left-sided breast cancer and risks of secondary lung cancer and ischemic heart disease : Effects of modern radiotherapy techniques. Strahlenther Onkol 2017; 194:196-205. [PMID: 28916844 DOI: 10.1007/s00066-017-1213-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 08/30/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Modern breast cancer radiotherapy techniques, such as respiratory-gated radiotherapy in deep-inspiration breath-hold (DIBH) or volumetric-modulated arc radiotherapy (VMAT) have been shown to reduce the high dose exposure of the heart in left-sided breast cancer. The aim of the present study was to comparatively estimate the excess relative and absolute risks of radiation-induced secondary lung cancer and ischemic heart disease for different modern radiotherapy techniques. METHODS Four different treatment plans were generated for ten computed tomography data sets of patients with left-sided breast cancer, using either three-dimensional conformal radiotherapy (3D-CRT) or VMAT, in free-breathing (FB) or DIBH. Dose-volume histograms were used for organ equivalent dose (OED) calculations using linear, linear-exponential, and plateau models for the lung. A linear model was applied to estimate the long-term risk of ischemic heart disease as motivated by epidemiologic data. Excess relative risk (ERR) and 10-year excess absolute risk (EAR) for radiation-induced secondary lung cancer and ischemic heart disease were estimated for different representative baseline risks. RESULTS The DIBH maneuver resulted in a significant reduction of the ERR and estimated 10-year excess absolute risk for major coronary events compared to FB in 3D-CRT plans (p = 0.04). In VMAT plans, the mean predicted risk reduction through DIBH was less pronounced and not statistically significant (p = 0.44). The risk of radiation-induced secondary lung cancer was mainly influenced by the radiotherapy technique, with no beneficial effect through DIBH. VMAT plans correlated with an increase in 10-year EAR for radiation-induced lung cancer as compared to 3D-CRT plans (DIBH p = 0.007; FB p = 0.005, respectively). However, the EARs were affected more strongly by nonradiation-associated risk factors, such as smoking, as compared to the choice of treatment technique. CONCLUSION The results indicate that 3D-CRT plans in DIBH pose the lowest risk for both major coronary events and secondary lung cancer.
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Affiliation(s)
- Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - Hendrik Ballhausen
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Helmut Weingandt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Philipp Freislederer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - Cristoforo Simonetto
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Markus Eidemüller
- Institute of Radiation Protection, Helmholtz Zentrum München, Neuherberg, Germany
| | - Ute Ganswindt
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
- Department of Radiation Oncology, Medical University, Innsbruck, Austria
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Internal mammary lymph nodes radiotherapy of breast cancer in the era of individualized medicine. Oncotarget 2017; 8:81583-81590. [PMID: 29113416 PMCID: PMC5655311 DOI: 10.18632/oncotarget.20186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 07/25/2017] [Indexed: 12/26/2022] Open
Abstract
Inclusion internal mammary lymph nodes as a part of regional nodal irradiation have a potential to reduce local recurrence, distant recurrence, and improve survival in breast cancer. However, the increased risk of cardiac toxicity and lungs injure associated with internal mammary lymph nodes irradiation has drew more and more attention. Estimating risk of metastasis in internal mammary lymph nodes based on axillary lymph nodes metastasis status is not always reliable: low-risk do not always mean negative in internal mammary lymph nodes and high-risk do not always indicate positive in internal mammary lymph nodes. Inaccurate prediction of in internal mammary lymph nodes metastasis might lead to over- or under-treatment of in internal mammary lymph node. Internal mammary sentinel lymph node biopsy is a minimally invasive technique which has a high potential to accurately evaluate the metastasis status in in internal mammary lymph nodes and improve accuracy of nodal staging. This technique might be a useful tool to guide individualized internal mammary lymph nodes irradiation.
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Groom N, Wilson E, Faivre-Finn C. Effect of accurate heart delineation on cardiac dose during the CONVERT trial. Br J Radiol 2017; 90:20170036. [PMID: 28362511 PMCID: PMC5605115 DOI: 10.1259/bjr.20170036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/07/2017] [Accepted: 03/29/2017] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE This study investigated the effect of deviation from protocol in heart delineation for the Concurrent Once-daily Versus twice-daily Radiotherapy (CONVERT) Trial ( ClinicalTrials.gov Identifier NCT00433563) quality assurance (QA) programme and the effect of that on mean cardiac dose and percentage of heart volume receiving ≥5 Gy (V5%) and percentage of heart volume receiving ≥30 Gy (V30%). METHODS Patients with limited-stage small-cell lung cancer in the CONVERT trial were randomized to receive 45 Gy in 30# twice daily or 66 Gy in 33# once daily radiotherapy, with concurrent chemotherapy in both arms. Of the 100 trial patient cases reviewed by the QA team [for patient selection, disease/organs at risk (OARs) outlining and treatment planning], 50 patient cases were selected, and the heart was reoutlined according to the "gold standard" trial protocol. Dose-volume histogram (DVH) data were extracted. The impact of change in heart volume on cardiac DVH is presented. RESULTS For gold standard cardiac outlines, an increase in V5% and V30% was seen in 77.3% and 81.8% of cases, respectively, in the control arm (45 Gy) and in 78.6% and 82.1% of cases, respectively, in the experimental arm (66 Gy). The median increase in V5% was 1.4% and in V30%, it was 3.4%. The average of the mean cardiac dose for the control arm increased by 2.1 Gy (from 15.2 Gy for the centres outline to 17.3 Gy for the gold standard outline) and for the experimental arm by 2.4 Gy (from 16.2 to 18.6 Gy). CONCLUSION This study demonstrates the importance of having a robust QA programme in place to ensure accuracy of cardiac delineation to facilitate future studies investigating the impact of cardiac dose on toxicity. Advances in knowledge: This study highlights the importance of ensuring accurate delineation of OARs in clinical trials, where conclusions about normal tissue toxicity are to be drawn.
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Affiliation(s)
- Nicki Groom
- Department of Radiotherapy Physics, Mount Vernon Cancer Centre, Northwood, UK
| | - Elena Wilson
- Department of Radiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Corinne Faivre-Finn
- University of Manchester, Manchester Academic Health Science Centre, Institute of Cancer Sciences, Manchester, UK
- Radiotherapy Related Research, The Christie NHS Foundation Trust, Manchester, UK
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Ming X, Feng Y, Yang C, Wang W, Wang P, Deng J. Radiation-induced heart disease in lung cancer radiotherapy: A dosimetric update. Medicine (Baltimore) 2016; 95:e5051. [PMID: 27741117 PMCID: PMC5072944 DOI: 10.1097/md.0000000000005051] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 09/08/2016] [Accepted: 09/13/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Radiation-induced heart disease (RIHD), which affects the patients' prognosis with both acute and late side effects, has been published extensively in the radiotherapy of breast cancer, lymphoma and other benign diseases. Studies on RIHD in lung cancer radiotherapy, however, are less extensive and clear even though the patients with lung cancer are delivered with higher doses to the heart during radiation treatment. METHODS In this article, after extensive literature search and analysis, we reviewed the current evidence on RIHD in lung cancer patients after their radiation treatments and investigated the potential risk factors for RIHD as compared to other types of cancers. RESULT Cardiac toxicity has been found highly relevant in lung cancer radiotherapy. So far, the crude incidence of cardiac complications in the lung cancer patients after radiotherapy has been up to 33%. CONCLUSION The dose to the heart, the lobar location of tumor, the treatment modality, the history of heart and pulmonary disease and smoking were considered as potential risk factors for RIHD in lung cancer radiotherapy. As treatment techniques improve over the time with better prognosis for lung cancer survivors, an improved prediction model can be established to further reduce the cardiac toxicity in lung cancer radiotherapy.
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Affiliation(s)
- Xin Ming
- Department of Biomedical Engineering, Tianjin University
| | - Yuanming Feng
- Department of Biomedical Engineering, Tianjin University
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Chengwen Yang
- Department of Biomedical Engineering, Tianjin University
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Wei Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Ping Wang
- Department of Radiation Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jun Deng
- Department of Therapeutic Radiology, Yale University, New Haven, CT, USA
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18
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Cooper BT, Li X, Shin SM, Modrek AS, Hsu HC, DeWyngaert JK, Jozsef G, Lymberis SC, Goldberg JD, Formenti SC. Preplanning prediction of the left anterior descending artery maximum dose based on patient, dosimetric, and treatment planning parameters. Adv Radiat Oncol 2016; 1:373-381. [PMID: 28740908 PMCID: PMC5514165 DOI: 10.1016/j.adro.2016.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/27/2016] [Accepted: 08/02/2016] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Maximum dose to the left anterior descending artery (LADmax) is an important physical constraint to reduce the risk of cardiovascular toxicity. We generated a simple algorithm to guide the positioning of the tangent fields to reliably maintain LADmax <10 Gy. METHODS AND MATERIALS Dosimetric plans from 146 consecutive women treated prone to the left breast enrolled in prospective protocols of accelerated whole breast radiation therapy, with a concomitant daily boost to the tumor bed (40.5 Gy/15 fraction to the whole breast and 48 Gy to the tumor bed), provided the training set for algorithm development. Scatter plots and correlation coefficients were used to describe the bivariate relationships between LADmax and several parameters: distance from the tumor cavity to the tangent field edge, cavity size, breast separation, field size, and distance from the tangent field. A logistic sigmoid curve was used to model the relationship of LADmax and the distance from the tangent field. Furthermore, we tested this prediction model on a validation data set of 53 consecutive similar patients. RESULTS A lack of linear relationships between LADmax and distance from cavity to LAD (-0.47), cavity size (-0.18), breast separation (-0.02), or field size (-0.28) was observed. In contrast, distance from the tangent field was highly negatively correlated to LADmax (-0.84) and was used in the models to predict LADmax. From a logistic sigmoid model we selected a cut-point of 2.46 mm (95% confidence interval, 2.19-2.74 mm) greater than which LADmax is <10 Gy (95% confidence interval, 9.30-10.72 Gy) and LADmean is <3.3 Gy. CONCLUSIONS Placing the edge of the tangents at least 2.5 mm from the closest point of the contoured LAD is likely to assure LADmax is <10 Gy and LADmean is <3.3 Gy in patients treated with prone accelerated breast radiation therapy.
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Affiliation(s)
- Benjamin T Cooper
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Xiaochun Li
- Division of Biostatistics and Department of Population Health, New York University School of Medicine, New York, New York
| | - Samuel M Shin
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Aram S Modrek
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Howard C Hsu
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - J K DeWyngaert
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Gabor Jozsef
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Stella C Lymberis
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Judith D Goldberg
- Division of Biostatistics and Department of Population Health, New York University School of Medicine, New York, New York
| | - Silvia C Formenti
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
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Eldredge-Hindy HB, Duffy D, Yamoah K, Simone NL, Skowronski J, Dicker AP, Anne PR. Modeled risk of ischemic heart disease following left breast irradiation with deep inspiration breath hold. Pract Radiat Oncol 2016; 5:162-168. [PMID: 25957186 DOI: 10.1016/j.prro.2014.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/01/2014] [Accepted: 10/09/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE Deep inspiration breath hold (DIBH) dramatically reduces radiation dose to the heart during radiation therapy (RT) for left-sided breast cancer, but the subsequent risk of radiation-related ischemic heart disease (IHD) is unknown. Our primary objective was to quantify the risk of IHD following RT with DIBH using modeled risk estimates (MRE). METHODS AND MATERIALS Patients with stage 0-III left-sided breast cancer who received RT with DIBH were retrospectively studied. Computed tomography simulations were performed with DIBH and during free breathing (FB) for comparison of dosimetry. Patients were classified as high risk, at risk, or at optimal risk for IHD and baseline risk estimates for IHD were obtained from historic controls. The excess relative risk of IHD because of left breast RT was calculated using patient-specific dosimetry and an existing dose-effect model. MRE were determined from the sum of baseline risk estimates and excess risk. RESULTS Between 2002 and 2011, 111 patients were treated using DIBH and 104 were available for analysis. MRE for 10-year risk of IHD with DIBH and FB were 3.25% (interquartile range [IQR], 1.20-3.44) and 3.64% (IQR, 1.43-3.81) (P < .0001), respectively. MRE for lifetime risk of IHD with DIBH and FB were 9.71% (IQR, 1.98-16.62) and 10.28% (IQR, 2.05-16.97) (P < .0001), respectively. MRE were significantly reduced by use of DIBH in all risk groups. The largest absolute risk reduction resulting from the DIBH technique was observed in patients at high risk for IHD. The median relative risk reduction in MRE resulting from DIBH was 11.4% (range, 0-32.0) and 6.4% (range, 0-23.4) at 10 years and throughout the patients' lifetime, respectively. After a median follow-up of 7.0 years (range, 1.3-11.2), the estimated 10-year freedom from IHD was 99.0% (95% confidence interval 93.4-99.8). CONCLUSIONS RT with DIBH may provide breast cancer survivors a clinically significant reduction in the risk of IHD.
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Affiliation(s)
- Harriet B Eldredge-Hindy
- Department of Radiation Oncology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Danielle Duffy
- Division of Cardiology, Department of Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kosj Yamoah
- Department of Radiation Oncology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicole L Simone
- Department of Radiation Oncology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jenna Skowronski
- Department of Radiation Oncology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Pramila R Anne
- Department of Radiation Oncology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
Heart disease is the number one killer of women. Although there are many similarities between men and women, the evolving understanding of ischemic heart disease in women allow us to emphasize the important differences that need to be recognized. These differences, including symptoms at presentation, importance of particular risk factors, pathophysiology of disease, and treatments/outcomes, will be discussed in this review.
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Ming X, Feng Y, Liu H, Zhang Y, Zhou L, Deng J. Cardiac Exposure in the Dynamic Conformal Arc Therapy, Intensity-Modulated Radiotherapy and Volumetric Modulated Arc Therapy of Lung Cancer. PLoS One 2015; 10:e0144211. [PMID: 26630566 PMCID: PMC4667972 DOI: 10.1371/journal.pone.0144211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 11/13/2015] [Indexed: 02/05/2023] Open
Abstract
Purpose To retrospectively evaluate the cardiac exposure in three cohorts of lung cancer patients treated with dynamic conformal arc therapy (DCAT), intensity-modulated radiotherapy (IMRT), or volumetric modulated arc therapy (VMAT) at our institution in the past seven years. Methods and Materials A total of 140 lung cancer patients were included in this institutional review board approved study: 25 treated with DCAT, 70 with IMRT and 45 with VMAT. All plans were generated in a same commercial treatment planning system and have been clinically accepted and delivered. The dose distribution to the heart and the effects of tumor laterality, the irradiated heart volume and the beam-to-heart distance on the cardiac exposure were investigated. Results The mean dose to the heart among all 140 plans was 4.5 Gy. Specifically, the heart received on average 2.3, 5.2 and 4.6 Gy in the DCAT, IMRT and VMAT plans, respectively. The mean heart doses for the left and right lung tumors were 4.1 and 4.8 Gy, respectively. No patients died with evidence of cardiac disease. Three patients (2%) with preexisting cardiac condition developed cardiac disease after treatment. Furthermore, the cardiac exposure was found to increase linearly with the irradiated heart volume while decreasing exponentially with the beam-to-heart distance. Conclusions Compared to old technologies for lung cancer treatment, modern radiotherapy treatment modalities demonstrated better heart sparing. But the heart dose in lung cancer radiotherapy is still higher than that in the radiotherapy of breast cancer and Hodgkin’s disease where cardiac complications have been extensively studied. With strong correlations of mean heart dose with beam-to-heart distance and irradiated heart volume, cautions should be exercised to avoid long-term cardiac toxicity in the lung cancer patients undergoing radiotherapy.
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Affiliation(s)
- Xin Ming
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
- Department of Therapeutic Radiology, Yale University, New Haven, CT, United States of America
| | - Yuanming Feng
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
| | - Huan Liu
- Department of Therapeutic Radiology, Yale-New Haven Hospital, New Haven, CT, United States of America
| | - Ying Zhang
- Department of Biomedical Engineering, Tianjin University, Tianjin, China
- Department of Therapeutic Radiology, Yale University, New Haven, CT, United States of America
| | - Li Zhou
- Center for Radiation Physics and Technology, West China Hospital Cancer Center, Sichuan University, Chengdu, China
| | - Jun Deng
- Department of Therapeutic Radiology, Yale University, New Haven, CT, United States of America
- Department of Therapeutic Radiology, Yale-New Haven Hospital, New Haven, CT, United States of America
- * E-mail:
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Abstract
Breast cancer treatments have evolved over the past decades, although several widely used treatments have adverse cardiac effects. Radiotherapy generally improves the survival of women with breast cancer, although its deleterious cardiovascular effects pose competing risks of morbidity and/or mortality. In the past, radiation-associated cardiovascular disease was a phenomenon considered to take more than a decade to manifest, but newer research suggests that this latency is much shorter. Knowledge of coronary anatomy relative to the distribution of the delivered radiation dose has improved over time, and as a result, techniques have enabled this risk to be decreased. Studies continue to be performed to better understand, prevent and mitigate against radiation-associated cardiovascular disease. Treatments such as anthracyclines, which are a mainstay of chemotherapy for breast cancer, and newer targeted agents such as trastuzumab both have established risks of cardiotoxicity, which can limit their effectiveness and result in increased morbidity and/or mortality. Interest in whether β-blockers, statins and/or angiotensin-converting enzyme (ACE)-inhibitors might have therapeutic and/or preventative effects in these patients is currently increasing. This Review summarizes the incidence, risks and effects of treatment-induced cardiovascular disease in patients with breast cancer and describes strategies that might be used to minimize this risk.
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Shin SM, No HS, Vega RM, Fenton-Kerimian M, Maisonet O, Hitchen C, Keith DeWyngaert J, Formenti SC. Breast, chest wall, and nodal irradiation with prone set-up: Results of a hypofractionated trial with a median follow-up of 35 months. Pract Radiat Oncol 2015; 6:e81-e88. [PMID: 26723552 DOI: 10.1016/j.prro.2015.10.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/28/2015] [Accepted: 10/30/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To test clinical feasibility, safety, and toxicity of prone hypofractionated breast, chest wall, and nodal radiation therapy. METHODS AND MATERIALS Following either segmental or total mastectomy with axillary node dissection, patients were treated in an institutional review board-approved prospective trial of prone radiation therapy to the breast, chest wall, and supraclavicular and level III axillary lymph nodes. A dose of 40.5 Gy/15 fractions with a concomitant daily boost to the tumor bed of 0.5 Gy (total dose, 48 Gy) was prescribed. In postmastectomy patients, the same treatment was prescribed, but without a tumor bed boost. The primary endpoint was incidence of >grade 2 acute skin toxicity. The secondary endpoints were feasibility of treatment using prone set-up, compliance with protocol-defined dosimetric constraints, and incidence of late toxicity. A dosimetric comparison was performed between protocol plans (prone) and nonprotocol plans (supine), targeting the same treatment volumes. RESULTS Sixty-nine patients with stage IB-IIIA breast cancer enrolled in this trial. Surgery was segmental mastectomy (n = 45), mastectomy (n = 23), and bilateral mastectomy (n = 1), resulting in 70 cases. None experienced >grade 2 acute skin toxicity according to the Common Terminology Criteria for Adverse Events, v 3.0, meeting our primary endpoint. Ninety-six percent of patients could be treated with this technique prone. However, 17 plans (24%) exceeded protocol constraints to the brachial plexus. Maximum long-term toxicity was 1 grade 2 arm lymphedema, 1 grade 3 breast retraction, and no occurrence of brachial plexopathy. Dosimetric comparison of protocol with nonprotocol plans demonstrated significantly decreased lung and heart doses in prone plans. CONCLUSIONS Prone hypofractionated breast, chest wall, and nodal radiation therapy is safe and well tolerated in this study. Although the initial pattern of local and regional control is encouraging, longer follow-up is warranted for efficacy and late toxicity assessment, particularly to the brachial plexus.
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Affiliation(s)
- Samuel Minkee Shin
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Hyun Soo No
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Raymond Mailhot Vega
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Maria Fenton-Kerimian
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Olivier Maisonet
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Christine Hitchen
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - J Keith DeWyngaert
- Department of Radiation Oncology, New York University School of Medicine and Langone Medical Center, New York, New York
| | - Silvia Chiara Formenti
- Department of Radiation Oncology, New York Weill Cornell Medical Center, New York, New York.
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Sanzari JK, Billings PC, Wilson JM, Diffenderfer ES, Arce-Esquivel AA, Thorne PK, Laughlin MH, Kennedy AR. Effect of electron radiation on vasomotor function of the left anterior descending coronary artery. LIFE SCIENCES IN SPACE RESEARCH 2015; 4:6-10. [PMID: 26072960 PMCID: PMC4452954 DOI: 10.1016/j.lssr.2014.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The left anterior descending (LAD, interventricular) coronary artery provides the blood supply to the mid-region of the heart and is a major site of vessel stenosis. Changes in LAD function can have major effects on heart function. In this report, we examined the effect of electron simulated solar particle event (eSPE) radiation on LAD function in a porcine animal model. Vasodilatory responses to adenosine diphosphate (ADP; 10(−9)–10(−4) M), bradykinin (BK; 10(−11)–10(−6) M), and sodium nitroprusside (SNP; 10(−10)–10(−4) M) were assessed. The LAD arteries from Control (non-irradiated) and the eSPE (irradiated) animals were isolated and exhibited a similar relaxation response following treatment with either ADP or SNP. In contrast, a significantly reduced relaxation response to BK treatment was observed in the eSPE irradiated group, compared to the control group. These data demonstrate that simulated SPE radiation exposure alters LAD function.
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Affiliation(s)
- Jenine K. Sanzari
- 3620 Hamilton Walk, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Paul C. Billings
- 3620 Hamilton Walk, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Jolaine M. Wilson
- 3620 Hamilton Walk, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Eric S. Diffenderfer
- 3620 Hamilton Walk, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Arturo A. Arce-Esquivel
- E102 Veterinary Medicine, Department of Biomedical Sciences, University of Missouri, Columbia, MO 65211, USA
- 3900 University Blvd., Department of Health and Kinesiology, The University of Texas at Tyler, Tyler, TX 75799, USA
| | - Pamela K. Thorne
- E102 Veterinary Medicine, Department of Biomedical Sciences, University of Missouri, Columbia, MO 65211, USA
| | - M. H. Laughlin
- E102 Veterinary Medicine, Department of Biomedical Sciences, University of Missouri, Columbia, MO 65211, USA
| | - Ann R. Kennedy
- 3620 Hamilton Walk, Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Breast Cancer Laterality Does Not Influence Survival in a Large Modern Cohort: Implications for Radiation-Related Cardiac Mortality. Int J Radiat Oncol Biol Phys 2014; 90:329-34. [DOI: 10.1016/j.ijrobp.2014.06.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 06/05/2014] [Accepted: 06/07/2014] [Indexed: 01/17/2023]
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26
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Thorsen LBJ, Thomsen MS, Berg M, Jensen I, Josipovic M, Overgaard M, Overgaard J, Skogholt P, Offersen BV. CT-planned internal mammary node radiotherapy in the DBCG-IMN study: benefit versus potentially harmful effects. Acta Oncol 2014; 53:1027-34. [PMID: 24957557 DOI: 10.3109/0284186x.2014.925579] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The DBCG-IMN is a nationwide population-based cohort study on the effect of internal mammary node radiotherapy (IMN-RT) in patients with node positive early breast cancer. Due to the risk of RT-induced heart disease, only patients with right-sided breast cancer received IMN-RT, whereas patients with left-sided breast cancer did not. At seven-year median follow-up, a 3% gain in overall survival with IMN-RT has been reported. This study estimates IMN doses and doses to organs at risk (OAR) in patients from the DBCG-IMN. Numbers needed to harm (NNH) if patients with left-sided breast cancer had received IMN-RT are compared to the number needed to treat (NNT). MATERIAL AND METHODS Ten percent of CT-guided treatment plans from the DBCG-IMN patients were selected randomly. IMNs and OAR were contoured in 68 planning CT scans. Dose distributions were re-calculated. IMNs and OAR dose estimates were compared in right-sided versus left-sided breast cancer patients. In six left-sided patients, IMN-RT was simulated, and OAR doses were compared to those in the original plan. The NNH resulting from the change in mean heart dose (MHD) was calculated using a published model for risk of RT-related ischemic heart death. RESULTS In original plans, the absolute difference between right- and left-sided V90% to the IMNs was 38.0% [95% confidence interval (5.5%; 70.5%), p < 0.05]. Heart doses were higher in left-sided plans. With IMN-RT simulation without regard to OAR constraints, MHD increased 4.8 Gy (0.9 Gy; 8.7 Gy), p < 0.05. Resulting NNHs from ischemic heart death were consistently larger than the NNT with IMN-RT. CONCLUSION Refraining from IMN-RT on the left side may have spared some ischemic heart deaths. Assuming left-sided patients benefit as much from IMN-RT as right-sided patients, the benefits from IMN-RT outweigh the costs in terms of ischemic heart death.
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Accordino MK, Neugut AI, Hershman DL. Cardiac effects of anticancer therapy in the elderly. J Clin Oncol 2014; 32:2654-61. [PMID: 25071122 DOI: 10.1200/jco.2013.55.0459] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Cancer incidence increases with age, and as life expectancy increases, the number of elderly patients with cancer is increasing. Cancer treatments, including chemotherapy and radiotherapy, have significant short- and long-term effects on cardiovascular function. These cardiotoxic effects can be acute, such as changes in electrocardiogram (ECG), arrhythmias, ischemia, and pericarditis and/or myocarditis-like syndromes, or they can be chronic, such as ventricular dysfunction. Anticancer therapies can also have indirect effects, such as alterations in blood pressure, or can cause metabolic abnormalities that subsequently increase risk for cardiac events. In this review, we explore both observational and clinical trial evidence of cardiac risk in the elderly. In both observational and clinical trial data, risk of cardiotoxicity with anthracycline-based chemotherapy increases with age. However, it is less clear whether the association between age and cardiotoxicity exists for newer treatments. The association may not be well demonstrated as a result of under-representation of elderly patients in clinical trials and avoidance of these therapies in this population. In addition, we discuss strategies for surveillance and prevention of cardiotoxicity in the elderly. In the elderly, it is important to be aware of the potential for cardiotoxicity during long-term follow-up and to consider both prevention and surveillance of these late effects.
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Affiliation(s)
| | - Alfred I Neugut
- All authors: Columbia University Medical Center, New York, NY
| | - Dawn L Hershman
- All authors: Columbia University Medical Center, New York, NY.
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28
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Osa EOO, DeWyngaert K, Roses D, Speyer J, Guth A, Axelrod D, Fenton Kerimian M, Goldberg JD, Formenti SC. Prone breast intensity modulated radiation therapy: 5-year results. Int J Radiat Oncol Biol Phys 2014; 89:899-906. [PMID: 24867535 PMCID: PMC4684090 DOI: 10.1016/j.ijrobp.2014.03.036] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 03/05/2014] [Accepted: 03/21/2014] [Indexed: 11/21/2022]
Abstract
PURPOSE To report the 5-year results of a technique of prone breast radiation therapy delivered by a regimen of accelerated intensity modulated radiation therapy with a concurrent boost to the tumor bed. METHODS AND MATERIALS Between 2003 and 2006, 404 patients with stage I-II breast cancer were prospectively enrolled into 2 consecutive protocols, institutional trials 03-30 and 05-181, that used the same regimen of 40.5 Gy/15 fractions delivered to the index breast over 3 weeks, with a concomitant daily boost to the tumor bed of 0.5 Gy (total dose 48 Gy). All patients were treated after segmental mastectomy and had negative margins and nodal assessment. Patients were set up prone: only if lung or heart volumes were in the field was a supine setup attempted and chosen if found to better spare these organs. RESULTS Ninety-two percent of patients were treated prone, 8% supine. Seventy-two percent had stage I, 28% stage II invasive breast cancer. In-field lung volume ranged from 0 to 228.27 cm(3), mean 19.65 cm(3). In-field heart volume for left breast cancer patients ranged from 0 to 21.24 cm(3), mean 1.59 cm(3). There was no heart in the field for right breast cancer patients. At a median follow-up of 5 years, the 5-year cumulative incidence of isolated ipsilateral breast tumor recurrence was 0.82% (95% confidence interval [CI] 0.65%-1.04%). The 5-year cumulative incidence of regional recurrence was 0.53% (95% CI 0.41%-0.69%), and the 5-year overall cumulative death rate was 1.28% (95% CI 0.48%-3.38%). Eighty-two percent (95% CI 77%-85%) of patients judged their final cosmetic result as excellent/good. CONCLUSIONS Prone accelerated intensity modulated radiation therapy with a concomitant boost results in excellent local control and optimal sparing of heart and lung, with good cosmesis. Radiation Therapy Oncology Group protocol 1005, a phase 3, multi-institutional, randomized trial is ongoing and is evaluating the equivalence of a similar dose and fractionation approach to standard 6-week radiation therapy with a sequential boost.
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MESH Headings
- Breast/radiation effects
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/radiotherapy
- Carcinoma, Lobular/surgery
- Dose Fractionation, Radiation
- Feasibility Studies
- Female
- Follow-Up Studies
- Humans
- Lung/radiation effects
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Staging
- Neoplasms, Second Primary/pathology
- Organs at Risk/radiation effects
- Patient Positioning/methods
- Prone Position
- Prospective Studies
- Radiation Injuries/prevention & control
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy, Intensity-Modulated/adverse effects
- Radiotherapy, Intensity-Modulated/methods
- Time Factors
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Affiliation(s)
- Etin-Osa O Osa
- Department of Radiation Oncology, New York University School of Medicine, New York, New York
| | - Keith DeWyngaert
- Department of Radiation Oncology, New York University School of Medicine, New York, New York
| | - Daniel Roses
- Department of Surgery, New York University School of Medicine, New York, New York
| | - James Speyer
- Department of Medical Oncology, New York University School of Medicine, New York, New York
| | - Amber Guth
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Deborah Axelrod
- Department of Surgery, New York University School of Medicine, New York, New York
| | - Maria Fenton Kerimian
- Department of Radiation Oncology, New York University School of Medicine, New York, New York
| | - Judith D Goldberg
- Department of Population Health, New York University School of Medicine, New York, New York
| | - Silvia C Formenti
- Department of Radiation Oncology, New York University School of Medicine, New York, New York.
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Brenner DJ. Advances in the use of radiotherapy to reduce second breast cancers. BREAST CANCER MANAGEMENT 2014. [DOI: 10.2217/bmt.14.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
David Brenner* speaks to Ruth Williamson, Commissioning Editor of Breast Cancer Management: David Brenner focuses on developing mechanistic models for the effects of ionizing radiation on living systems, dividing his research between the effects of high doses of ionizing radiation (relating to radiation therapy) and the effects of low doses of radiation (relating to medical, environmental and occupational exposures). In the field of medical imaging, he has focused on the risk–benefit balance of higher-dose imaging techniques; and in the field of radiotherapy, he has focused on optimizing fractionation schemes for different tumor types, to maximize tumor killing and minimize serious side effects. As well as being Director of the Center for Radiological Research (Columbia University, CO, USA), Brenner is the Director of the Radiological Research Accelerator Facility (Columbia University) and principal investigator of the Center for High-Throughput Minimally-Invasive Radiation Biodosimetry (Columbia University).
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Williams NR, Pigott KH, Brew-Graves C, Keshtgar MRS. Intraoperative radiotherapy for breast cancer. Gland Surg 2014; 3:109-19. [PMID: 25083504 PMCID: PMC4115764 DOI: 10.3978/j.issn.2227-684x.2014.03.03] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/19/2014] [Indexed: 12/19/2022]
Abstract
Intra-operative radiotherapy (IORT) as a treatment for breast cancer is a relatively new technique that is designed to be a replacement for whole breast external beam radiotherapy (EBRT) in selected women suitable for breast-conserving therapy. This article reviews twelve reasons for the use of the technique, with a particular emphasis on targeted intra-operative radiotherapy (TARGIT) which uses X-rays generated from a portable device within the operating theatre immediately after the breast tumour (and surrounding margin of healthy tissue) has been removed. The delivery of a single fraction of radiotherapy directly to the tumour bed at the time of surgery, with the capability of adding EBRT at a later date if required (risk-adaptive technique) is discussed in light of recent results from a large multinational randomised controlled trial comparing TARGIT with EBRT. The technique avoids irradiation of normal tissues such as skin, heart, lungs, ribs and spine, and has been shown to improve cosmetic outcome when compared with EBRT. Beneficial aspects to both institutional and societal economics are discussed, together with evidence demonstrating excellent patient satisfaction and quality of life. There is a discussion of the published evidence regarding the use of IORT twice in the same breast (for new primary cancers) and in patients who would never be considered for EBRT because of their special circumstances (such as the frail, the elderly, or those with collagen vascular disease). Finally, there is a discussion of the role of the TARGIT Academy in developing and sustaining high standards in the use of the technique.
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Incidental dose to coronary arteries is higher in prone than in supine whole breast irradiation. Strahlenther Onkol 2014; 190:563-8. [DOI: 10.1007/s00066-014-0606-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 12/09/2013] [Indexed: 10/25/2022]
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