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Wong LY, Kapula N, He H, Guenthart BA, Vitzthum LK, Horst K, Liou DZ, Backhus LM, Lui NS, Berry MF, Shrager JB, Elliott IA. Risk of developing subsequent primary lung cancer after receiving radiation for breast cancer. JTCVS OPEN 2023; 16:919-928. [PMID: 38204675 PMCID: PMC10775166 DOI: 10.1016/j.xjon.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 01/12/2024]
Abstract
Background Radiotherapy (RT) is integral to breast cancer treatment, especially in the current era that emphasizes breast conservation. The aim of our study was to determine the incidence of subsequent primary lung cancer after RT exposure for breast cancer over a time span of 3 decades to quantify this risk over time as modern oncologic treatment continues to evolve. Methods The SEER (Surveillance, Epidemiology, and End Results) database was queried from 1988 to 2014 for patients diagnosed with nonmetastatic breast cancer. Patients who subsequently developed primary lung cancer were identified. Multivariable regression modeling was performed to identify independent factors associated with the development of lung cancer stratified by follow up intervals of 5 to 9 years, 10 to 15 years, and >15 years after breast cancer diagnosis. Results Of the 612,746 patients who met our inclusion criteria, 319,014 (52%) were irradiated. primary lung cancer developed in 5556 patients (1.74%) in the RT group versus 4935 patients (1.68%) in the non-RT group. In a multivariable model stratified by follow-up duration, the overall HR of developing subsequent ipsilateral lung cancer in the RT group was 1.14 (P = .036) after 5 to 9 years of follow-up, 1.28 (P = .002) after 10 to 15 years of follow-up, and 1.30 (P = .014) after >15 years of follow-up. The HR of contralateral lung cancer was not increased at any time interval. Conclusions The increased risk of developing a primary lung cancer secondary to RT exposure for breast cancer is much lower than previously published. Modern RT techniques may have contributed to the improved risk profile, and this updated study is important for counseling and surveillance of breast cancer patients.
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Affiliation(s)
- Lye-Yeng Wong
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Ntemena Kapula
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Hao He
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Brandon A. Guenthart
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Lucas K. Vitzthum
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, Calif
| | - Kathleen Horst
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, Calif
| | - Douglas Z. Liou
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Leah M. Backhus
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- Department of Cardiothoracic Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
| | - Natalie S. Lui
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
| | - Mark F. Berry
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- Department of Cardiothoracic Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
| | - Joseph B. Shrager
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- Department of Cardiothoracic Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
| | - Irmina A. Elliott
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif
- Department of Cardiothoracic Surgery, VA Palo Alto Health Care System, Palo Alto, Calif
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Agrawal S, Raza W, Lal P, Maria Das K, Agarwal G. Post-chemotherapy target volumes are safe as boost volume for intact breast radiotherapy in locally advanced breast cancer. Rep Pract Oncol Radiother 2020; 25:266-270. [PMID: 32140084 PMCID: PMC7049594 DOI: 10.1016/j.rpor.2020.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/14/2019] [Accepted: 02/19/2020] [Indexed: 10/25/2022] Open
Abstract
PURPOSE The purpose of our study is to evaluate the challenges in identification of postoperative complexes (POC), the utility of clips in delineation of clinical target volume for boost in LABC downstaged with neoadjuvant chemotherapy (NACT) and to correlate this with patterns of recurrence. METHODS AND MATERIALS LABC patients who underwent NACT followed by BCS and radiotherapy (2007-2014) were the subject of our analysis. The data on visibility and characteristics of postoperative cavity (POC), concordance of its volume with clip volume on radiation planning scan were retrieved. A 1 cm margin beyond POC was delineated as a clinical target volume (CTV). Postoperative whole breast and supraclavicular radiotherapy (50 Gy/25fractions/5wk or 42.4 Gy/16#/3 wk) followed by boost (10-16 Gy/5-8#/1-1.5wk) were delivered. Patterns of recurrence were evaluated. RESULTS Out of 60 patients, 28.3% patients had stage II disease and 71.7% had stage III disease. 25% patients achieved pathological CR (complete response). The median POC volume was 30 cc and the median clip volume was 40 cc. The concordance of POC volume with clip volume was seen in 80%. Clips served as a good surrogate for POC in 80% of patients. At a median follow-up of 65 months (IQ range 32-84 months), and a lost to follow-up rate of 11.6 %, 3.3% (n = 2) patients had local recurrence (LR) and 8.3% (n = 5) had regional recurrence (LRR) in the supraclavicular region. CONCLUSIONS Delineation of post NACT excision cavity as POC for boost radiotherapy is safe. Clips serve as a good surrogate for CTV delineation in 75% patients.
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Affiliation(s)
- Sushma Agrawal
- Departments of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Waseem Raza
- Departments of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Punita Lal
- Departments of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - K.J. Maria Das
- Departments of Radiotherapy, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Gaurav Agarwal
- Endocrine Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Serban M, Lambert C, Ruo R, Maietta C, Parker W, Evans M, Hijal T. Computed tomography-based virtual simulation versus ultrasound-based clinical setup in electron breast boost radiotherapy: Methodology for CT-based electron virtual simulation. Phys Med 2019; 67:100-106. [PMID: 31704390 DOI: 10.1016/j.ejmp.2019.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To compare clinical setup using ultrasound (U/S)-delineated target versus computed tomography (CT) virtual simulation using CT-outlined target in breast electron boost. To describe a methodology for electron virtual simulation and collision testing with the treatment planning system (TPS). METHODS The two techniques were compared in a prospective study on 12 patients, who were treated using a clinical setup. Target definition was performed by both U/S and CT imaging. The U/S-based target was made visible on CT images by placing a radio-opaque wire on U/S skin markings. The dose distribution of the clinical setup was reproduced in the TPS using the actual electron patient treatment parameters. A CT-based TPS virtual simulation/dose optimization was compared to the clinical setup technique. RESULTS Mean beam aperture was larger by 16.3 cm2 (p = 0.011) for U/S compared to CT-outlined target. Target mean depth difference (CT minus U/S) was 0.03 cm (p = 0.875). Target coverage at depth was adequate in all cases with CT-based simulation while under/overcovering the target at depth by more than 5 mm in 2 out of 12 cases with clinical setup. Mean target V90% was 98.5% (CT-based simulation) and 84.4% (clinical setup). Ipsilateral lung/breast were better spared with CT-based simulation. To date, the methodology for CT virtual simulation was applied on 152 patients and collision was avoided in all cases. CONCLUSIONS CT-based simulation and target delineation allows for improved definition of the en-face electron field with less amount of normal tissue irradiated while including the entire target with an adequate margin and optimal electron energy.
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Affiliation(s)
- Monica Serban
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada.
| | - Christine Lambert
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Russell Ruo
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Ciro Maietta
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - William Parker
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Michael Evans
- Department of Medical Physics, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
| | - Tarek Hijal
- Department of Radiation Oncology, Cedars Cancer Centre, McGill University Health Centre, Glen Campus, 1001 Décarie Boul., Montreal H4A 3J1, Canada
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La Rocca E, Lici V, Giandini T, Bonfantini F, Frasca S, Dispinzieri M, Gennaro M, S DC, Di Cosimo S, Lozza L, Pignoli E, Valdagni R, De Santis MC. Interobserver variability (between radiation oncologist and radiation therapist) in tumor bed contouring after breast-conserving surgery. TUMORI JOURNAL 2019; 105:210-215. [PMID: 30915903 DOI: 10.1177/0300891619839288] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE To examine interobserver variability between the radiation oncologist (RTO) and the radiation therapist (RTT) in delineating the tumor bed (TB) in early breast cancer (BC). METHODS We retrospectively analyzed patients who received a radiotherapy boost to the TB. In a first group, the clinical target volume (CTV) for the boost was the surgical bed, defined by using surgical clips. In a second group, the CTV was defined by identifying a seroma cavity or a metallic find on the scar. These contours were compared in terms of volume, number of slices, and Dice similarity coefficient (DSC). RESULTS Forty patients were assessed: 20 had surgical clips (group 1) while the other 20 had none (group 2). There was no difference in the number of slices contoured by the 2 operators for group 1, but a statistically significant difference emerged in the volumes: the RTT identified a TB that was a mean 45% smaller than the one identified by the RTO. Random differences were found between the 2 operators for group 2. The TBs delineated for this group were significantly larger (P<0.05) than those identified by the RTT for group 1. The mean Dice value between the RTO's and the RTT's TBs was 0.69±0.07 (range 0.53-0.81) for group 1 and 0.37±0.18 (range 0-0.58) for group 2 (P<0.05). CONCLUSIONS This study showed that the use of clips coincided with less interoperator variability. With appropriate training, the RTT may play an important part in the multidisciplinary radiotherapy team.
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Affiliation(s)
- Eliana La Rocca
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,2 Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
| | - Vanessa Lici
- 2 Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
| | - Tommaso Giandini
- 3 Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Francesca Bonfantini
- 3 Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sarah Frasca
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Michela Dispinzieri
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.,2 Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy
| | - Massimiliano Gennaro
- 4 Breast Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Serena Di Cosimo
- 5 Department of Applied Research and Technological Development (DRAST), Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Lozza
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Pignoli
- 3 Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- 2 Department of Oncology and Hemato-oncology, Università degli Studi di Milano, Milan, Italy.,6 Radiation Oncology 1 and Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Pulsed-dose-rate peri-operative brachytherapy as an interstitial boost in organ-sparing treatment of breast cancer. J Contemp Brachytherapy 2017; 8:492-496. [PMID: 28115954 PMCID: PMC5241379 DOI: 10.5114/jcb.2016.64512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/17/2016] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate peri-operative multicatheter interstitial pulsed-dose-rate brachytherapy (PDR-BT) with an intra-operative catheter placement to boost the tumor excision site in breast cancer patients treated conservatively. Material and methods Between May 2002 and October 2008, 96 consecutive T1-3N0-2M0 breast cancer patients underwent breast-conserving therapy (BCT) including peri-operative PDR-BT boost, followed by whole breast external beam radiotherapy (WBRT). The BT dose of 15 Gy (1 Gy/pulse/h) was given on the following day after surgery. Results No increased bleeding or delayed wound healing related to the implants were observed. The only side effects included one case of temporary peri-operative breast infection and 3 cases of fat necrosis, both early and late. In 11 patients (11.4%), subsequent WBRT was omitted owing to the final pathology findings. These included eight patients who underwent mastectomy due to multiple adverse prognostic pathological features, one case of lobular carcinoma in situ, and two cases with no malignant tumor. With a median follow-up of 12 years (range: 7-14 years), among 85 patients who completed BCT, there was one ipsilateral breast tumor and one locoregional nodal recurrence. Six patients developed distant metastases and one was diagnosed with angiosarcoma within irradiated breast. The actuarial 5- and 10-year disease free survival was 90% (95% CI: 84-96%) and 87% (95% CI: 80-94%), respectively, for the patients with invasive breast cancer, and 91% (95% CI: 84-97%) and 89% (95% CI: 82-96%), respectively, for patients who completed BCT. Good cosmetic outcome by self-assessment was achieved in 58 out of 64 (91%) evaluable patients. Conclusions Peri-operative PDR-BT boost with intra-operative tube placement followed by EBRT is feasible and devoid of considerable toxicity, and provides excellent long-term local control. However, this strategy necessitates careful patient selection and histological confirmation of primary diagnosis.
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Updated feasibility and reproducibility results of multi-institutional study of noninvasive breast tumor bed boost. Brachytherapy 2016; 15:804-811. [DOI: 10.1016/j.brachy.2016.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 08/24/2016] [Accepted: 09/06/2016] [Indexed: 11/20/2022]
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De Santis MC, Nardone L, Diletto B, Canna R, Dispinzieri M, Marino L, Lozza L, Valentini V. Comparison of two radiation techniques for the breast boost in patients undergoing neoadjuvant treatment for breast cancer. Br J Radiol 2016; 89:20160264. [PMID: 27452265 DOI: 10.1259/bjr.20160264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE After breast conservative surgery (BCS) and whole-breast radiotherapy (WBRT), the use of boost irradiation is recommended especially in patients at high risk. However, the standard technique and the definition of the boost volume have not been well defined. METHODS We retrospectively compared an anticipated pre-operative photon boost on the tumour, administered with low-dose fractionated radiotherapy, and neoadjuvant chemotherapy with two different sequential boost techniques, administered after BCS and standard adjuvant WBRT: (1) a standard photon beam (2) and an electron beam technique on the tumour bed of the same patients. The plans were analyzed for the dosimetric coverage of the CT-delineated irradiated volume. The minimal dose received by 95% of the target volume (D95), the minimal dose received by 90% of the target volume (D90) and geographic misses were evaluated. RESULTS 15 patients were evaluated. The sequential photon and electron boost techniques resulted in inferior target volume coverage compared with the anticipated boost technique, with a median D95 of 96.3% (range 94.7-99.6%) and 0.8% (range 0-30%) and a median D90 of 99.1% (range 90.2-100%) and 54.7% (range 0-84.8%), respectively. We observed a geographic miss in 26.6% of sequential electron plans. The results of the anticipated boost technique were better: 99.4% (range 96.5-100%) and 97.1% (range 86.2-99%) for median D90 and median D95, respectively, and no geographic miss was observed. We observed a dose reduction to the heart, with left-sided breast irradiation, using the anticipated pre-operative boost technique, when analyzed for all dose-volume parameters. When compared with the sequential electron plans, the pre-operative photon technique showed a higher median ipsilateral lung Dmax. CONCLUSION Our data show that an anticipated pre-operative photon boost results in a better coverage with respect to the standard sequential boost while also saving the organs at risk and consequently fewer side effects. ADVANCES IN KNOWLEDGE This is the first dosimetric study that evaluated the association between an anticipated boost and neoadjuvant chemotherapy treatment.
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Affiliation(s)
- Maria C De Santis
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Luigia Nardone
- 2 Department of Radiation Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Barbara Diletto
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Roberta Canna
- 2 Department of Radiation Oncology, Catholic University of the Sacred Heart, Rome, Italy
| | - Michela Dispinzieri
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Lorenza Marino
- 3 Division of Radiotherapy, REM-Istituto Oncologico del Mediterraneo, Catania, Italy
| | - Laura Lozza
- 1 Radiotherapy Unit 1, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Vincenzo Valentini
- 2 Department of Radiation Oncology, Catholic University of the Sacred Heart, Rome, Italy
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Davidson S, Kirsner S, Mason B, Kisling K, Barrett RD, Bonetati A, Ballo MT. Dosimetric impact of setup accuracy for an electron breast boost technique. Pract Radiat Oncol 2015; 5:e499-e504. [PMID: 25858772 DOI: 10.1016/j.prro.2015.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/29/2015] [Accepted: 02/21/2015] [Indexed: 12/01/2022]
Abstract
PURPOSE To determine the setup error on an electron breast boost technique using daily cone beam computed tomography (CBCT). Patient and setup attributes were studied as contributing factors to the accuracy. METHODS AND MATERIALS Reproducibility of a modified lateral decubitus position breast boost setup was verified for 33 patients using CBCT. Three-dimensional matching was performed between the CBCT and the initial planning CT for each boost fraction by matching the tumor bed and/or surgical clips. The dosimetric impact of the daily positioning error was achieved by rerunning the initial treatment plans incorporating the recorded shifts to study the dose differences. Breast compression, decubitus angle, tumor bed location and volume, and cup size were studied for their contribution to setup error. RESULTS The range of setup errors was: 1.5 cm anterior to 9 mm posterior, 1.3 cm superior to 2.3 cm inferior, and 3.2 cm medial to 2.4 cm lateral. Seven patients had setup errors that were ≥2-cm margin placed on the tumor bed and scar. Four of those 7 patients had unacceptable coverage as defined by the volume of the tumor bed plus scar that is covered by the 90% isodose line (V90) compared with the original plan. All other patients had no discernible difference in the coverage (V90). The use of compression, tumor bed location, or volumes >20 mL showed no effect on coverage. CONCLUSIONS In general, this study supported that a 2-cm margin was adequate (29 of 33 patients) when patients are treated under typical conditions. Care should be taken when high electron energies are selected because the coverage at depth is more difficult to maintain in the clinical environment.
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Affiliation(s)
- Scott Davidson
- Department of Radiation Oncology, The University of Texas Medical Branch, Galveston, Texas.
| | - Steven Kirsner
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Bryan Mason
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Kelly Kisling
- Department of Radiation Physics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Renee D Barrett
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Anthony Bonetati
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
| | - Matthew T Ballo
- Department of Radiation Oncology, The University of Tennessee Health Science Center, Memphis, Tennessee
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Munhoz AM, Montag E, Gemperli R. Oncoplastic breast surgery: indications, techniques and perspectives. Gland Surg 2014; 2:143-57. [PMID: 25083476 DOI: 10.3978/j.issn.2227-684x.2013.08.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 08/20/2013] [Indexed: 11/14/2022]
Abstract
Breast-conservation surgery (BCS) is established as a safe option for most women with early breast cancer. Recently, advances in oncoplastic techniques have reduced surgical trauma and thus are capable of preserving the breast form and quality of life. In spite of the most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Oncoplastic reconstruction may begin at the time of BCS (immediate), weeks (delayed-immediate) or months to years afterwards (delayed). With immediate reconstruction, the surgical process is smooth, since both procedures can be associated in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reducing the incidence of margin involvement. The oncoplastic techniques are related to volume displacement or replacement procedures including local flaps, latissimus dorsi myocutaneous flap and reduction mammaplasty/masthopexy. Regardless of the fact that there is no consensus concerning the best approach, the criteria are determined by the surgeon's experience and the size of the defect in relation to the size of the remaining breast. On the basis of our 15-year experience, it is possible to identify trends in types of breast defects and to develop an algorithm for immediate BCS reconstruction on the basis of the initial breast volume, the extent/location of glandular tissue ressection and the remaining available breast tissue. The main advantages of the technique utilized should include reproducibility, low interference with the oncologic treatment and long-term results. Surgical planning should include the patients's preferences, and chiefly addressing individual reconstructive requirements, enabling each patient to receive an individual "custom-made" reconstruction.
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Affiliation(s)
- Alexandre Mendonça Munhoz
- 1 Plastic Surgery Division, Hospital Sírio-Libanês, São Paulo/ Brazil ; 2 Breast Reconstruction Group, University of São Paulo School of Medicine, Brazil ; 3 Division of Plastic Surgery, University of São Paulo School of Medicine, Brazil
| | - Eduardo Montag
- 1 Plastic Surgery Division, Hospital Sírio-Libanês, São Paulo/ Brazil ; 2 Breast Reconstruction Group, University of São Paulo School of Medicine, Brazil ; 3 Division of Plastic Surgery, University of São Paulo School of Medicine, Brazil
| | - Rolf Gemperli
- 1 Plastic Surgery Division, Hospital Sírio-Libanês, São Paulo/ Brazil ; 2 Breast Reconstruction Group, University of São Paulo School of Medicine, Brazil ; 3 Division of Plastic Surgery, University of São Paulo School of Medicine, Brazil
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Munhoz AM, Montag E, Gemperli R. Current aspects of therapeutic reduction mammaplasty for immediate early breast cancer management: An update. World J Clin Oncol 2014; 5:1-18. [PMID: 24527398 PMCID: PMC3920176 DOI: 10.5306/wjco.v5.i1.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/02/2013] [Accepted: 11/16/2013] [Indexed: 02/06/2023] Open
Abstract
Breast-conservation surgery (BCS) is established as a safe surgical treatment for most patients with early breast cancer. Recently, advances in oncoplastic techniques are capable of preserving the breast form and quality of life. Although most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable. Among technical options, therapeutic reduction mammaplasty (TRM) remains a useful procedure since the BCS defect can be repaired and the preoperative appearance can be improved, resulting in more proportional breasts. As a consequence of rich breast tissue vascularization, the greater part of reduction techniques have based their planning on preserving the pedicle of the nipple-areola complex after tumor removal. Reliable circulation and improvement of a conical shape to the breast are commonly described in TRM reconstructions. With an immediate approach, the surgical process is smooth since both procedures can be carried out in one operative setting. Additionally, it permits wider excision of the tumor, with a superior mean volume of the specimen and potentially reduces the incidence of margin involvement. Regardless of the fact that there is no consensus concerning the best TRM technique, the criteria is determined by the surgeon’s experience, the extent/location of glandular tissue resection and the size of the defect in relation to the size of the remaining breast. The main advantages of the technique utilized should include reproducibility, low interference with the oncological treatment and long-term results. The success of the procedure depends on patient selection, coordinated planning and careful intra-operative management.
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Senthi S, Link E, Chua BH. Cosmetic Outcome and Seroma Formation After Breast-Conserving Surgery With Intraoperative Radiation Therapy Boost for Early Breast Cancer. Int J Radiat Oncol Biol Phys 2012; 84:e139-44. [DOI: 10.1016/j.ijrobp.2012.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 02/26/2012] [Accepted: 03/06/2012] [Indexed: 10/27/2022]
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Gloi AM, Buchanan R. Discrepancies in determining electron energy for lumpectomy boost treatment. J Med Phys 2012; 37:138-44. [PMID: 22973080 PMCID: PMC3437170 DOI: 10.4103/0971-6203.99234] [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: 02/03/2012] [Revised: 04/19/2012] [Accepted: 04/30/2012] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to compare lumpectomy cavity depth measurements obtained through ultrasound (U/S) and retrospective computed tomography (CT). Twenty-five patients with stage T1-2 invasive breast cancer formed the cohort of this study. Their U/S and CT measurements were converted into electron energy and compared. The mean U/S depth was 3.6 ± 1.3 cm, while the mean CT depth was 4.9 ± 1.9 cm; the listed error ranges are one standard deviation. Electron energies for treatment ranged from 6 MeV to 12 MeV based on the U/S determination. There was no significant correlation between cavity depths measured by U/S and CT (R2= 0.459, P < 0.002). Furthermore, only 20% of CT-based electron energy determinations matched the corresponding U/S determinations. This ratio increased to 40% when taking into account an upper limit based on the depth of organs at risk below the cavity. The study shows that there is a significant discrepancy between cavity depths determined by U/S and CT. It also supports the concept that post-lumpectomy radiotherapy boosts should be tailored according to the needs and comfort of individual practices and institutions.
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Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: A review. Crit Rev Oncol Hematol 2012; 81:1-20. [PMID: 21376625 DOI: 10.1016/j.critrevonc.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 01/03/2011] [Accepted: 01/25/2011] [Indexed: 01/03/2023] Open
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Cho H, Kim C. Volumetric changes in the lumpectomy cavity during whole breast irradiation after breast conserving surgery. Radiat Oncol J 2011; 29:277-82. [PMID: 22984681 PMCID: PMC3429913 DOI: 10.3857/roj.2011.29.4.277] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 10/28/2011] [Accepted: 10/28/2011] [Indexed: 12/28/2022] Open
Abstract
Purpose This study was performed to evaluate the change in the lumpectomy cavity volumes before and after whole breast radiation therapy (WBRT) and to identify factors associated with the change of volume. Materials and Methods From September 2009 to April 2010, the computed tomography (CT) simulation data from 70 patients obtained before and after WBRT was evaluated. The lumpectomy cavity volumes were contoured based on surgical clips, seroma, and postoperative changes. Significant differences in the data from pre-WBRT CT and post-WBRT CT were assessed. Multiple variables were examined for correlation with volume reduction in the lumpectomy cavity. Results The mean and median volume reduction in the lumpectomy cavity after WBRT were 17.6 cm3 and 16.1 cm3, respectively with the statistical significance (p < 0.001). The volume reduction in the lumpectomy cavity was inversely correlated with time from surgery to radiation therapy (R = 0.390). The presence of seroma was significantly associated with a volumetric change in the lumpectomy cavity after WBRT (p = 0.011). Conclusion The volume of lumpectomy cavity reduced significantly after WBRT. As the time from surgery to the start of WBRT increased, the volume reduction in the lumpectomy cavity during WBRT decreased. A strong correlation was observed between the presence of seroma and the reduced volume. To ensure appropriate coverage and to limit normal tissue exposure during boost irradiation in patients who has seroma at the time of starting WBRT, repeating CT simulation at boost planning is suggested.
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Affiliation(s)
- Heunglae Cho
- Department of Radiation Oncology, Inje University College of Medicine, Busan, Korea
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Has Placement of Surgical Clips in the Lumpectomy Bed Fallen Out of Favor? Indian J Surg Oncol 2011. [DOI: 10.1007/s13193-011-0089-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Azu M, Goyal S, Patel U, Haffty B, Kearney T. Has Placement of Surgical Clips in the Lumpectomy Bed Fallen Out of Favor? Ann Surg Oncol 2011; 18:1529-32. [DOI: 10.1245/s10434-011-1672-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Chua BH, Henderson MA, Milner AD. Intraoperative radiotherapy in women with early breast cancer treated by breast-conserving therapy. ANZ J Surg 2010; 81:65-9. [DOI: 10.1111/j.1445-2197.2010.05431.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Strauss JB, Gielda BT, Chen SS, Shah AP, Abrams RA, Griem KL. Variation in Post-Surgical Lumpectomy Cavity Volume With Delay in Initiation of Breast Irradiation Because of Chemotherapy. Int J Radiat Oncol Biol Phys 2010; 77:831-5. [DOI: 10.1016/j.ijrobp.2009.05.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/28/2009] [Accepted: 05/29/2009] [Indexed: 11/16/2022]
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3-D Conformal Photon Boost in the Treatment of Early Stage Breast Cancer: Four Year Follow Up Results. Pathol Oncol Res 2010; 17:17-23. [DOI: 10.1007/s12253-010-9264-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 03/22/2010] [Indexed: 10/19/2022]
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Uwini SA, Antonini N, Poortmans PM, Boersma L, Hurkmans C, Leer JW, Horiot JC, Struikmans H, Bartelink H. The influence of the use of CT-planning on the irradiated boost volume in breast conserving treatment. Radiother Oncol 2009; 93:87-93. [DOI: 10.1016/j.radonc.2009.05.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Revised: 04/14/2009] [Accepted: 05/02/2009] [Indexed: 11/17/2022]
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Change in seroma volume during whole-breast radiation therapy. Int J Radiat Oncol Biol Phys 2009; 75:89-93. [PMID: 19362786 DOI: 10.1016/j.ijrobp.2008.10.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Revised: 10/16/2008] [Accepted: 10/22/2008] [Indexed: 12/27/2022]
Abstract
PURPOSE After breast-conserving surgery, a seroma often forms in the surgical cavity. If not drained, it may affect the volume of tumor bed requiring a boost after whole-breast radiation therapy (WBRT). Our objective was to evaluate the change in seroma volume that occurs during WBRT, before boost planning. METHODS AND MATERIALS A retrospective review was performed of women receiving breast-conserving therapy with evidence of seroma at the time of WBRT planning. Computed tomography (CT) simulation was performed before WBRT and before the tumor bed boost. All patients received either a hypofractionated (42.4 Gy/16 fraction + 9.6 Gy/4 fraction boost) or standard fractionated (50.4 Gy/28 fraction + 10 Gy/5 fraction boost) regimen. Seroma volumes were contoured and compared on CT at the time of WBRT simulation and tumor bed boost planning. RESULTS Twenty-four patients with evidence of seroma were identified and all patients received WBRT without drainage of the seroma. Mean seroma volume before WBRT and at boost planning were significantly different at 65.7 cm(3) (SD, 50.5 cm(3)) and 35.6 cm(3) (SD, 24.8 cm(3)), respectively (p < 0.001). Mean and median reduction in seroma volume during radiation were 39.6% (SD, 23.8%) and 46.2% (range, 10.7-76.7%), respectively. Fractionation schedule was not correlated with change in seroma volume. Length of time from surgery to start of radiation therapy showed an inverse correlation with change in seroma volume (Pearson correlation r = -0.53, p < 0.01). CONCLUSIONS The volume of seroma changes significantly during WBRT. Consequently, the accuracy of breast boost planning is likely affected, as is the volume of normal breast tissue irradiated. CT-based boost planning before boost irradiation is suggested to ensure appropriate coverage.
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Repeat computed tomography simulation to assess lumpectomy cavity volume during whole-breast irradiation. Int J Radiat Oncol Biol Phys 2009; 75:751-6. [PMID: 19289260 DOI: 10.1016/j.ijrobp.2008.11.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2008] [Revised: 10/09/2008] [Accepted: 11/11/2008] [Indexed: 12/27/2022]
Abstract
PURPOSE To determine whether the lumpectomy cavity (LPC) decreases in volume during whole-breast radiotherapy (RT) and what factors influence the decrease. PATIENTS AND METHODS Forty-three women with 44 breast lesions were prospectively enrolled. Eligible patients underwent lumpectomy followed by a CT simulation (CT1) within 60 days of surgery. Patients were treated to the entire breast to a dose of 45-50.4 Gy. After 21-23 treatments, a second planning CT simulation (CT2) was done. The LPC was contoured on CT2, and the volumes (LCV) were compared between CT1 and CT2. RESULTS The median LCV on CT1 and CT2 was 38.2 cm(3) and 21.7 cm(3), respectively. The median percent change and volume decrease between CT1 and CT2 was -32.0% and 11.2 cm(3), respectively (n = 44). The LCV decreased in 38 of 44 patients (86%). There was a significant correlation between initial LCV and decrease in volume (p = 0.001) and initial LCV and percent decrease in volume (p < 0.001). There was no correlation between time from surgery to CT1, to start of RT, or to CT2 and change in volume. CONCLUSIONS Patients who undergo lumpectomy almost always have a decrease in their LCV during whole-breast RT. There was a correlation between the initial LCV and decrease in volume on repeat CT simulation. Evaluating patients for this change can potentially lead to decreased doses of radiation to the remaining breast and other critical structures when delivering a small-field boost. Repeat CT simulation should be considered in patients with larger cavities or cavities near critical structures.
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Prendergast B, Indelicato DJ, Grobmyer SR, Saito AI, Lightsey JL, Snead FE, Morris CG, Copeland EM, Mendenhall NP. The dynamic tumor bed: volumetric changes in the lumpectomy cavity during breast-conserving therapy. Int J Radiat Oncol Biol Phys 2009; 74:695-701. [PMID: 19168296 DOI: 10.1016/j.ijrobp.2008.08.044] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Revised: 08/15/2008] [Accepted: 08/29/2008] [Indexed: 12/27/2022]
Abstract
PURPOSE To characterize the magnitude of volume change in the postoperative tumor bed before and during radiotherapy, and to identify any factors associated with large volumetric change. METHODS AND MATERIALS Thirty-six consecutive patients with early-stage or preinvasive breast cancer underwent breast-conserving therapy at our institution between June 2006 and October 2007. Computed tomography (CT) scans of the breast were obtained shortly after surgery, before the start of radiotherapy (RT) for treatment planning, and, if applicable, before the tumor bed boost. Postoperative changes, seroma, and surgical clips were used to define the tumor bed through consensus agreement of 3 observers (B.P., D.I., and J.L.). Multiple variables were examined for correlation with volumetric change. RESULTS Between the first and last scan obtained (median time, 7.2 weeks), the tumor bed volume decreased at least 20% in 86% of patients (n = 31) and at least 50% in 64% of patients (n = 23). From the postoperative scan to the planning scan (median time, 3 weeks), the tumor bed volume decreased by an average of 49.9%, or approximately 2.1% per postoperative day. From planning scan to boost scan (median interval, 7 weeks), the median tumor bed volume decreased by 44.6%, at an average rate of 0.95% per postoperative day. No single factor was significantly associated with a change in tumor bed volume greater than 20%. CONCLUSIONS The average postlumpectomy cavity undergoes dramatic volumetric change after surgery and continues this change during RT. The rate of change is inversely proportional to the duration from surgery. In this study no factors studied predicted large volumetric change.
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Affiliation(s)
- Brendan Prendergast
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL 32610-0385, USA
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Whipp EC, Halliwell M. Magnetic Resonance Imaging Appearances in the Postoperative Breast: The Clinical Target Volume–Tumor and Its Relationship to the Chest Wall. Int J Radiat Oncol Biol Phys 2008; 72:49-57. [DOI: 10.1016/j.ijrobp.2007.12.021] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2007] [Revised: 12/12/2007] [Accepted: 12/13/2007] [Indexed: 11/28/2022]
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Mannino M, Yarnold JR. Local relapse rates are falling after breast conserving surgery and systemic therapy for early breast cancer: can radiotherapy ever be safely withheld? Radiother Oncol 2008; 90:14-22. [PMID: 18502528 DOI: 10.1016/j.radonc.2008.05.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 05/01/2008] [Indexed: 11/30/2022]
Abstract
Rates of local tumour relapse after breast conservation treatment in women with early breast cancer are falling. Explanations for this decline are considered in this review including advances in breast cancer management and aging of the breast cancer population. Breast surgery has become more standardised following publication of practice guidelines and is mostly carried out by specialist surgeons. Systemic therapies (hormonal therapy and chemotherapy) are now more effective and are recommended to a higher proportion of patients than ever before. Radiotherapy techniques have also improved. The contributions of each factor are difficult to quantify precisely, but all are likely to be relevant. In order to identify a subgroup of women that might safely be spared radiotherapy, several factors are analysed, including the prognostic significance for local relapse of tumour characteristics (pathologic data, gene-expression profiles), patient characteristics and life expectancy (age and comorbidities).
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Affiliation(s)
- Mariella Mannino
- Royal Marsden Hospital, Department of Clinical Oncology, Surrey, UK
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Effect of External Boost Volume in Breast-Conserving Therapy on Local Control With Long-Term Follow-Up. Int J Radiat Oncol Biol Phys 2008; 71:115-22. [DOI: 10.1016/j.ijrobp.2007.09.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 09/13/2007] [Accepted: 09/18/2007] [Indexed: 11/22/2022]
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Jalali R, Singh S, Budrukkar A. Techniques of tumour bed boost irradiation in breast conserving therapy: current evidence and suggested guidelines. Acta Oncol 2008; 46:879-92. [PMID: 17851869 DOI: 10.1080/02841860701441798] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Breast conservation surgery followed by external beam radiotherapy to breast has become the standard of care in management of early carcinoma breast. A boost to the tumour bed after whole breast radiotherapy is employed in view of the pattern of tumour bed recurrences in the index quadrant and was particularly considered in patients with some adverse histopathological characteristics such as positive margins, extensive intraductal carcinoma (EIC), lymphovascular invasion dose in patients even without such factors and for all age groups. The maximum absolute reduction of local recurrences by the addition of boost is especially seen in young premenopausal patients. At the same time, the addition of boost is associated with increased risk of worsening of cosmesis and no clear cut survival advantage. Radiological modalities such as fluoroscopy, ultrasound and CT scan have aided in accurate delineation of tumour bed with increasing efficacy. A widespread application of these techniques might ultimately translate into improved local control with minimal cosmetic deficit. The present article discusses the role of radiotherapy boost and the means to delineate and deliver the same, identify the high risk group, optimal technique and the doses and fractionations to be used. It also discusses the extent of adverse cosmetic outcome after boost delivery, means to minimise it and relevance of tumour bed in present day scenario of advanced radiotherapy delivery techniques like Intensity modulated radiation therapy (IMRT).
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Kovacs A, Hadjiev J, Lakosi F, Glavak C, Antal G, Bogner P, Horvath A, Repa I. Comparison of Photon with Electron Boost in Treatment of Early Stage Breast Cancer. Pathol Oncol Res 2008; 14:193-7. [DOI: 10.1007/s12253-008-9015-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Accepted: 11/16/2007] [Indexed: 10/21/2022]
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Abstract
Radiotherapy to the affected breast or chest wall is well established as an integral part of postoperative management of breast cancer. However, it is known to be associated with increased cardiac and pulmonary morbidities and mortalities. Modern technologies, such as CT planning, have shown to improve treatment planning by accurately delivering optimal doses to the target volumes, while minimizing doses to sensitive structures, thus reducing potential treatment-related adverse effects. The purpose of this study is to report on our experiences with CT planning of adjuvant radiotherapy for breast cancer.
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Affiliation(s)
- T S Lim
- Perth Radiation Oncology, Royal Perth Hospital, Perth, Western Australia, Australia.
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Munhoz AM, Montag E, Arruda E, Aldrighi C, Filassi JR, de Barros AC, Piato JR, Prado L, Petti D, Baracat E, Ferreira MC. Reliability of inferior dermoglandular pedicle reduction mammaplasty in reconstruction of partial mastectomy defects: surgical planning and outcome. Breast 2007; 16:577-89. [PMID: 17566738 DOI: 10.1016/j.breast.2007.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 02/25/2007] [Accepted: 04/25/2007] [Indexed: 10/23/2022] Open
Abstract
The objective of this study is to describe the surgical planning of the inferior dermoglandular pedicle (IDP) technique and its outcome following partial mastectomy reconstruction. A total of 26 patients with breast cancer underwent immediate IDP reconstruction. IDP was indicated to reconstruct superior/central breast defects. Postoperative complications were evaluated and information on esthetic result and satisfaction were collected. About 57.6 percent had tumors measuring 2cm or less (T1). Immediate complications occurred in 34.2 percent with skin necrosis in 11.4 and dehiscence in 7.6 percent. Late complications were observed in 11.4 percent. The cosmetic result was considered to be good or very good in 88.4 percent and the majority of patients were satisfied. All complications were treated by conservative approach. IDP is a reliable technique and should be given consideration in cases of superior/central quadrant reconstruction. The success of the procedure depends on patient selection and careful intra-operative management.
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Affiliation(s)
- Alexandre Mendonça Munhoz
- Division of Plastic Surgery and Breast Surgery Group, University of São Paulo School of Medicine, Rua da Consolação 3605 ap 91 ZIP 01416-001 Sao Paulo, SP, Brazil.
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Bates AT, Swift CL, Kwa W, Moravan V, Aquino-Parsons C. A Computed Tomography-based Protocol vs Conventional Clinical Mark-up for Breast Electron Boost. Clin Oncol (R Coll Radiol) 2007; 19:349-55. [PMID: 17379487 DOI: 10.1016/j.clon.2007.02.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Revised: 01/15/2007] [Accepted: 02/02/2007] [Indexed: 11/23/2022]
Abstract
AIMS Computed tomography planning of whole breast radiotherapy (WBRT) improves breast coverage and reduces the normal tissue dose. Computed tomography planning may increase tumour bed boost treatment accuracy. The aims of this investigation were (1) to compare the breast boost volume treated with clinical mark-up with the volume delineated with computed tomography planning and (2) to study tumour bed volume changes between the initial planning computed tomography scan and a second computed tomography scan at the time of breast boost mark-up. MATERIALS AND METHODS Women receiving adjuvant WBRT and an electron boost after breast-conserving surgery were eligible. As per standard practice, WBRT was computed tomography planned while the boost electron portal was clinically defined. Electron field borders were then traced with wire and a second computed tomography scan was carried out in the boost treatment position. Post-surgical radiological abnormalities were contoured to create a tumour bed clinical target volume (CTV) on both scans (CTV1 and CTV2). A 1cm margin to CTV2 defined the planning target volume (PTV). The proportions of the CTV2 and PTV receiving 90% (V90) and 80% (V80) of the dose were calculated. Changes in volume between CTV1 and CTV2 were analysed. RESULTS Data from 47 eligible patients were analysed. The mean V90 for the PTV was 61%. Lower electron energy (P<0.001) and small field sizes (P=0.004) were associated with a low V90. The mean CTV decreased by 4.3 cm3 (P=0.014) and was smaller in those with a long surgery to computed tomography interval (P=0.008). On average, the 90% isodose covered 61 cm3 of normal tissue. CONCLUSIONS Conventional clinical breast boost planning is inaccurate. Electron boost computed tomography planning together with appropriate surgical clip placement and the use of mammograms and pathological information should provide optimal coverage of the tumour site. The boost could usually be planned from the initial computed tomography scan.
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Affiliation(s)
- A T Bates
- Department of Clinical Oncology, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK, and Department of Medical Physics, British Columbia Cancer Agency, University of British Columbia, Vancouver, Canada.
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Oh KS, Kong FM, Griffith KA, Yanke B, Pierce LJ. Planning the breast tumor bed boost: changes in the excision cavity volume and surgical scar location after breast-conserving surgery and whole-breast irradiation. Int J Radiat Oncol Biol Phys 2006; 66:680-6. [PMID: 16863683 DOI: 10.1016/j.ijrobp.2006.04.042] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Revised: 04/11/2006] [Accepted: 04/16/2006] [Indexed: 12/28/2022]
Abstract
PURPOSE The aims of this study were to determine the changes in breast and excision cavity volumes after whole-breast irradiation and the adequacy of using the surgical scar to guide boost planning. METHODS AND MATERIALS A total of 30 women consecutively treated for 31 breast cancers were included in this study. Simulation CT scans were performed before and after whole-breast irradiation. CT breast volumes were delineated using clinically defined borders. Excision cavity volumes were contoured based on surgical clips, the presence of a hematoma, and/or other surgical changes. Hypothetical electron boost plans were generated using the surgical scar with a 3-cm margin and analyzed for coverage. RESULTS The mean CT breast volumes were 774 and 761 cc (p = 0.22), and the excision cavity volumes were 32.1 and 25.1 cc (p < 0.0001), before and after 40 Gy (39-42 Gy) of whole-breast irradiation, respectively. The volume reduction in the excision cavity was inversely correlated with time elapsed since surgery (R = 0.46, p < 0.01) and body weight (R = 0.50, p < 0.01). The scar-guided hypothetical plans failed to cover the excision cavity adequately in 62% and 53.8% of cases using the pretreatment and postradiation CTs, respectively. Per the hypothetical plans, the minimum dose to the excision cavity was significantly lower for tumors located in the inner vs. outer quadrants (p = 0.02) and for cavities >20 cc vs. <20 cc (p = 0.01). CONCLUSIONS This study demonstrates a significant reduction in the volume of the excision cavity during whole-breast irradiation. Scar-guided boost plans provide inadequate coverage of the excision cavity in the majority of cases.
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Affiliation(s)
- Kevin S Oh
- Department of Radiation Oncology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Raj KA, Evans ES, Prosnitz RG, Quaranta BP, Hardenbergh PH, Hollis DR, Light KL, Marks LB. Is There an Increased Risk of Local Recurrence Under the Heart Block in Patients with Left-Sided Breast Cancer? Cancer J 2006; 12:309-17. [PMID: 16925976 DOI: 10.1097/00130404-200607000-00010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Tangential radiotherapy for left-sided breast cancer may be cardiotoxic. Shaping the field with a heart block reduces cardiac exposure but may under-dose the breast and/or chest wall. We compared the incidence and location of local recurrences in patients irradiated with and without a heart block. METHODS AND MATERIALS Between 1994 and 1998, 180 patients irradiated to the left breast and/or chest wall were retrospectively reviewed. The local recurrence rates in patients treated with and without a heart block were compared using a 2-tailed Fisher exact test. An in-depth dosimetric analysis was performed in 23 patients to assess the percentage of breast tissue under-dosed by inclusion of the heart block. RESULTS Overall, the local recurrence rates in patients with or without a heart block were similar. In postlumpectomy patients with inferiorly located tumors, the rates of local recurrence with and without a heart block were 2 of 6 patients versus 0 of 19 patients, respectively. In the dosimetric analysis, the average percentage of breast tissue under-dosed by the inclusion of a heart block was 2.8% (range, 0%-11%). DISCUSSION A heart block is a reasonable method to limit cardiac dose but should be used cautiously following a lumpectomy in patients with inferiorly located tumors. Additional study with larger numbers of patients is warranted.
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MESH Headings
- Breast Neoplasms/pathology
- Breast Neoplasms/physiopathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/physiopathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Heart Block/etiology
- Heart Block/physiopathology
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/physiopathology
- Radiotherapy/methods
- Radiotherapy Dosage
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Affiliation(s)
- Katelyn A Raj
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Jacobson G, Betts V, Smith B. Change in volume of lumpectomy cavity during external-beam irradiation of the intact breast. Int J Radiat Oncol Biol Phys 2006; 65:1161-4. [PMID: 16682143 DOI: 10.1016/j.ijrobp.2006.02.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 12/30/2005] [Accepted: 02/04/2006] [Indexed: 11/21/2022]
Abstract
PURPOSE Definition of the lumpectomy cavity is an important component of irradiation of the breast. We use computed tomography (CT)-based planning and contour the lumpectomy volume on the planning CT. We obtained a second CT in the 4th or 5th week of treatment for boost planning and compared the volume change with the first planning-CT scan. METHODS AND MATERIALS This retrospective study reviewed the planning-CT data for 20 patients. In the first CT, images were obtained from the mandible to 2 cm below the breast in 3-mm slices. In the second CT, for the boost, images were obtained from the top to the bottom of the clinically defined breast, in 3-mm slices. Lumpectomy cavities were contoured on both CT scans and volumes compared. RESULTS Sixteen of the 20 patients (80%) had more than a 20% decrease from the first to the second volume, with a corresponding 95% confidence interval. The mean decrease was 16.13 cc, with a standard deviation of 14.05. The Spearman correlation coefficient of 0.18 did not show a significant correlation between the initial volume and the percent change. CONCLUSIONS During external breast irradiation, many patients will have significant volume reduction in the lumpectomy cavity. Because CT-based definition of the lumpectomy cavity can influence the planning of a boost technique, further study appears warranted.
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Affiliation(s)
- Geraldine Jacobson
- Department of Radiation Oncology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.
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Goldberg H, Prosnitz RG, Olson JA, Marks LB. Definition of postlumpectomy tumor bed for radiotherapy boost field planning: CT versus surgical clips. Int J Radiat Oncol Biol Phys 2005; 63:209-13. [PMID: 16111591 DOI: 10.1016/j.ijrobp.2005.01.044] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2004] [Revised: 01/13/2005] [Accepted: 01/20/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the location and extent of the tumor bed as defined by surgical clips and computed tomography (CT) scans, after lumpectomy, for electron boost planning as part of breast radiotherapy. METHODS AND MATERIALS Planning CT images of 31 operated breasts in 30 patients who underwent lumpectomy were reviewed. One or more clips were placed in the lumpectomy cavity. Serial CT images were used to measure the depth and transverse and longitudinal dimensions. The area and geometric center of the tumor bed were defined by the clips and CT. RESULTS The CT and clip measurements were identical for the maximal tumor depth in 27 of 30 patients. The CT bed extended beyond the clips by 0-7 mm medially in the transverse/longitudinal extent (multiclip patients). The median distance between the geometric centers in the coronal plane for the tumor bed center was larger for patients with single clips than for those with multiple clips (p < 0.025). Tumor bed areas in the coronal plane defined by both methods correlated strongly. However, the CT-defined area was larger by 13.9 mm2. The CT bed was more readily visible in patients with a shorter interval between surgery and radiotherapy. CONCLUSION The maximal depth of the tumor bed was similar using the two methods. The extent and centers of the clip-and CT-determined beds differed significantly. This may indicate an underestimation of the tumor bed as defined by clips only and justifies integration of CT information in boost field planning.
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MESH Headings
- Adult
- Aged
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma in Situ/diagnostic imaging
- Carcinoma in Situ/radiotherapy
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Electrons/therapeutic use
- Female
- Humans
- Mastectomy, Segmental
- Middle Aged
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Adjuvant
- Surgical Instruments
- Tomography, X-Ray Computed
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Coles CE, Moody AM, Wilson CB, Burnet NG. Reduction of radiotherapy-induced late complications in early breast cancer: the role of intensity-modulated radiation therapy and partial breast irradiation. Clin Oncol (R Coll Radiol) 2005; 17:98-110. [PMID: 15830572 DOI: 10.1016/j.clon.2004.08.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Radiotherapy after conservation surgery has been proven to decrease local relapse and death from breast cancer, and is now firmly established in the management of early breast carcinoma. Currently, the challenge is to optimise the therapeutic ratio by minimising treatment-related morbidity, while maintaining or improving local control and survival. The second part of this review examines the role of two approaches: intensity-modulated radiation therapy (IMRT) and partial breast irradiation, as means of improving the therapeutic ratio. Discussion of IMRT includes both inverse- and forward-planned methods: the breast usually requires minimal modulation to improve dose homogeneity, and therefore lends itself to simpler forward-planned IMRT techniques; whereas inverse-planned IMRT may be useful in selected cases. There are many dosimetry studies reporting the superiority of IMRT over conventional breast radiotherapy, but there is still a paucity of clinical data regarding patient benefit from these techniques. A critical literature review of clinical partial breast radiotherapy studies focuses on the influence of irradiated breast volume, dose and fractionation, and patient selection on normal tissue side-effects and local control. Clinical reports of partial breast irradiation show several encouraging, but some concerning results about local recurrence rates. Therefore, mature results from randomised trials comparing partial breast irradiation with whole-breast radiotherapy are required. Accurate localisation of the tumour bed and application of appropriate clinical target volumes and planning target volumes are discussed in detail, as these concepts are fundamental for partial breast irradiation.
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Affiliation(s)
- C E Coles
- Oncology Centre, Box 193, Addenbrookes's Hospital, Hills Road, Cambridge, CB2 2QQ, UK.
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Warszawski A, Baumann R, Karstens JH. Sonographic guidance for electron boost planning after breast-conserving surgery. JOURNAL OF CLINICAL ULTRASOUND : JCU 2004; 32:333-337. [PMID: 15293299 DOI: 10.1002/jcu.20050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE This study was conducted to determine the feasibility of using sonography for electron boost planning in breast cancer treatment and to define the factors that influence the accuracy and reproducibility of this technique. PATIENTS AND METHODS Seventy-seven patients underwent 102 sonographic examinations after breast-conserving surgery and before and after radiotherapy. The size of the electron boost field was defined by measuring the postoperative cavity. Reproducibility of the sonographic findings was investigated in 25 of the patients who were examined before and after radiotherapy (at a total dose of 46-50.4 Gy). Depth (distance from the skin surface to the posterior aspect of the postoperative cavity) was measured, and sonographic appearance of the postoperative cavity was evaluated. Type of surgical procedure, time elapsed since surgery, use of systemic therapy, menopausal status, breast size, and radiation dose were investigated for their influence on sonographic appearance and visualization of the postoperative cavity. RESULTS The postoperative cavity was well visualized in 78% of patients and visualized with some difficulty in 22%. In all but 5 patients, it was hypoechoic and inhomogeneous. The mean depth of the postoperative cavity after radiotherapy was 27 +/- 4 mm. Smaller breast (p < 0.001) and younger age (p < 0.05) were associated with decreased visibility of the postoperative cavity. Sonographic appearance was the same before and after radiotherapy, but the mean difference in postoperative cavity depth between the 2 measurements was 2 mm (range, 0-4 mm). In 43/77 (56%) of the patients, changes in electron energy or in field size were required after sonographic measurement. CONCLUSION Sonography is a useful and reproducible means of electron boost planning, helping to avoid underdosage of the postoperative cavity and overdosage of normal tissue.
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Affiliation(s)
- Antje Warszawski
- Department of Radiotherapy and Special Oncology, Medical University Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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Ringash J, Whelan T, Elliott E, Minuk T, Sanders K, Lukka H, Reiter H. Accuracy of ultrasound in localization of breast boost field. Radiother Oncol 2004; 72:61-6. [PMID: 15236875 DOI: 10.1016/j.radonc.2004.03.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2003] [Revised: 03/10/2004] [Accepted: 03/16/2004] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND PURPOSE To prospectively compare diagnostic ultrasound to the 'gold standard' of surgical clips for localization of the lumpectomy site for electron boost irradiation. PATIENTS AND METHODS Consecutive breast cancer patients referred following lumpectomy underwent diagnostic ultrasound in radiation treatment position 21-100 days post-surgery. All patients had 3-6 surgical clips defining the excision cavity. The site was marked on the skin and depth was measured. Target depth was the deepest aspect of the cavity plus a 1 cm deep margin. Treatment fields were prescribed with a 2 cm margin on the cavity, and electron energy was chosen to cover the target depth. Surgical clip position was assessed on orthogonal simulator films. RESULTS Localizations were performed in 54 breasts (52 women). The mean interval post-surgery was 53 (SD 17) days. Overall, 35/54 (65%) of localizations were adequate, 15/54 (28%) were marginal and 4/54 (7%) were inadequate. Regression showed that lower patient weight (r=-0.37, P=0.006) predicted adequacy of localization, with better accuracy in lighter women. CONCLUSIONS The accuracy rate for ultrasound exceeds the 20-50% reported for clinical localization. Diagnostic ultrasound may be used to improve the accuracy when surgical clips are not present.
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Affiliation(s)
- Jolie Ringash
- Department of Radiation Oncology, Princess Margaret Hospital and University of Toronto, 610 University Avenue, Toronto, ON, Canada M5G 2M9
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Frank SJ, McNeese MD, Strom EA, Perkins G, Salehpour M, Schechter N, Buchholz TA. Advances in Radiation Treatments of Breast Cancer. Clin Breast Cancer 2004; 4:401-6. [PMID: 15023240 DOI: 10.3816/cbc.2004.n.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
During the past decade, improvements in treatment-planning tools, computer and imaging technologies, and new therapeutic modalities have allowed radiation to be delivered in a conformal fashion while minimizing treatment toxicity. It is important that physicians involved in breast cancer treatment recognize the numerous advances that have occurred in the delivery of radiation therapy. Changes in 3 specific areas in treatment planning and delivery have revolutionized the way we approach breast cancer treatment: the design of radiation fields using computed tomography (CT) data sets, the development of 3-dimensional dose-calculation algorithms, and the development of new methods to modulate the delivery of radiation dose. With the advent of CT simulators, individual patient anatomy and pathology can be readily visualized and reconstructed in axial, coronal, and sagittal views. With an improved anatomic delineation between the target volumes and critical organ structures, the treatment fields can be designed to be more congruous to the areas at highest risk. In the past few years, new 3-dimensional dose-calculation algorithms have been generated that more accurately calculate dose distributions throughout the treatment-planning volume. Finally, modern linear accelerators allow for modulation of the dose intensity of the radiation beam, which may lead to improved aesthetics and decreased side effects while ensuring that the volumes at high risk receive the prescribed dose. Radiation therapy can be delivered safely and effectively to patients with breast cancer.
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Affiliation(s)
- Steven J Frank
- Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, 77030, USA
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40
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Benda RK, Yasuda G, Sethi A, Gabram SGA, Hinerman RW, Mendenhall NP. Breast boost: are we missing the target? Cancer 2003; 97:905-9. [PMID: 12569589 DOI: 10.1002/cncr.11142] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Randomized trials have shown improved local control with the use of a breast boost for patients given breast-conserving treatment for breast carcinoma. Although the use of a breast boost is routine practice, no standard technique has been established. The authors compared the commonly used clinical technique with a technique based on computed tomography (CT) imaging of surgical clips in the tumor bed. METHODS Thirty patients underwent CT simulation for postoperative radiation treatment planning as part of breast conservation therapy. During simulation, a CT-compatible wire was placed on the patient's skin, outlining the intended electron boost field; an electron boost volume (EBV) was generated by contouring the tissue underlying the wire. Also contoured was a CT-based clinical target volume (CTV) using surgical clips and postsurgical changes in the tumor bed as a guide. A planning target volume (PTV) was generated using a 1 cm margin around the CTV. An electron beam treatment plan was generated for each technique using the FOCUS three-dimensional treatment planning system. Dose-volume histograms (DVH) were generated to determine the fraction of the PTV receiving 90% of the prescribed dose if treatment was delivered using the EBV. In addition, DVH analysis was done to determine the volume of normal tissue unnecessarily irradiated when using the EBV. RESULTS Although the electron cone size remained unchanged in most patients for both EBV and PTV, the isocenter differed more than 1 cm in the medial-lateral direction in 5 patients and in the cephalocaudal direction in 12 patients. The en face gantry angle differed for most patients. On average, only 51% (range, 27-79%) of the PTV received 90% or more of the prescribed dose when the electron plan was generated using the EBV (P < 0.0001). Ten patients received the prescription dose to less than 50% of the PTV. Mean volume of normal tissue receiving more than 50% of prescribed dose was 64.5 cm(3) (range, 24-119 cm(3)). CONCLUSIONS Clinical delineation of the tumor bed not only carries a significant risk of missing the target, but unnecessarily treats breast tissue that may otherwise be spared. Better delineation of the tumor bed, which optimizes coverage of the target volume and spares normal breast tissue, has the potential to improve both local control and cosmetic outcome. The authors recommend the use of surgical clips to delineate the target volume, followed by CT-based treatment planning, accounting for not only microscopic disease, but also organ motion and daily setup error.
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Affiliation(s)
- Rashmi K Benda
- Department of Radiation Oncology, University of lorida Health Science Center, University of Florida College of Medicine, Gainesville, Florida 32610-0385, USA.
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Polgár C, Fodor J, Major T, Orosz Z, Németh G. The role of boost irradiation in the conservative treatment of stage I-II breast cancer. Pathol Oncol Res 2002; 7:241-50. [PMID: 11882903 DOI: 10.1007/bf03032380] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In this article, we review the current status, indication, technical aspects, controversies, and future prospects of boost irradiation after breast conserving surgery (BCS). BCS and radiotherapy (RT) of the conserved breast became widely accepted in the last decades for the treatment of early invasive breast cancer. The standard technique of RT after breast conservation is to treat the whole breast up to a total dose of 45 to 50 Gy. However, there is no consensus among radiation oncologists about the necessity of boost dose to the tumor bed. Generally accepted criteria for identification of high risk subgroups, in which boost is recommended, have not been established yet. Further controversy exists regarding the optimal boost technique (electron vs. brachytherapy), and their impact on local tumor control and cosmesis. Based on the results of numerous retrospective and recently published prospective trials, the European brachytherapy society (GEC-ESTRO), as well as the American Brachytherapy Society has issued their guidelines in these topics. These guidelines will help clinicians in their medical decisions. Some aspects of boost irradiation still remain somewhat controversial. The final results of prospective boost trials with longer follow-up, involving analyses based on pathologically defined subgroups, will clarify these controversies. Preliminary results with recently developed boost techniques (intraoperative RT, CT-image based 3D conformal brachytherapy, and 3D virtual brachytherapy) are promising. However, more experience and longer follow-up are required to define whether these methods might improve local tumor control for breast cancer patients treated with conservative surgery and RT.
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Affiliation(s)
- C Polgár
- National Institute of Oncology, Department of Radiotherapy Ráth György u. 7-9., Budapest, H-1122, Hungary.
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Suntharalingam M, Laskey W, Lansky AJ, Waksman R, White L, Teirstien P, Massullo V, Rutherford B, Elman A, Kuntz RE, Popma JJ, Bonan R. Clinical and angiographic outcomes after use of 90Strontium/90Yttrium beta radiation for the treatment of in-stent restenosis: results from the Stents and Radiation Therapy 40 (START 40) registry. Int J Radiat Oncol Biol Phys 2002; 52:1075-82. [PMID: 11958904 DOI: 10.1016/s0360-3016(01)02712-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of a 40-mm 90Strontium/90Yttrium source train in the management of in-stent restenosis within native coronary arteries. MATERIALS AND METHODS This multicenter, prospective registry was designed to compare the results of patients with in-stent restenosis treated with a 40-mm source train to the placebo arm of the previously reported randomized Stents and Radiation Trial (START). All patients entered in the registry were treated with repeat balloon angioplasty followed by intravascular brachytherapy. Radiation dose was prescribed based on vessel size. 18 Gy was delivered at 2 mm for vessel diameters between 2.75 and 3.35 mm, and 23 Gy was used for vessels between 3.36 and 4.0 mm. The efficacy endpoints for the START 40 registry included a reduction in the target lesion revascularization (TLR) rate, target vessel revascularization rates, and target vessel failure (TVF) at 8 months. Secondary angiographic efficacy endpoints were binary restenosis at 8 months, in-stent minimum luminal diameter (MLD), and late loss. The safety endpoints included major adverse cardiac events as well as late aneurysm formation. The registry was designed to allow a statistically valid comparison of these results to the placebo group of the START 30 trial. Quantitative angiographic analysis was performed on the 8-month follow-up examination. Rates of restenosis were evaluated for various segments of the treated vessel. A separate analysis was performed to evaluate the relationship between vessel injury length and the radiated segment. RESULTS A total of 207 patients were entered into the START 40 registry. The postprocedure angiographic results, including the postprocedure MLD and percent diameter stenosis, were similar between the START 40 patients and the placebo group from the START trial in the stented segment of the treated vessel. Eight-month angiographic follow-up was available on 150 patients from the registry. The TLR rate was significantly reduced when compared to the placebo group (11% vs. 22.4% respectively, p = 0.008). A similar reduction was seen in terms of target vessel revascularization (15.9% vs. 24.1%, p = 0.03). The 8-month MLD was found to be significantly larger in the START 40 patients (1.85 mm vs. 1.47 mm, p < 0.0001). The difference seen in the clinical endpoint of TVF (19.3% vs. 25.9%) did not reach statistical significance (p = 0.1). Analysis of the procedural angiograms revealed mismatch between the length of vessel injured and the location of the 90% isodose in 46% of the treated cases. Angiographic analysis revealed that geographic miss was associated with a higher rate of binary restenosis (32% vs. 18% p = 0.04) in the analysis segment. CONCLUSIONS This multicenter registry demonstrates the safety and efficacy of a 40-mm 90Strontium/90Yttrium source train in the management of patients with in-stent restenosis. Restenosis rates were lowered with the use of this longer source train when compared to the placebo arm of the START trial for lesions with a maximum vessel injury length of 20 mm. Angiographic analysis identified the importance of the accurate delineation of injury length and correct source positioning. These results support the continued use of beta radiation for the treatment of this disease process.
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Affiliation(s)
- Mohan Suntharalingam
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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Kokubo M, Mitsumori M, Yamamoto C, Fujishiro S, Mise K, Kodama H, Nagata Y, Hiraoka M. Impact of boost irradiation with surgically placed radiopaque clips on local control in breast-conserving therapy. Breast Cancer 2002; 8:222-8. [PMID: 11668244 DOI: 10.1007/bf02967512] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study was to determine whether boost irradiation relying on radiopaque clips placed surgically around the resected margin of breast cancer contributes to increasing the local control rate in patients with close or positive margins in breast-conserving therapy (BCT). METHODS Among 837 patients with breast cancer who underwent BCT between November 1987 and December 1998, 181 patients with close or positive surgical margins received boost irradiation following conventional tangential whole breast irradiation. Since 1994, four radiopaque clips were surgically placed around the resected margin of the breast cancer in 155 patients treated with wide excision. The four clips were clearly and accurately identified with a CT-simulator (CT-S). The boost irradiation field was automatically determined with a safety margin of 3 cm according to one-to-one correspondence of radiopaque clips to pathologically close or positive surgical margins. In the remaining 26 patients treated before 1994, the boost irradiation field was determined according to the skin tattoo of the primary tumor. RESULTS The median follow-up period of the 155 patients receiving the radiopaque clips was 42 months (range: 19 to 78), and that of the 26 patients without the clips was 87 months. Local recurrence was observed in two of the 155 patients who underwent boost irradiation using the radiopaque clips 39 and 54 months after the surgery, while 4 of the 26 patients developed local recurrence 14, 23, 51, and 76 months after BCT. In three of the four patients without the clips developing local recurrences, local recurrences were observed at the margin of the boost irradiation field. The 5-year local recurrence-free survival rate of patients who received boost irradiation with the radiopaque clips was 97%, and that of patients without the clips was 88%. The difference of local recurrence-free survival rates between the patients with and without the clips was significant (p<0.05). CONCLUSION Surgically placed radiopaque clips appear to be useful for determining adequate boost field in the BCT using the CT-S and help increase the local control rate.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Contrast Media
- Disease-Free Survival
- Female
- Humans
- Japan
- Mastectomy, Segmental/methods
- Mastectomy, Segmental/mortality
- Middle Aged
- Radiotherapy, Adjuvant
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- M Kokubo
- Department of Therapeutic Radiology and Oncology, Graduate School of Medicine, Kyoto University, Japan
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Abstract
PURPOSE To compare computed tomography (CT) with ultrasonography (US) for depiction of the biopsy cavity. MATERIALS AND METHODS Thirty-two consecutive patients who underwent radiation therapy following lumpectomy with a planned electron boost were examined. At the time of simulation for whole-breast radiation therapy, all patients underwent planning CT (CT 1) at 3-mm section intervals. At the time of electron boost simulation, US was performed to define the biopsy cavity. In 17 cases, a second CT examination (CT 2) was performed at the time of electron boost simulation. CT and US studies were reviewed jointly and assigned a cavity visualization score (CVS) of 1 (cavity not visualized) to 5 (all cavity margins clearly defined). RESULTS The median CVS at CT 1 was 5; at CT 2, 4; and at US, 4. For patients who underwent all three studies, the median CVS at CT 1 was 5; at CT 2, 4; and at US, 4. Factors related to CVS at CT 1 were homogeneous versus heterogeneous appearance (score, 5 vs 4), surgery-to-CT interval (< or =30 days, 5; 31-60 days, 4; >60 days, 4), and cavity size (>15 cm(3), 5; <15 cm(3), 4). In all cases, cavity volume decreased somewhat during the CT 1-to-CT 2 interval. CONCLUSION CT performed at the time of whole-breast simulation can be used to plan electron boost fields, with cavity visualization similar to that at US.
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MESH Headings
- Adult
- Aged
- Biopsy
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Computer Simulation
- Female
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Staging
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Adjuvant
- Tomography, X-Ray Computed
- Ultrasonography, Mammary
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Affiliation(s)
- M C Smitt
- Department of Radiation Oncology, Stanford Hospital, Stanford University Medical Center, 300 Pasteur Dr, Stanford, CA 94305, USA.
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Kantorowitz DA. The impact of dose-specification policies upon nominal radiation dose received by breast tissue in the conservation treatment of breast cancer. Int J Radiat Oncol Biol Phys 2000; 47:841-8. [PMID: 10837972 DOI: 10.1016/s0360-3016(00)00453-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE In the context of breast conservation treatment, absorbed dose is influenced by (1) prescribed nominal dose, and (2) dose-specification characteristics employed. Breast doses are generally specified either at tangent isocenter, varying anatomical points within the breast, or at isodoses varying from 90% to 100%. Boost doses are generally specified at 80-100%. METHODS An idealized axial slice of breast tissue at central axis is presented. Assuming varying dose-specification characteristics, absorbed doses are normalized and compared to those received by nominal prescriptions of 46 Gy to the breast and 20 Gy to the boost volume, both specified at 100%. RESULTS Absorbed doses vary from the normalized total of 66 Gy (with specification of breast and boost at 100%) in gradations up to a maximum of 76.11 Gy (when breast dose is specified at the 90% isodose and boost dose at 80%), a 13.3% difference. CONCLUSION The impact of dose specification is largely ignored in the breast irradiation literature and unappreciated in clinical practice. Its impact, however, is illustrated as dwarfing modest nominal dose escalations commonly recommended and prescribed among margin compromised patients. Progress in delineation of a dose-response relationship for treatment of breast cancer requires consensus as to dose specification. Arguments are offered that ICRU Report 50 dose-specification standards, as verified for reproducibility by the EORTC (22881/10882) trial group, constitutes the best data source currently available from which dose-specification consensus may be reached (1, 2). Dose to PTV(1) (whole breast plus 1- to 2-cm margin) should be specified at the tangent beam intersection on the central plane or, where such point is irrelevant, at two-thirds distance from dorsal beam edge to skin along the perpendicular breast bisector. Where irradiated via electrons, dose to the boost PTV(2) (lumpectomy cavity plus 1- to 3-cm margins) should be specified at 90%. Electron energy sufficient to provide 85% isodose coverage to all aspects of PTV(2) is recommended.
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Affiliation(s)
- D A Kantorowitz
- North Puget Oncology, Affiliated Health Services, Sedro Woolley, WA 98284, USA
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46
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Kovner F, Agay R, Merimsky O, Stadler J, Klausner J, Inbar M. Clips and scar as the guidelines for breast radiation boost after lumpectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1999; 25:483-6. [PMID: 10527596 DOI: 10.1053/ejso.1999.0683] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND AIMS Breast-conserving therapy in early breast cancer is equally effective as mastectomy, with advantages of cosmesis and quality of life over mastectomy. Local control is improved when entire breast irradiation is combined with a radiation boost to the tumour bed. METHODS Localization of the tumour bed was compared in 45 consecutive patients using surgical scar and radiopaque clips placed intra-operatively in the lumpectomy cavity. RESULTS The area (A) of the radiation boost field and volume (V) of the tumour bed, designed on the basis of scar (AS and VS), were 1.4 times larger than those designed on the basis of the clips (AC and VC). AS and VS missed about one-quarter of the tumour bed which had been delineated by clips intra-operatively, while about one-half of it encompassed tissues beyond the AC and VC. CONCLUSIONS A boost planned by scar dimensions can miss a substantial portion of the tumour bed, compromising local control. On the other hand, a substantial amount of breast tissue beyond the tumour bed can be unnecessarily irradiated, compromising cosmetic treatment results. Thus, the scar provides an inadequate landmark for radiation boost planning in breast-conserving therapy.
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Affiliation(s)
- F Kovner
- Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Helyer SJ, Moskovic E, Ashley S, Hastings L, Yarnold JR. A study testing the routine use of ultrasound measurements when selecting the electron energy for breast boost radiotherapy. Clin Oncol (R Coll Radiol) 1999; 11:164-8. [PMID: 10465469 DOI: 10.1053/clon.1999.9034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The determination of the depth of the tumour bed within the breast requiring an electron therapy boost dose is generally judged clinically and can be inconsistent between individual radiotherapists. High frequency ultrasound provides a reproducible, safe and quick method of measuring this depth. In order to improve current working practice at the Royal Marsden NHS Trust the routine use of ultrasound when planning breast boost radiotherapy was established. Fifty-three early stage postoperative breast cancer patients had both clinical and ultrasound assessments of boost depth performed. These measurements were converted into electron energy and compared. Measurements ranged from 0.8 cm to 4.9 cm and electron energy from 4 MeV to 15 MeV. As a direct result of the ultrasound measurements taken, 60% of patients had their electron energy changed from that chosen by the clinically assessed measurement. Overall, the energy was as likely to be increased as decreased. Breast size did not influence the need for change but patients with small breasts never required an increase in the energy from that chosen clinically. It was concluded that the use of ultrasound, once integrated into the planning process, can improve accuracy when selecting electron energy for patients receiving breast boost irradiation.
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Affiliation(s)
- S J Helyer
- Royal Marsden NHS Trust and Institute of Cancer Research, Sutton, UK
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Valdagni R, Amichetti M, Ciocca M. Patterns of radiotherapy for early breast cancer in Northern Italy compared with European and national standards. Radiother Oncol 1999; 51:79-85. [PMID: 10386720 DOI: 10.1016/s0167-8140(99)00028-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the current practice of early breast cancer (EBC) post-operative irradiation in Northern Italy and to evaluate its conformance with European standards and recently defined national guidelines. MATERIALS AND METHODS Fifty Radiotherapy departments in Northern Italy received a questionnaire assessing parameters on pre-treatment evaluation of patients, on preparation, prescription and execution phases of irradiation (XRT), on surgery-XRT-chemotherapy integration and on follow-up. The analysis of collected information was compared with both the 1991 EORTC-EUSOMA guidelines and the 1997 AIRO (Italian Association for Radiation Oncology) minimal requirements on EBC post-operative irradiation. RESULTS Thirty-nine out of 50 (78%) departments answered the questionnaire. All treat T1-T2 tumours, after tumourectomy or, mostly, quadrantectomy. The mean interval between surgery and XRT is 45 +/- 14 days. Chemotherapy is delivered concurrently in 70% of departments, CTV is represented by residual mammary gland in 100% of cases, while 38% and 52% of departments occasionally treat internal mammary and axillary or supra-clavicular nodes, respectively. Total dose delivered to the whole breast is 46-50 Gy in 98% (1.8-2 Gy/fraction). The tumour bed is boosted in 79% of cases. An immobilization device is used in 28% of cases CTV is clinically localized in 62% of patients. Tangential fields are simulated in 85% of centres, with film storage in 78% of cases. Co-60 units are used in 58% and/or 4-6 MV X-rays in 70% of centres, mostly utilizing beam modifiers. Computerized treatment planning is performed in 95% of cases. Fifty-five percent of departments prescribe the dose at the ICRU point. Portal films are routinely taken in 50% of cases. Boost irradiation is mainly performed using external XRT. Lastly, acute and late side effects and cosmesis are respectively evaluated in 100%, 98% and 90% of centres. CONCLUSIONS Results on current practice in Northern Italy generally show a good conformance with European standards. However, some variables related to treatment prescription, simulation and treatment planning need to be standardized. This set of information was largely utilized by the AIRO to define national guidelines adapted to the Italian resources and situation.
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Affiliation(s)
- R Valdagni
- Department of Radiation Oncology, Casa di Cura S.Pio X, Milan, Italy
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Krawczyk JJ, Engel B. The importance of surgical clips for adequate tangential beam planning in breast conserving surgery and irradiation. Int J Radiat Oncol Biol Phys 1999; 43:347-50. [PMID: 10030260 DOI: 10.1016/s0360-3016(98)00402-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE To evaluate the role of surgical clips in the planning of tangential beams in patients undergoing breast conserving surgery and adjuvant radiotherapy. METHODS AND MATERIALS Between September 1996 and April 1998, 25 consecutive female patients with ductal carcinoma in situ, Stage I and II cancer of the breast, underwent lumpectomy with the excision cavity marked by the surgical clips. Subsequently, tangential fields were planned using clinical and radiologic information obtained during simulation without the clips position being visible. RESULTS When measured from the center of the deepest clip to the posterior field border of the tangential fields in 6/25 patients (24%) the distance was less than 2 cm, with the closest being only 0.5 cm. Respective measurements for the distal end of the clip and the posterior border were: 9/25 patients (36%); less than 2 cm, with the closest distance of 0.3 cm. There was a positive correlation between the distance from the scar to the palpable breast border and the distance between the deepest clip and the posterior border of the tangential beams. CONCLUSION The lumpectomy scar is often a poor indicator of the excision cavity as demarcated by surgical clips. Without the clips, part of the cavity may be underdosed by the tangential radiation beams. This is more likely for the cavities located close to the lateral or medial border of the breast tissue.
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Affiliation(s)
- J J Krawczyk
- Department of Radiation Oncology, Allan Blair Cancer Centre, Regina, Saskatchewan, Canada
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DiBiase SJ, Komarnicky LT, Schwartz GF, Xie Y, Mansfield CM. The number of positive margins influences the outcome of women treated with breast preservation for early stage breast carcinoma. Cancer 1998. [DOI: 10.1002/(sici)1097-0142(19980601)82:11<2212::aid-cncr16>3.0.co;2-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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