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Wei TN, Yeh HL, Lin JF, Hung CC. The clinical outcome of postoperative radiotherapy using hybrid planning technique in left breast cancer after breast-conserving surgery. Cancer Med 2023; 12:5364-5371. [PMID: 36250354 PMCID: PMC10028103 DOI: 10.1002/cam4.5358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 09/18/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study is to observe the preliminary clinical outcome and acute toxicity of hybrid intensity modulated radiotherapy and volumetric modulated arc therapy planning technique with simultaneous integrated boost (SIB). METHODS From November 2015 to December 2018, 149 female patients with left-side breast cancer who underwent adjuvant radiotherapy with hybrid IMRT and VMAT planning technique with SIB were reviewed retrospectively. The primary endpoint was acute toxicities and the secondary endpoints were local recurrence-free survival (LRFS), distant metastasis-freesurvival (DMFS), disease-free survival (DFS), and overall survival (OS). RESULTS The median age was 52 years old and median follow-up was 43.4 months. Eighty-six percent of patients had acute grade 0 to grade1 dermatitis and 14% had grade 2 dermatitis. No acute radiation pneumonitis, esophagitis, or cardiovascular events were recorded during follow-up. The 3-year LRFS, DMFS, DFS, and OS rates were 95.1%, 95.1%, 90.3%, and 97.9%, respectively. The subgroup analysis revealed that patients with lymphovascular invasion had more local recurrence rate and worse DFS rate. Patients with advanced N stage had the trend of worse DMFS. CONCLUSION In conclusion, the hybrid IMRT and VMAT technique is feasible, safe and has less acute radiation related toxicities in SIB postoperative radiotherapy for left-sided breast cancer.
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Affiliation(s)
- Ting-Na Wei
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hui-Ling Yeh
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jia-Fu Lin
- Department of Radiation Physics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chih-Chiang Hung
- Department of Breast Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
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Zhang J, Sum SY, Hsu JG, Chiang MF, Lee TS, Wu SY. Adjuvant postmastectomy radiotherapy might be associated with better survival in women with heart failure receiving total mastectomy. Radiat Oncol 2022; 17:33. [PMID: 35151355 PMCID: PMC8840783 DOI: 10.1186/s13014-022-02000-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background To date, no data on the effect of adjuvant postmastectomy radiotherapy (PMRT) on oncologic outcomes, such as all-cause death, locoregional recurrence (LRR), and distant metastasis (DM), are available in women with left-side breast invasive ductal carcinoma (IDC) and heart failure with reduced ejection fraction (HFrEF).
Patients and methods We enrolled 646 women with left-breast IDC at clinical stages I–IIIC and HFrEF receiving radical total mastectomy (TM) followed by adjuvant PMRT or non-adjuvant PMRT. We categorized them into two groups based on their adjuvant PMRT status and compared their overall survival (OS), LRR, and DM outcomes. We calculated the propensity score and applied inverse probability of treatment weighting (IPTW) to create a pseudo-study cohort. Furthermore, we performed a multivariate analysis of the propensity score–weighted population to obtain hazard ratios (HRs).
Results In the IPTW-adjusted model, adjuvant PMRT (adjusted HR [aHR]: 0.52; 95% confidence interval [CI]: 0.37–0.74) was a significant independent prognostic factor for all-cause death (P = 0.0003), and the aHR (95% CI) of LRR and DM for adjuvant PMRT was 0.90 (0.79–0.96; P = 0.0356) and 0.89 (0.54–1.50; P = 0.6854), respectively, compared with the nonadjuvant PMRT group. Conclusion Adjuvant PMRT was associated with a decrease in all-cause death, and LRR in women with left IDC and HFrEF compared with nonadjuvant PMRT.
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Lai YH, Chen HHW, Tsai YS. Accelerated coronary calcium burden in breast cancer patients after radiotherapy: a comparison with age and race matched healthy women. Radiat Oncol 2021; 16:210. [PMID: 34727957 PMCID: PMC8561949 DOI: 10.1186/s13014-021-01936-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/20/2021] [Indexed: 12/25/2022] Open
Abstract
Background Radiotherapy (RT) might lead to atherosclerotic plaque buildup and coronary artery stenosis of breast cancer (BC) survivors, and coronary artery calcium (CAC) might be a sign of preclinical atherosclerosis. This study explores possible determinants affecting the acceleration of CAC burden in BC patients after adjuvant RT. Methods Female BC patients receiving adjuvant RT from 2002 to 2010 were included. All patients received noncontrast computed tomography (NCCT) of thorax before and after adjuvant RT. Their CAC burden was compared with healthy controls from the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. The progression of the CAC burden was manifested by the increment of CAC percentiles (%CACinc). Results Ninety-four patients, including both left- and right-side BC, were enrolled in this study. From undergoing the first to second NCCT, the %CACinc in BC patients significantly increased rather than non-BC women. In addition, the %CACinc was significantly higher in left-side than right-side BC patients (p < 0.05), and significant differences in most heart outcomes were found between the two groups. Besides, the lower the mean right coronary artery (RCA) dose, the lower the risks of CAC percentiles increase ≥ 50% after adjusting the disease's laterality. Conclusions A significantly higher accelerated CAC burden in BC patients than non-BC women represents that BC could affect accelerated CAC. A higher risk of accelerated CAC burden was found in left-side than right-side BC patients after adjuvant RT. A decrease of the mean RCA dose could reduce more than 50% of the risk of accelerated CAC burden in BC patients.
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Affiliation(s)
- Yu-Hsuan Lai
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Helen H W Chen
- Department of Radiation Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Oncology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Shan Tsai
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, No. 138 Sheng-Li Rd, Tainan, Taiwan.
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Two-year toxicity of simultaneous integrated boost in hypofractionated prone breast cancer irradiation: Comparison with sequential boost in a randomized trial. Radiother Oncol 2021; 158:62-66. [PMID: 33617910 DOI: 10.1016/j.radonc.2021.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/29/2021] [Accepted: 02/09/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A simultaneous integrated boost (SIB) leads to less acute toxicity. Less is known for late toxicity due to SIB. In this first and only randomized trial, two-years toxicity is analysed. MATERIALS AND METHODS Physician-assessed toxicity, using the LENT SOMA scale, and photographs, analysed with the BCCT.core software, was examined for 150 patients, randomized between SIB and sequential boost (SEB). RESULTS Differences in physician-assessed two-years toxicity and photographic analysis between SIB and SEB are very small and not significant. CONCLUSION There is no indication that a SIB leads to an excess in toxicity or worse cosmetic outcome at 2 years.
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5
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Dicuonzo S, Leonardi MC, Raimondi S, Corrao G, Bagnardi V, Gerardi MA, Morra A, Zerella MA, Zaffaroni M, Pansini F, Cattani F, Luraschi R, Fodor C, Veronesi P, Orecchia R, Rojas DP, Jereczek-Fossa BA. Acute and intermediate toxicity of 3-week radiotherapy with simultaneous integrated boost using TomoDirect: prospective series of 287 early breast cancer patients. Clin Transl Oncol 2021; 23:1415-1428. [PMID: 33537865 DOI: 10.1007/s12094-020-02538-w] [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: 08/27/2020] [Accepted: 11/27/2020] [Indexed: 11/26/2022]
Abstract
AIMS To report toxicity of a hypofractionated scheme of whole-breast (WB) intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to the tumor bed (TB) using Tomotherapy® with Direct modality. METHODS Patients with early breast cancer, undergoing radiotherapy (RT) in 15 daily fractions to WB (prescription dose 40.05 Gy) and SIB to the TB (48 Gy), between 2013 and 2017, was analyzed. Primary endpoint was acute and intermediate toxicity assessed at the end and within 6 months from RT, according to Radiation Therapy Oncology Group (RTOG) scale. Secondary endpoints included early chronic toxicity at 12-months follow-up, using the Late Effects Normal Tissue Task Subjective, Objective, Management, and Analytic (LENT-SOMA) scale, and cosmesis using Harvard criteria. RESULTS The study population was of 287 patients. Acute and intermediate toxicity was collected among 183 patients with data available at the end of RT and within 6 months, 85 (46%) experienced G2 toxicity and 84 (46%) G1 toxicity, while 14 (8%) did not report toxicity at any time. A significant reduction of any grade toxicity was observed between the two time points, with the majority of patients reporting no clinically relevant toxicity at 6 months. At univariate analysis, age < 40 years, breast volume > 1000 cm3 and Dmax ≤ 115% of prescription dose were predictive factors of clinically relevant acute toxicity (G ≥ 2) at any time. At multivariable analysis, only age and breast volume were confirmed as predictive factors, with Relative Risks (95% Confidence Intervals): 2.02 (1.13-3.63) and 1.84 (1.26-2.67), respectively. At 12-month follow-up, 113 patients had complete information on any toxicity with 53% of toxicity G < 2, while cosmetic evaluation, available for 102 patients, reported a good-excellent result for 86% of patients. CONCLUSIONS Hypofractionated WB IMRT with a SIB to the TB, delivered with TomoDirect modality, is safe and well-tolerated. Most patients reported no toxicity after 6 months and good-excellent cosmesis. Predictive factors of clinically relevant toxicity might be considered during treatment planning in order to further reduce side effects.
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Affiliation(s)
- S Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M C Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - S Raimondi
- Molecular and Pharmaco-Epidemiology Unit, Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - G Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - V Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - M A Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - A Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M A Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - F Pansini
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - F Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - R Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - C Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - P Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - R Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - D P Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - B A Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Van Hulle H, Vakaet V, Deckmyn K, Monten C, Paelinck L, Van Greveling A, Post G, Schoepen M, Fonteyne A, Speleers B, Deseyne P, Mareel M, De Neve W, Veldeman L. Two-year toxicity of hypofractionated breast cancer radiotherapy in five fractions. Acta Oncol 2020; 59:872-875. [PMID: 32285729 DOI: 10.1080/0284186x.2020.1747638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Hans Van Hulle
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Vincent Vakaet
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Kathleen Deckmyn
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Chris Monten
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Giselle Post
- 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
| | - Arthur Fonteyne
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Bruno Speleers
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Pieter Deseyne
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Marc Mareel
- Department of Human Structure and Repair, Ghent University, 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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Older age and comorbidity in breast cancer: is RT alone the new therapeutic frontier? J Cancer Res Clin Oncol 2020; 146:1791-1800. [PMID: 32405744 DOI: 10.1007/s00432-020-03243-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 05/01/2020] [Indexed: 10/24/2022]
Abstract
AIM To assess the impact of age, comorbidities and endocrine therapy (ET) in older breast cancer (BC) patients treated with hypofractionated radiotherapy (Hypo-RT). METHODS From June 2009 to December 2017, we enrolled in this study 735 ER-positive BC patients (stage pT1-T2, pNx-1, M0 and age ≥ 65 years) receiving hypo-RT and followed them until September 2019. Baseline comorbidities included in the hypertension-augmented Charlson Comorbidity Index were retrospectively retrieved. Logistic regression model estimated adjusted-odds ratios (ORs) of ET prescription in relation to baseline patient and tumor characteristics. Competing risk analysis estimated 5-year cumulative incidence function (CIF) of ET discontinuation due to side effects (with BC progression or death as competing events), and its effect on locoregional recurrence (LRR) and distant metastasis (DM) (with death as competing event). RESULTS ET has been prescribed in 89% patients. In multivariable analysis, the odds of ET prescription was significantly reduced in older patients (≥ 80 years, OR 0.08, 95% CI 0.03-0.20) and significantly increased in patients with moderate comorbidity. Patients ≥ 80 years discontinued the prescribed therapy earlier and more frequently than younger (65-69 years) patients (p = 0.060). Five-year CIF of LLR, DM and death from causes other that BC were 1.7%, 2.2% and 7.5%, respectively. Patients who discontinued ET had higher chance of LRR (p = 0.004). ET use did not impact on OS in any of the analyzed groups. CONCLUSIONS In older patients, ET did not show a benefit in terms of overall survival. Further studies focusing on tailored treatment approaches are warranted to offer the best care in terms of adjuvant treatment to these patients.
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8
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Feasibility and safety of 1.5 T MR-guided and daily adapted abdominal-pelvic SBRT for elderly cancer patients: geriatric assessment tools and preliminary patient-reported outcomes. J Cancer Res Clin Oncol 2020; 146:2379-2397. [PMID: 32372146 DOI: 10.1007/s00432-020-03230-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/18/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND We present preliminary data of the first older cancer patients treated with Hybrid Linac for stereotactic body radiotherapy (SBRT) consisting of 1.5 T MRI-guided and daily-adapted treatment. The aim was to assess feasibility, safety and the role of G8 and Charlson Comorbidity Index (CCI) questionnaires in predicting patients' QoL, evaluated by patient-reported outcome measures (PROMs). METHODS Two groups of patients with localized prostate cancer or abdominal-pelvic oligometastases were analyzed. SBRT schedule consisted of 35 Gy delivered in 5 fractions. The primary endpoint was to measure the impact of G8 and CCI on PROMs. Both G8 and the CCI were performed at baseline, while the EORTC Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) for PROMs assessment was prospectively performed at baseline and after SBRT. RESULTS Forty older patients were analyzed. The median age was 73 years (range 65-85). For the entire population, the median G8 score was 15 (10-17) and the median CCI score was 6 (4-11). Concerning the PROMS, the EORTC-QLQ C30 questionnaire reported no difference between the pre- and post-SBRT evaluation in all patients, except for the fatigue item that declined after SBRT, especially in the group of patients with a G8 score < 15 and with age < 75 years (p = 0.049). No grade 3 or higher acute toxicity occurred. CONCLUSION This is the first report documenting for older cancer patients that 1.5 T MRI-guided daily-adapted SBRT is feasible, safe and does not impact on the QoL at the end of treatment. Longer follow-up is advocated to report long-term outcomes. TRIAL REGISTRATION Date of approval April 2019 and numbered MRI/LINAC no. 23748.
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Adjuvant breast inversely planned intensity-modulated radiotherapy with simultaneous integrated boost for early stage breast cancer : Results from a phase II trial. Strahlenther Onkol 2020; 196:764-770. [PMID: 32318767 DOI: 10.1007/s00066-020-01611-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To report early toxicity and 5‑year clinical outcomes of adjuvant breast inversely planned intensity-modulated radiotherapy with simultaneously integrated boost (IMRT-SIB) after breast-conserving surgery for early stage breast cancer patients. PATIENTS AND METHODS In all, 467 patients including 406 invasive breast cancer and 61 ductal carcinoma in situ (DCIS) were enrolled in a single institutional phase II trial. All patients underwent IMRT-SIB treatment to irradiate the whole breast and the tumor bed. Doses to whole breast and surgical bed were 45 and 60 Gy, respectively, delivered in 25 fractions over 5 weeks. The grade of maximum acute skin toxicity during treatment was recorded. Lung toxicity was noted within 6 months and patient-reported cosmetic outcomes were recorded at the 12 month follow-up after the end of radiotherapy. Clinical outcomes were assessed during follow-up. RESULTS Median follow-up time was 5.46 years. Median age was 46 years old (range 22-70 years old). No patient with DCIS had a local recurrence or distant metastasis. Among 406 patients with invasive breast cancer, the unadjusted 5‑year actuarial rate of locoregional control was 98.7% (95% confidence interval [CI] 97.5-100), and distant metastasis-free survival 98.7% (95% CI 97.4-100), respectively. Acute skin toxicity was recorded at grade 0-1 in 76.5% of patients, and grade 2 in 23.5% of patients. None of these patients had grade 3 or more than grade 3 skin toxicity. Grade 1 pneumonitis was found in 25.3% of patients. Assessment of patient reported cosmetic outcomes at the 12 month follow-up showed good or excellent outcome in 86.5% of cases. CONCLUSIONS The use of inversely planned IMRT-SIB as part of breast-conserving therapy results in optimal 5‑year tumor control and minor early toxicities.
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Chen KW, Hsu HT, Lin JF, Yeh HL, Yeh DC, Lin CY, Chan S, Hsieh HY. Adjuvant whole breast radiotherapy with simultaneous integrated boost to tumor bed with intensity modulated radiotherapy technique in elderly breast cancer patients. Transl Cancer Res 2020; 9:S12-S22. [PMID: 35117944 PMCID: PMC8798908 DOI: 10.21037/tcr.2019.07.19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/01/2019] [Indexed: 12/25/2022]
Abstract
Background Adjuvant whole breast radiotherapy is the standard of care for breast cancer patients after partial mastectomy. Intensity-modulated radiation therapy (IMRT) has been reported to reduce acute toxicities compared to conventional radiotherapy. IMRT with simultaneous integrated boost (SIB) technique can deliver higher doses to tumor bed and irradiate whole breast with a lower dose level to shorten overall treatment duration. This study presents the long-term results of adjuvant IMRT with SIB in elderly breast cancer patients who received partial mastectomy. Methods From January 2007 to January 2018, 93 elder breast cancer patients (≥65-year-old) who received IMRT with SIB technique after partial mastectomy were reviewed retrospectively. The axillary areas were managed with either sentinel lymph node biopsies or axillary lymph node dissection. The dose to whole breast was 50.4 Gy in 28 fractions in all patients and the dose to tumor bed was 61.6 to 66.4 Gy in 28 fractions. The primary end point is locoregional control. Secondary end points include: overall survival, breast cancer-specific survival, distant-metastases-free survival, disease-free survival, and acute and chronic toxicities. Results The median follow-up was 56.1 months. One patient had ipsilateral breast tumor recurrence, 3 patients had regional lymph node recurrence, and 9 patients had distant metastases. Death occurred in 5 patients, including 3 patients died of breast cancer progression. Five-year overall survival is 96.3% and 5-year locoregional recurrence-free survival is 96.4%. The 5-year breast cancer specific survival and 5-year distant metastases-free survival is 97.5% and 87.2%, respectively. Seven patients developed second primary cancer after RT. Eighty-one point seven percent patients had acute grade 1 dermatitis while 18.3% suffered from grade 2 dermatitis. The incidence of grade 1 pneumonitis and grade 1 stomatitis was 4.3% and 8.6%, respectively. Conclusions Adjuvant IMRT with SIB technique is a safe and effective treatment strategy for elderly breast cancer patients after partial mastectomy.
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Affiliation(s)
- Kuan-Wen Chen
- Department of Radiation Oncology, Taichung Tzu-Chi Hospital, Buddhist Tzu-Chi Medical Foundation, Taichung, Taiwan
| | - Hsiu-Ting Hsu
- Department of Radiation Oncology, Taichung Tzu-Chi Hospital, Buddhist Tzu-Chi Medical Foundation, Taichung, Taiwan
| | - Jia-Fu Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hui-Ling Yeh
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Dah-Cherng Yeh
- Department of General Surgery, Cheng-Ching Hospital, Chung-Kang Branch, Taichung, Taiwan
| | - Chin-Yao Lin
- Breast Medical Center, Taichung Tzu-Chi Hospital, Buddhist Tzu-Chi Medical Foundation, Taichung, Taiwan
| | - Siwa Chan
- Department of Medical Imaging, Taichung Tzu-Chi Hospital, Buddhist Tzu-Chi Medical Foundation, Taichung, Taiwan
| | - He-Yuan Hsieh
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
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La Rocca E, Meneghini E, Dispinzieri M, Fiorentino A, Bonfantini F, Di Cosimo S, Gennaro M, Cosentino V, Sant M, Pignoli E, Valdagni R, Lozza L, De Santis MC. Hypofractionated irradiation in 794 elderly breast cancer patients: An observational study. Breast J 2019; 26:188-196. [DOI: 10.1111/tbj.13489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Eliana La Rocca
- Radiotherapy Unit 1 Fondazione IRCCS Istituto Nazionale dei Tumore Milan Italy
- Department of Oncology and Hemato‐oncology Università degli Studi di Milano Milan Italy
| | - Elisabetta Meneghini
- Analytical Epidemiology and Health Impact Unit Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Michela Dispinzieri
- Radiotherapy Unit 1 Fondazione IRCCS Istituto Nazionale dei Tumore Milan Italy
| | - Alba Fiorentino
- Radiation Oncology General Regional Hospital “F. Miulli” Acqua viva delle Fonti Italy
| | | | - Serena Di Cosimo
- Department of Applied Research and Technological Development (DRAST) Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | | | - Vito Cosentino
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Emanuele Pignoli
- Medical Physics Unit Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Riccardo Valdagni
- Department of Oncology and Hemato‐oncology Università degli Studi di Milano Milan Italy
- Radiation Oncology 1 and Prostate Cancer Program Fondazione IRCCS Istituto Nazionale dei Tumori Milan Italy
| | - Laura Lozza
- Radiotherapy Unit 1 Fondazione IRCCS Istituto Nazionale dei Tumore Milan Italy
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Zhi X, Yang X, Pan T, Liu J, Chen X, Lou L, Shi Z, Zhang J. Correlation of radiotherapy with prognosis of elderly patients with hormone receptor-positive breast cancer according to immunohistochemical subtyping. Chin J Cancer Res 2019; 31:471-480. [PMID: 31354216 PMCID: PMC6613505 DOI: 10.21147/j.issn.1000-9604.2019.03.09] [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] [Indexed: 11/23/2022] Open
Abstract
Objective The present study examined the effect of radiotherapy on recurrence and survival in elderly patients with hormone receptor-positive early breast cancer. Methods A retrospective analysis of 327 patients aged ≥65 years, with stage I−II, hormone receptor-positive breast cancer who underwent breast-conserving surgery and received endocrine therapy (ET) or radiotherapy plus endocrine therapy (ET+RT) was performed. Both groups were divided into luminal A type and luminal B type subgroups. Evaluation criteria were 5-year disease-free survival (DFS), local relapse rate (LRR), overall survival (OS), and distant metastasis rate (DMR). Results There were significant differences in 5-year DFS [hazard ratio (HR)=1.59, 95% confidence interval (95% CI), 1.15−2.19; P=0.005] and LRR (HR=3.33, 95% CI, 1.51−7.34; P=0.003), whereas there were no significant differences in OS and DMR between ET group and ET+RT group. In luminal A type, there was no significant difference in 5-year DFS, LRR, OS and DMR between ET group and ET+RT group. In luminal B type, there were statistically significant differences in 5-year DFS (HR=2.19, 95% CI, 1.37−3.49; P=0.001), LRR (HR=5.45, 95% CI, 1.65−17.98; P=0.005), and OS (HR=1.75, 95% CI, 1.01−3.05; P=0.048) between ET group and ET+RT group. In the ET group, there were significant differences between luminal A type and luminal B type in 5-year DFS (HR=1.84, 95% CI, 1.23−2.75; P=0.003) and OS (HR=1.76, 95% CI, 1.07−2.91; P=0.026). Conclusions After breast-conserving surgery, radiotherapy can reduce the LRR and improve the DFS and OS of luminal B type elderly patients, whereas luminal A type elderly patients do not benefit from radiotherapy. Without radiotherapy, luminal A type patients have better DFS and OS than luminal B type patients.
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Affiliation(s)
- Xiangcheng Zhi
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Xiaonan Yang
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Teng Pan
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Jingjing Liu
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Xiao Chen
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Liping Lou
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Zhendong Shi
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
| | - Jin Zhang
- Department of Breast Cancer, Tianjin Medical University Cancer Institute & Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Cancer for Cancer, Tianjin 300060, China
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13
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Fiorentino A, Gregucci F, Mazzola R, Figlia V, Ricchetti F, Sicignano G, Giajlevra N, Ruggieri R, Fersino S, Naccarato S, Massocco A, Corradini S, Alongi F. Intensity-modulated radiotherapy and hypofractionated volumetric modulated arc therapy for elderly patients with breast cancer: comparison of acute and late toxicities. LA RADIOLOGIA MEDICA 2018; 124:309-314. [PMID: 30547358 DOI: 10.1007/s11547-018-0976-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the differences between conventional fractionated intensity-modulated radiotherapy (IMRT) and hypofractionated (HypoRT) volumetric modulated arc therapy (VMAT) in elderly women affected by early-stage breast cancer (BC) in terms of RT-related acute/late side effect. MATERIALS AND METHODS Between October 2011 and July 2015, 80 consecutive elderly BC patients were treated with IMRT for 5 weeks (40 patients) or HypoRT-VMAT for 3 weeks (40 patients). Inclusion criteria were: age ≥ 70 years, early BC (pT1-2 pN0-1), no prior neoadjuvant chemotherapy and non-metastatic disease. For patients receiving IMRT or HypoRT-VMAT, a total dose of 50 Gy (25 fractions) or 40.5 Gy (15 fractions) was prescribed to the whole ipsilateral breast, respectively. All patients received a simultaneously integrated boost up to a total dose of 60 Gy for IMRT and 48 Gy for HypoRT-VMAT. Acute and late side effects were evaluated using the RTOG/EORTC radiation morbidity scoring system. RESULTS With a median follow-up of 45 months, acute skin toxicity was overall very low, with grade 1 in 25 cases (62.5%) of the IMRT group and 21 cases (52.5%) of the HypoRT-VMAT group, while grade 2 toxicity was reported in 10 IMRT patients (25%) and 1 HypoRT-VMAT patient (2.5%) (p = 0.001). Regarding late adverse events, only grade 1 skin toxicity was recorded. CONCLUSION The present study showed that whole breast IMRT and HypoRT-VMAT are feasible and well tolerated in early-stage BC elderly patients and that HypoRT-VMAT is affected by lower risk of acute and late RT-related side effects.
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Affiliation(s)
- Alba Fiorentino
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Fabiana Gregucci
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - Rosario Mazzola
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Vanessa Figlia
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Francesco Ricchetti
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Gianluisa Sicignano
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Niccolo Giajlevra
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Ruggero Ruggieri
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Sergio Fersino
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Stefania Naccarato
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Alberto Massocco
- Breast Unit, Cancer Care Center, Ospedale Sacro Cuore don Calabria, Negrar, Verona, Italy
| | - Stefanie Corradini
- Radiation Oncology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Filippo Alongi
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
- University of Brescia, Brescia, Italy
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14
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Linac-based radiosurgery or fractionated stereotactic radiotherapy with flattening filter-free volumetric modulated arc therapy in elderly patients : A mono-institutional experience on 110 brain metastases. Strahlenther Onkol 2018; 195:218-225. [PMID: 30478669 DOI: 10.1007/s00066-018-1405-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/15/2018] [Indexed: 12/22/2022]
Abstract
AIM The aim of this study was to analyze the feasibility and clinical results of linear accelerator (linac-)based stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (SFRT) with flattening filter-free (FFF) volumetric modulated arc therapy (VMAT) in elderly patients affected by brain metastases (BMs). PATIENTS AND METHODS Patients selected for the present analysis were ≥65 years old with a life expectancy of >3 months, a controlled or synchronous primary tumor, and <10 BMs with a diameter <3 cm. All patients were treated with FFF linac-based SRS/SFRT. The prescribed total dose (15-30 Gy/1-5 fractions) was based on BM size and proximity to organs at risk (OAR). Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. MedCalc v18.2 (MedCalc Software, Ostend, Belgium) was used for statistical analysis. RESULTS From April 2014 to December 2017, 40 elderly patients with 110 BMs were treated by FFF linac-based SRS/SFRT. With a median follow-up of 28 months (range 6-50 months), median and 1‑year overall survival were 9 months and 39%, respectively; median intracranial progression-free survival was 6 months. At the time of the analysis, local control was reported in 109/110 BMs (99.1%): 12 BMs had a complete response; 51 a partial response; 46 showed stable disease. One BM (0.9%) progressed after 2 months. BM volume (<1 cc) and higher SRS/SFRT dose correlated to treatment response (p = 0.01 and p = 0.0017, respectively). No adverse events higher than grade 2 were observed. CONCLUSION The present findings highlight the feasibility, safety, and effectiveness of FFF linac-based SRS/SFRT in elderly patients with BMs.
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15
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De Santis MC, Bonfantini F, Di Salvo F, Fiorentino A, Dispinzieri M, Caputo M, Di Cosimo S, Mariani G, Gennaro M, Cosentino V, Sant M, Pignoli E, Valdagni R, Lozza L. Hypofractionated Whole-Breast Irradiation With or Without Boost in Elderly Patients: Clinical Evaluation of an Italian Experience. Clin Breast Cancer 2018; 18:e1059-e1066. [PMID: 29773414 DOI: 10.1016/j.clbc.2018.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/07/2018] [Accepted: 04/02/2018] [Indexed: 01/11/2023]
Abstract
PURPOSE To examine local control, disease-free survival (DFS), and toxicity in elderly (≥ 65 years) breast cancer patients treated with hypofractionated radiotherapy (hypo-RT) with or without a boost to the tumor bed. PATIENTS AND METHODS The study was conducted on 752 patients treated from April 2009 to February 2017. Patients received 42.4 Gy in 16 daily fractions (2.65 Gy per fraction). A boost was only administered in cases of grade 3 primary tumor and close or positive margins. Acute and late toxicity was prospectively assessed during and after hypo-RT, based on the Radiation Therapy Oncology Group scale. DFS and local recurrence-free survival were estimated by the Kaplan-Meier method for cumulative probability. Log-rank tests were used to identify differences by subtype. Cox proportional hazard models were used to investigate the impact of various factors on the risk of disease progression. RESULTS Among the 752 patients treated, 41 (5.5%) experienced disease progression, including 7 (17.1%) exclusively local recurrences; 1 (2.4%) local and nodal recurrence; 1 (2.4%) local and nodal recurrence plus metastasis; 7 (17.1%) nodal recurrences plus metastases; and 25 (61%) exclusively distant metastases. The 5-year DFS, local recurrence-free survival, breast cancer-specific survival, and overall survival rates were 91.8% (95% confidence interval [CI], 88.6-94.2), 98.0% (95% CI, 96.1-99.1), 98.2% (95% CI, 96.5-99.1), and 87.5% (95% CI, 83.8-90.5), respectively. On univariate analysis, the administration of a boost, disease grade (grades 1 and 2 vs. 3), and molecular subtype (triple negative or human epidermal growth factor receptor 2 [HER2] positive, or luminal B vs. luminal A) significantly affected disease progression (P < .01). These findings were confirmed by multivariate analysis. CONCLUSION Hypo-RT is effective and well tolerated in the elderly population, and the routine use of a boost for patients over 65 years is not justified. Further studies on the boost issue are strongly advocated.
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Affiliation(s)
| | - Francesca Bonfantini
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Di Salvo
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alba Fiorentino
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar, Verona, Italy
| | - Michela Dispinzieri
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Mariangela Caputo
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Serena Di Cosimo
- Department of Applied Research and Technological Development (DRAST), Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Gabriella Mariani
- Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Massimiliano Gennaro
- Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Vito Cosentino
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Radiation Oncology 1 and Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy; Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
| | - Laura Lozza
- Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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16
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De Rose F, Fogliata A, Franceschini D, Iftode C, Torrisi R, Masci G, Sagona A, Tinterri C, Testori A, Gatzemeier W, Fernandes B, Rahal D, Cozzi L, Santoro A, Scorsetti M. Hypofractionated volumetric modulated arc therapy in ductal carcinoma in situ: toxicity and cosmetic outcome from a prospective series. Br J Radiol 2018; 91:20170634. [PMID: 29322827 DOI: 10.1259/bjr.20170634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Hypofractionated radiotherapy in early stage breast cancer is an effective adjuvant treatment, but there is a lack of randomized data for patients with ductal carcinoma in situ (DCIS). The aim of this study is the evaluation of skin toxicity and cosmesis, and early clinical outcome of DCIS patients enrolled in an institutional Phase II trial of hypofractionated breast irradiation. METHODS 137 DCIS patients were enrolled in the trial. All patients underwent volumetric modulated arc therapy (VMAT) to the whole breast with a total dose of 40.5 Gy in 15 fractions over 3 weeks, without tumour bed boost. Acute and late skin toxicities were recorded. Cosmetic outcomes were assessed as excellent/good or fair/poor. Early clinical outcome was reported. RESULTS Median age was 58 y.o. (range 30-86). The median follow-up time was 22 months (range 6-45). At the end of the radiotherapy, skin toxicity was grade G1 in 56% of the patients, G2 in 15%, no patients presented G3 toxicity. In the range of 3-9 months of follow-up, the skin toxicity was G1 in 28% of patients, no G2-G3 cases; cosmetic outcome was good/excellent in 95% of patients. In the follow-up interval of 9-24 months, the skin toxicity was G1 in 12% of patients, no G2-G3 toxicity; cosmetic outcome was good/excellent in 96% of patients. After an early evaluation of clinical outcomes, 5 patients (3.6%) presented an in-breast recurrence. CONCLUSION Hypofractionated radiotherapy using VMAT is a viable option for DCIS. A longer follow-up is needed to assess clinical outcomes and late toxicity. Advances in knowledge: The use of hypofractionated VMAT is dosimetrically feasible for treating breast DCIS.
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Affiliation(s)
- Fiorenza De Rose
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Antonella Fogliata
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Davide Franceschini
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Cristina Iftode
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Rosalba Torrisi
- 2 Department of Medical Oncology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Giovanna Masci
- 2 Department of Medical Oncology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Andrea Sagona
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Corrado Tinterri
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Alberto Testori
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Wolfgang Gatzemeier
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Bethania Fernandes
- 4 Department of Pathology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Daoud Rahal
- 4 Department of Pathology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Luca Cozzi
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy.,5 Department of Biomedical Sciences, Humanitas University , Milan, Rozzano , Italy
| | - Armando Santoro
- 2 Department of Medical Oncology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Marta Scorsetti
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy.,5 Department of Biomedical Sciences, Humanitas University , Milan, Rozzano , Italy
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