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Berger L, Grimm A, Sütterlin M, Spaich S, Sperk E, Tuschy B, Berlit S. Major complications after intraoperative radiotherapy with low-energy x-rays in early breast cancer. Strahlenther Onkol 2024; 200:276-286. [PMID: 37591980 DOI: 10.1007/s00066-023-02128-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/23/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE To describe and analyze major local complications after intraoperative radiotherapy (IORT) with low-energy x‑rays during breast-conserving surgery (BCS) in early breast cancer. METHODS Ten women out of 408 who were treated with IORT between 2002 and 2017 and subsequently developed a severe local complication requiring surgical intervention were retrospectively identified and analyzed. Demographic, clinical, and surgical parameters as well as complication characteristics and treatment methods were evaluated. RESULTS At initial presentation, eight patients (80%) showed redness, six (60%) seroma, six (60%) wound infection, six (60%) suture dehiscence, and four (40%) induration of the former surgical area. Hematoma and necrosis were observed in one case (10%) each. Time interval until appearance of the first symptoms ranged from directly postoperative until 15 years postoperatively (median 3.1 months). Initial treatment modalities comprised antibiotic therapy (n = 8/80%) and transcutaneous aspiration of seroma (n = 3/30%). In the majority of patients, smaller surgical interventions (excision of a necrotic area/fistula [n = 6/60%] or secondary suture [n = 5/50%]) were sufficient to overcome the complication, yet larger interventions such as complex flap surgery and mastectomy were necessary in one patient each. CONCLUSION IORT is an efficient and safe treatment method as < 2.5% of all IORT patients experienced major local complications. However, it seems to pose the risk of causing severe local complications that may require lengthy and burdensome treatment. Thorough preoperative counseling, implementation of recommended intraoperative precautions, and high vigilance for first symptoms of complications during follow-up appointments are necessary measures.
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Affiliation(s)
- Laura Berger
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Anja Grimm
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Marc Sütterlin
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Saskia Spaich
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Benjamin Tuschy
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Sebastian Berlit
- Department of Obstetrics and Gynecology, University Medical Center Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Yang G, Kim JW, Lee IJ, Jeong J, Ahn SG, Bae SJ, Kim JH, Cho Y. Feasibility of Intraoperative Radiotherapy Tumor Bed Boost in Patients with Breast Cancer after Neoadjuvant Chemotherapy. Yonsei Med J 2024; 65:129-136. [PMID: 38373832 PMCID: PMC10896667 DOI: 10.3349/ymj.2023.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 02/21/2024] Open
Abstract
PURPOSE This study aimed to assess the feasibility and safety of administering intraoperative radiotherapy (IORT) as a boost during breast-conserving surgery (BCS) following neoadjuvant chemotherapy for patients at high risk of breast cancer recurrence. MATERIALS AND METHODS Patients who underwent neoadjuvant chemotherapy received a single 20-Gy dose of IORT during BCS, followed by external beam radiotherapy 4-6 weeks after surgery. RESULTS The median follow-up duration was 31.0 months (range, 18.0-59.0 months). Initial tumor sizes had a median of 2.6 cm (range: 0.8-5.3 cm), reducing to 0.3 cm (range: 0-4.0 cm) after neoadjuvant chemotherapy. The most common neoadjuvant chemotherapy regimen was doxorubicin and cyclophosphamide, followed by paclitaxel (n=42, 73.7%). Among 57 patients who received neoadjuvant chemotherapy before BCS and IORT, 2 patients (3.5%) required secondary surgery to achieve negative resection margins due to initially positive margins. Regional lymph node irradiation was performed in 37 (64.9%) patients. There was no grade 3 or higher adverse events, with 4 patients (7.0%) experiencing grade 2 acute radiation dermatitis and 3 (5.3%) having less than grade 2 breast edema. Binary correlation analysis did not reveal statistically significant associations between applicator size or radiation therapy modality and the risk of treatment-related toxicity. Furthermore, chi-square analysis showed that the grade of treatment-related toxicity was not associated with the fractionated regimen (p=0.375). CONCLUSION Most patients successfully received IORT as a tumor bed boost after neoadjuvant chemotherapy. Thus, IORT may be a safe and feasible option for patients with advanced-stage breast cancer receiving neoadjuvant chemotherapy.
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Affiliation(s)
- Gowoon Yang
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Yonsei Cancer Center, Heavy Ion Therapy Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Hung Kim
- Division of Medical Oncology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeona Cho
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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He J, Chen S, Ye L, Sun Y, Dai Y, Song X, Lin X, Xu R. Intraoperative Radiotherapy as a Tumour-Bed Boost Combined with Whole Breast Irradiation Versus Conventional Radiotherapy in Patients with Early-Stage Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg Oncol 2023; 30:8436-8452. [PMID: 37507556 PMCID: PMC10625949 DOI: 10.1245/s10434-023-13955-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND There is no definitive answer regarding the efficacy of intraoperative radiotherapy (IORT) as a tumour bed boost for patients with early-stage breast cancer. The purpose of this meta-analysis was to summarise the available evidence and explore the efficacy and safety of IORT combined with whole breast irradiation (WBI) versus conventional radiotherapy in women with early-stage breast cancer who underwent breast-conserving surgery. METHODS The PUBMED, MEDLINE, EMBASE, Web of Science, and Cochrane Library databases were searched from inception to December 31, 2022. We collected studies on the efficacy, cosmetic outcome, and safety of IORT boost combined with WBI compared with those of conventional radiotherapy in patients with early-stage breast cancer after breast-conserving surgery. Two authors independently performed the literature selection and data extraction. The quality of the randomised, controlled trials (RCTs) was assessed according to the PEDro scale. The quality of non-RCTs was assessed according to the Methodological Index for Non-Randomised Studies. Risk ratios (RRs) for the local recurrence rate (LRR), distant metastasis rate (DMR), disease-free survival (DFS), cosmetic outcome, and toxicity were pooled using fixed or random effects models. Meta-analysis of the included studies was performed by using RevMan 5.3 software. RESULTS Nine studies, including one RCT and eight non-RCTs, with a total of 3219 patients were included. In terms of LRR, there was no significant benefit of IORT boost+WBI over conventional radiotherapy (with or without the tumour bed boost) (RR = 0.77, 95% confidence interval (CI): 0.54-1.09, P = 0.14), but a trend towards benefit could be identified. There was a significant reduction in DMR in the IORT boost+WBI group (RR = 0.63, 95% CI: 0.46-0.85, P = 0.003) and a significant improvement in DFS (RR = 0.40, 95% CI: 0.25-0.65, P = 0.0002). Exploratory subgroup analysis showed that the DMR and DFS of the electron boost group were significantly better than those of conventional radiotherapy group, and there was a tendency for LRR to improve in the electron boost group. However, the LRR, DMR, and DFS did not effectively improve in the x-ray boost group. In terms of appearance and toxicity, there were no significant differences in cosmetic outcome, fibrosis, and hyperpigmentation between the two groups (RR = 0.99, 95% CI: 0.91-1.07, P = 0.78; RR = 1.02, 95% CI: 0.41-2.56, P = 0.96; RR = 0.42, 95% CI: 0.10-1.72, P = 0.23), but the incidence of oedema was significantly reduced in the IORT boost+WBI group (RR = 0.27, 95% CI: 0.13-0.59, P = 0.0009). CONCLUSIONS IORT boost+WBI is more effective than conventional radiotherapy after breast-conserving surgery in patients with early-stage breast cancer, and electron boost exhibits better efficacy than x-ray boost. In addition, the cosmetic and safety profiles of IORT boost+WBI are not inferior to those of conventional radiotherapy.
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Affiliation(s)
- Jiafa He
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Shengying Chen
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Lingling Ye
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Yang Sun
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Yan Dai
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Xue Song
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Xiaojie Lin
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China
| | - Rui Xu
- Breast Department, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, Guangdong, China.
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Hochhertz F, Hass P, Röllich B, Ochel HJ, Gawish A. A single-institution retrospective analysis of intraoperative radiation boost during breast-conservation treatment for breast cancer. J Cancer Res Clin Oncol 2023; 149:5743-5749. [PMID: 36566484 PMCID: PMC10356640 DOI: 10.1007/s00432-022-04534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND As part of a breast-conservation strategy for breast cancer, there are presently no data from randomized controlled studies on the use of intraoperative radiation (IORT) as a tumor bed boost. The effectiveness and safety of IORT as a boost therapy at a tertiary cancer center were retrospectively reviewed in this study. METHODS Patients had breast-conserving surgery from 2012 to 2016 that included staging of the axillary lymph nodes, a single dose of 20 Gy IORT with 50-kV photons, whole-breast irradiation (WBI), and (neo-)adjuvant systemic treatment (if applicable). During the follow-up patients were monitored for the assessment of acute and late toxicities (using the Common Terminology Criteria for Adverse Events version 4.03). Results included ipsilateral (IBTR), contralateral (CBE), and distant metastasis-free (DMFS) breast progression-free survival, as well as overall survival (OS). RESULTS The 68 patients had a median follow-up of 91.5 months (with a range of 9-125). Most patients (n = 51) had T1 disease and were clinically node negative. Only a small number of individuals had triple negative or high-grade illness. The majority of patients had sentinel node biopsy, and three (4.4%) had to have their tumors removed again since their original margins were positive. Finally, there were no distinct tumor bed margins. Neoadjuvant chemotherapy was administered to ten (14.7%). The median duration from BCS to WBI was 54.5 days, and conventionally fractionated WBI was used to accomplish WBI most frequently (n = 57, 96.6%). IORT was administered in a single 20 Gy dosage. 50 Gy was the median WBI dosage (range 40.05-50.4 Gy). There were no grade 4 adverse events for any patients in. Toxicities following surgery were minimal. There were only one patient with grade 3 toxicity (radiation dermatitis) to observe. Five tumor bed recurrences and two contralateral breast incident each occurred. CONCLUSION This work adds to the preliminary evidence already in the literature and supports the use of IORT in boost settings. When randomized trials like TARGIT-B are eventually published, these hopeful findings should be prospectively evaluated.
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Affiliation(s)
- Franka Hochhertz
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Peter Hass
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
- Department of Radiation Oncology, Erfurt Helios Hospital, Erfurt, Germany
| | - Burkard Röllich
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Hans-Joachim Ochel
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Ahmed Gawish
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
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Fan Y, Chen R, Lu Y, Lin Y, Zhang Y, Shao N, Wang S, Nie D, Shan Z. The Efficacy of Low-Kilovoltage X-Rays Intraoperative Radiation as Boost for Breast Cancer: A Systematic Review and Meta-Analysis. Breast J 2023; 2023:9035266. [PMID: 37435101 PMCID: PMC10332922 DOI: 10.1155/2023/9035266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/05/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Background Intraoperative radiotherapy (IORT) is a novel promising technology that may replace external beam radiation therapy (EBRT) as boost for patients receiving breast-conserving surgery. To better evaluate the efficacy of IORT using low-kilovoltage (low-kV) X-rays as boost, we presented this meta-analysis according to the PRISMA checklist. Methods Studies reported survival outcomes of intraoperative radiation using low-kilovoltage X-rays system (Intrabeam®, Carl Zeiss Meditec, Dublin, CA, USA) as boost were identified through electronic bibliographic database: PUBMED. The meta-analysis module in Stata (16.0) is used to pool the studies. A Poisson regression model is used to predict a 5-year local recurrence rate. Results Twelve studies including 3006 cases were included in the final analysis, with a median follow-up of 55 months weighted by sample size. The pooled local recurrence rate is 0.39% per person-year (95% CI: 0.15%-0.71%), with a low degree of heterogeneity (I2 = 0%). The predicted 5-year local recurrence rate was 3.45%. No difference in pooled local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies (0.41% per person-year vs. 0.58% per person-year, P = 0.580). Conclusions This study shows that low-kV IORT is an effective method as boost in breast cancer patients, with a low pooled local recurrence rate and low predicted 5-year local recurrence rate. Besides, no difference in the local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies. Low-kV IORT boost may be a promising alternative to EBRT boost in the future, which is being tested in the ongoing TARGIT-B trial.
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Affiliation(s)
- Yuanjian Fan
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ruiwan Chen
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Lu
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Lin
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yunjian Zhang
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Nan Shao
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shenming Wang
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dahong Nie
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhen Shan
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Stoian R, Exner JPH, Gainey M, Erbes T, Gkika E, Popp I, Spohn SKB, Krug D, Juhasz-Böss I, Grosu AL, Sprave T. Comparison of intraoperative radiotherapy as a boost vs. simultaneously integrated boosts after breast-conserving therapy for breast cancer. Front Oncol 2023; 13:1210879. [PMID: 37409247 PMCID: PMC10318399 DOI: 10.3389/fonc.2023.1210879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/30/2023] [Indexed: 07/07/2023] Open
Abstract
Background Currently, there are no data from randomized trials on the use of intraoperative radiotherapy (IORT) as a tumor bed boost in women at high risk of local recurrence. The aim of this retrospective analysis was to compare the toxicity and oncological outcome of IORT or simultaneous integrated boost (SIB) with conventional external beam radiotherapy (WBI) after breast conserving surgery (BCS). Methods Between 2009 and 2019, patients were treated with a single dose of 20 Gy IORT with 50 kV photons, followed by WBI 50 Gy in 25 or 40.05 in 15 fractions or WBI 50 Gy with SIB up to 58.80-61.60 Gy in 25-28 fractions. Toxicity was compared after propensity score matching. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. Results A 1:1 propensity-score matching resulted in an IORT + WBI and SIB + WBI cohort of 60 patients, respectively. The median follow-up for IORT + WBI was 43.5 vs. 32 months in the SIB + WBI cohort. Most women had a pT1c tumor: IORT group 33 (55%) vs. 31 (51.7%) SIB group (p = 0.972). The luminal-B immunophenotype was most frequently diagnosed in the IORT group 43 (71.6%) vs. 35 (58.3%) in the SIB group (p = 0.283). The most reported acute adverse event in both groups was radiodermatitis. In the IORT cohort, radiodermatitis was grade 1: 23 (38.3%), grade 2: 26 (43.3%), and grade 3: 6 (10%) vs. SIB cohort grade 1: 3 (5.1%), grade 2: 21 (35%), and grade 3: 7 (11.6%) without a meaningful difference (p = 0.309). Fatigue occurred more frequently in the IORT group (grade 1: 21.7% vs. 6.7%; p = 0.041). In addition, intramammary lymphedema grade 1 occurred significantly more often in the IORT group (11.7% vs. 1.7%; p = 0.026). Both groups showed comparable late toxicity. The 3- and 5-year local control (LC) rates were each 98% in the SIB group vs. 98% and 93% in the IORT group (LS: log rank p = 0.717). Conclusion Tumor bed boost using IORT and SIB techniques after BCS shows excellent local control and comparable late toxicity, while IORT application exhibits a moderate increase in acute toxicity. These data should be validated by the expected publication of the prospective randomized TARGIT-B study.
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Affiliation(s)
- Raluca Stoian
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Philipp Harald Exner
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mark Gainey
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thalia Erbes
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ilinca Popp
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Simon K. B. Spohn
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str., Kiel, Germany
| | - Ingolf Juhasz-Böss
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld, Heidelberg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Günay S, Gökçek B, Kandemir Ö, Akan A, Yalçın O. Long-term results of breast cancer patients who received IOERT as boost during BCS: A single-institution retrospective analysis. Turk J Surg 2023; 39:115-120. [PMID: 38026906 PMCID: PMC10681109 DOI: 10.47717/turkjsurg.2023.5978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/23/2023] [Indexed: 12/01/2023]
Abstract
Objectives Intraoperative electron radiotherapy (IOERT) applied as boost to the tumor bed during breast conserving surgery is advantageous in terms of local recurrence in breast cancer patients. In addition, it has other advantages over the adjuvant boost RT such as no risk of tumor bed change, ease of sequencing radiotherapy chemotherapy, and reduced workload of the radiotherapy clinic. This study aimed to evaluate the long-term results of our patients who were treated with this method in our institution and are still being followed up. Material and Methods One hundred and three patients enrolled in this study received IOERT equivalent to 10 Gy as boost during BCS and were subsequently given adjuvant WBI according to the biological subtype of the tumor systemic therapy. These patients were analyzed using their files and hospital records. Patients were evaluated for overall survival, local recurrence, distant metastasis, and cosmetic outcome (using LENT-SOMA scale). Results Median age was 53,5 (27-74), mean follow-up time was 75 (48-106) months. Mean pathological tumor size was 18 mm (4-30), 90 of the patients had invasive ductal carcinoma, eight of them were lobular and five of them had mixed histological structure. Ninety-three of the patients presented histological grade II, 15 grade III; 74 patients were luminal A-like, 15 luminal B-like, eight HER2 positive and six triple negative breast cancer. According to the LENT-SOMA scale, 35 had grade 0, 42 each had grade I, 23 had grade II, and two had grade III. All patients underwent whole breast irradiation after surgery, 81 received chemotherapy and 90 endocrine therapy. There was one local recurrence, distant recurrence was seen in four patients and one patient died of non-breast cancer causes. Overall survival was %99, and event free survival %96. Conclusion IOERT for breast cancer treatment during BCS is a safe option with low chronic toxicity and the cosmetic outcome gets better over time.
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Affiliation(s)
- Semra Günay
- Clinic of Breast and Endocrine Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Berk Gökçek
- Clinic of General Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Özge Kandemir
- Clinic of Radiation Oncology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Arzu Akan
- Clinic of Breast and Endocrine Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Orhan Yalçın
- Clinic of Breast and Endocrine Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
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Wolf J, Stoller S, Lübke J, Rothe T, Serpa M, Scholber J, Zamboglou C, Gkika E, Baltas D, Juhasz-Böss I, Verma V, Krug D, Grosu AL, Nicolay NH, Sprave T. Deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a single-institution retrospective dosimetric analysis of organs at risk doses. Strahlenther Onkol 2023; 199:379-388. [PMID: 36074138 PMCID: PMC10033469 DOI: 10.1007/s00066-022-01998-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 08/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Radiotherapy can induce cardiac injury in left-sided breast cancer cases. Cardiac-sparing irradiation using the deep inspiration breath-hold (DIBH) technique can achieve substantial dose reduction to vulnerable cardiac substructures compared with free breathing (FB). This study evaluated the dosimetric differences between both techniques at a single institution. METHODS From 2017 to 2019, 130 patients with left-sided breast cancer underwent breast-conserving surgery (BCS; n = 121, 93.1%) or mastectomy (ME; n = 9, 6.9%) along with axillary lymph node staging (n = 105, 80.8%), followed by adjuvant irradiation in DIBH technique; adjuvant systemic therapy was included if applicable. 106 (81.5%) patients received conventional and 24 (18.5%) hypofractionated irradiation. Additionally, 12 patients received regional nodal irradiation. Computed tomography (CT) scans in FB and DIBH position were performed for all patients. Intrafractional 3D position monitoring of the patient surface in deep inspiration and breath gating was performed using Sentinel and Catalyst HD 3D surface scanning systems (C-RAD, Catalyst, C‑RAD AB, Uppsala, Sweden). Individual coaching and determination of breathing amplitude during the radiation planning CT was performed. Three-dimensional treatment planning was performed using standard tangential treatment portals (6 or 18 MV). The delineation of cardiac structures and both lungs was done in both the FB and the DIBH scan. RESULTS All dosimetric parameters for cardiac structures were significantly reduced (p < 0.01 for all). The mean heart dose (Dmean) in the DIBH group was 1.3 Gy (range 0.5-3.6) vs. 2.2 Gy (range 0.9-8.8) in the FB group (p < 0.001). The Dmean for the left ventricle (LV) in DIBH was 1.5 Gy (range 0.6-4.5), as compared to 2.8 Gy (1.1-9.5) with FB (p < 0.001). The parameters for LV (V10 Gy, V15 Gy, V20 Gy, V23 Gy, V25 Gy, V30 Gy) were reduced by about 100% (p < 0.001). The LAD Dmean in the DIBH group was 4.1 Gy (range 1.2-33.3) and 14.3 Gy (range 2.4-37.5) in the FB group (p < 0.001). The median values for LAD such as V15 Gy, V20 Gy, V25 Gy, V30 Gy, and V40 Gy decreased by roughly 100% (p < 0.001). An increasing volume of left lung in the DIBH position resulted in dose sparing of cardiac structures. CONCLUSION For all ascertained dosimetric parameters, a significant dose reduction could be achieved in DIBH technique.
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Affiliation(s)
- Jule Wolf
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Sabine Stoller
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jördis Lübke
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thomas Rothe
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Marco Serpa
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jutta Scholber
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Constantinos Zamboglou
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
- Department of Molecular and Radiation Oncology, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Str. 3, 79106, Freiburg, Germany.
- German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (dkfz), Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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9
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Cell-In-Cell Structures in Early Breast Cancer Are Prognostically Valuable. Cells 2022; 12:cells12010081. [PMID: 36611874 PMCID: PMC9818278 DOI: 10.3390/cells12010081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/15/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Cell-in-cell (CIC) structures in breast cancer have so far been studied in a small inhomogeneous patient population, suggesting the prognostic importance of CIC. In the present study, we focused on CIC in early hormone-sensitive breast cancer. With in vitro co-culture experiments, we compared the homotypic phagocytic capacity of two breast cancer cell lines to that of primary human fibroblasts. Afterward, we studied 601 tissue specimens from 147 patients participating in an institutional accelerated partial breast irradiation (APBI) phase II trial. Both breast cancer cell lines performed non-professional phagocytosis at a higher rate than primary human fibroblasts. In this study cohort, 93.2% of the patients had T1 tumours, and 6.8% had T2 tumours. CIC was found in 61.2% of the patients, with a CIC rate ranging from <1/mm2 to 556.5/mm2 with a mean of 30.9/mm2 ± 68.4/mm2. CIC structures were prognostically favourable for local recurrence-free survival and disease-free survival. Regarding metastasis-free survival, CIC-positive patients had an unfavourable prognosis. Subgroup analysis indicated a correlation between a high proliferation index and high CIC rates. CIC had the highest prognostic value in young breast cancer patients (p = 0.004). With this study, we provide further evidence of CIC as a prognostic marker in breast cancer.
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10
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Wolf J, Kurz S, Rothe T, Serpa M, Scholber J, Erbes T, Gkika E, Baltas D, Verma V, Krug D, Juhasz-Böss I, Grosu AL, Nicolay NH, Sprave T. Incidental irradiation of the regional lymph nodes during deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a dosimetric analysis. BMC Cancer 2022; 22:682. [PMID: 35729505 PMCID: PMC9210647 DOI: 10.1186/s12885-022-09784-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022] Open
Abstract
Background Radiotherapy using the deep inspiration breath-hold (DIBH) technique compared with free breathing (FB) can achieve substantial reduction of heart and lung doses in left-sided breast cancer cases. The anatomical organ movement in deep inspiration also cause unintended exposure of locoregional lymph nodes to the irradiation field. Methods From 2017–2020, 148 patients with left-sided breast cancer underwent breast conserving surgery (BCS) or mastectomy (ME) with axillary lymph node staging, followed by adjuvant irradiation in DIBH technique. Neoadjuvant or adjuvant systemic therapy was administered depending on hormone receptor and HER2-status. CT scans in FB and DIBH position with individual coaching and determination of the breathing amplitude during the radiation planning CT were performed for all patients. Intrafractional 3D position monitoring of the patient surface in deep inspiration and gating was performed using Sentinel and Catalyst HD 3D surface scanning systems (C-RAD, Catalyst, C-RAD AB, Uppsala, Sweden). Three-dimensional treatment planning was performed using standard tangential treatment portals (6 or 18 MV). The delineation of ipsilateral locoregional lymph nodes was done on the FB and the DIBH CT-scan according to the RTOG recommendations. Results The mean doses (Dmean) in axillary lymph node (AL) level I, II and III in DIBH were 32.28 Gy (range 2.87–51.7), 20.1 Gy (range 0.44–53.84) and 3.84 Gy (range 0.25–39.23) vs. 34.93 Gy (range 10.52–50.40), 16.40 Gy (range 0.38–52.40) and 3.06 Gy (range 0.21–40.48) in FB (p < 0.0001). Accordingly, in DIBH the Dmean for AL level I were reduced by 7.59%, whereas for AL level II and III increased by 22.56% and 25.49%, respectively. The Dmean for the supraclavicular lymph nodes (SC) in DIBH was 0.82 Gy (range 0.23–4.11), as compared to 0.84 Gy (range 0.22–10.80) with FB (p = 0.002). This results in a mean dose reduction of 2.38% in DIBH. The Dmean for internal mammary lymph nodes (IM) was 12.77 Gy (range 1.45–39.09) in DIBH vs. 11.17 Gy (range 1.34–44.24) in FB (p = 0.005). This yields a mean dose increase of 14.32% in DIBH. Conclusions The DIBH technique may result in changes in the incidental dose exposure of regional lymph node areas.
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Affiliation(s)
- Jule Wolf
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Steffen Kurz
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thomas Rothe
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Marco Serpa
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jutta Scholber
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thalia Erbes
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Molecular and Radiation Oncology, German Cancer Research Center (Dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany. .,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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11
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Sarria GR, Ramos ML, Palacios A, Del Castillo R, Castro F, Calvo A, Cotrina JM, Heredia A, Galarreta JA, Fuentes-Rivera P, Avalos A, Martinez DA, Colqui K, Ziegler G, Schmeel LC, Pinillos LV, Wenz F, Giordano FA, Sarria GJ, Sperk E. Long-Term Outcomes of an International Cooperative Study of Intraoperative Radiotherapy Upfront Boost With Low Energy X-Rays in Breast Cancer. Front Oncol 2022; 12:850351. [PMID: 35371998 PMCID: PMC8968081 DOI: 10.3389/fonc.2022.850351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose The purpose of this study was to assess the effectivity of upfront kilovoltage intraoperative radiotherapy (IORT) as a boost in high-risk early-stage breast cancer patients from an international pooled cohort. Materials/Methods Patients from four centers in three different countries were retrospectively screened. Those with a minimum 1-year follow-up were included. Cumulative local (LR), regional (RR), and distant metastasis rates (DM) were analyzed. Additionally, the estimated overall survival (OS) was assessed. The Cox regression analysis was performed to identify failure predicting factors. Results A total of 653 patients from centers in Peru, Spain, and Germany were included. The median follow-up was 55 (12–180) months, and age was 58 (27–86) years. Clinical tumor (T) staging was T1 65.85%, T2 30.17%, and T3 3.98%. Positive margins were found in 7.9% and in-situ component in 20.06%. The median IORT dose was 20 (6–20). The median time from IORT to EBRT was 74.5 (13-364) days. An overall 3.4% (n = 22) of patients developed local recurrence at some point during follow-up. The 12-, 60-, and 120-month cumulative LR were 0.3%, 2.3%, and 7.9%, respectively. After multivariate analysis, only age <50 remained to be a significant prognostic factor for local recurrence (HR 0.19, 95% CI 0.08–0.47; p < 0.05). The 10-year estimated OS was 81.2%. Conclusion Upfront boost with IORT yields similar local control outcomes to those EBRT-based reports. Results from prospective trials, regarding toxicity, cosmesis, and effectivity are awaited to confirm these findings.
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Affiliation(s)
- Gustavo R Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Maria L Ramos
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Amalia Palacios
- Department of Radiation Oncology, University Hospital Reina Sofia, Cordoba, Spain
| | | | - Felipe Castro
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angel Calvo
- Department of Radiation Oncology, University Hospital Reina Sofia, Cordoba, Spain
| | - Jose M Cotrina
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Adela Heredia
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jose A Galarreta
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Paola Fuentes-Rivera
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Alicia Avalos
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | - Kevin Colqui
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Gonzalo Ziegler
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | - Luis V Pinillos
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Frederik Wenz
- University Hospital Freiburg, University of Freiburg, Freiburg, Germany
| | - Frank A Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Gustavo J Sarria
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru.,Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Elena Sperk
- Department of Radiation Oncology, Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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