1
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Nichols EM, Bentzen SM, Milburn M, Kesmodel SB, Bellavance E, Becker SJ, Mutaf Y, Tkaczuk K, Rosenblatt P, Feigenberg SJ. A Prospective Trial of Single-Fraction Radiation to the Tumor Bed with a Novel Breast-Specific Stereotactic Radiation Therapy Device: The GammaPod. Adv Radiat Oncol 2024; 9:101398. [PMID: 38778822 PMCID: PMC11110030 DOI: 10.1016/j.adro.2023.101398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 09/24/2023] [Indexed: 05/25/2024] Open
Abstract
Purpose Radiation therapy for early-stage breast cancer is typically delivered in a hypofractionated regimen to the whole breast followed by a tumor bed boost. This results in a treatment course of approximately 4 weeks. In this study, the tumor bed boost was delivered in a single fraction as part of a safety and feasibility study for FDA clearance of the device. Methods and Materials Eligible women with early-stage breast cancer underwent lumpectomy followed by radiation therapy. Patients underwent breast immobilization using a system specific to the GammaPod followed by CT simulation, boost treatment planning, and boost treatment delivery all in a single treatment day. Patients then started whole-breast radiation therapy within 1 week of the boost treatment. Patients and treatments were assessed for safety and feasibility. Acute toxicities were recorded. Results A single-fraction boost of 8 Gy was delivered to the tumor bed before a course of whole-breast radiation. The GammaPod treatment was successfully delivered to 14 of 17 enrolled patients. Acute toxicities from all radiation therapy, inclusive of the boost and whole-breast radiation, were limited to grade 1 events. Conclusions The GammaPod device successfully delivered a single-fraction boost treatment to the tumor bed with no change in expected acute toxicities. The results of this study led to FDA clearance of the device through the Investigational Device Exemption process at the FDA. The GammaPod is in clinical use at 4e institutions nationally and internationally, with additional sites pending in 2023.
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Affiliation(s)
- Elizabeth M. Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Søren M. Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | - Steven J. Feigenberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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2
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Kaidar-Person O, Offersen BV, Tramm T, Christiansen P, Damsgaard TE, Kothari A, Poortmans P. The King is in the altogether: Radiation therapy after oncoplastic breast surgery. Breast 2023; 72:103584. [PMID: 37783134 PMCID: PMC10562190 DOI: 10.1016/j.breast.2023.103584] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/24/2023] [Indexed: 10/04/2023] Open
Abstract
Breast cancer is the most common malignancy, and the majority of the patients are diagnosed at an early disease stage. Breast conservation is the preferred locoregional approach, and oncoplastic breast conservation surgery is becoming more popular. This narrative review aims to discuss the challenges and uncertainties in target volume definition for postoperative radiation after these procedures, to improve radiation therapy decisions and encourage multidisciplinary.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Radiation Unit, Oncology Institute, Sheba Tel Hashomer, Ramat Gan, Israel; Tel Aviv University, Israel.
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Tine Engberg Damsgaard
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
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3
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Dejonckheere CS, Abramian A, Lindner K, Bachmann A, Layer K, Anzböck T, Layer JP, Sarria GR, Scafa D, Koch D, Leitzen C, Kaiser C, Faridi A, Schmeel LC. Objective, Clinician- and Patient-Reported Evaluation of Late Toxicity Following Adjuvant Radiation for Early Breast Cancer: Long-Term Follow-Up Results of a Randomised Series. J Clin Med 2023; 12:4212. [PMID: 37445247 DOI: 10.3390/jcm12134212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/15/2023] Open
Abstract
Background and Purpose: This study aimed to differentially assess the frequency and severity of late radiation-induced toxicity following adjuvant whole-breast irradiation for early breast cancer with conventional fractionation (CF) and moderate hypofractionation (mHF). Materials and Methods: Patients recruited in a previous randomised controlled trial comparing acute toxicity between CF and mHF without disease recurrence were included in a post hoc analysis. Spectrophotometric and ultrasonographic examinations were performed for an objective evaluation and subsequent comparison of long-term skin toxicity. Furthermore, patient- and clinician-reported outcomes were recorded. Results: Sixty-four patients with a median age of 58 (37-81) years were included. The median follow-up was 57 (37-73) months. A total of 55% underwent CF and 45% mHF. A total of 52% received a sequential boost to the tumour bed. A significant decrease in mean L* (p = 0.011) and an increase in a* (p = 0.040) and b* values (p < 0.001) were observed, indicating hyperpigmentation. In comparison with the non-irradiated breast, there was a significant increase in both cutis (+14%; p < 0.001) and subcutis (+17%; p = 0.011) thickness, significantly more pronounced in CF patients (p = 0.049). In CF patients only, a sequential boost significantly increased the local cutis thickness and oedema compared to non-boost regions in the same breast (p = 0.001 and p < 0.001, respectively). Conclusions: mHF objectively resulted in reduced long-term skin toxicity compared to CF. A sequential boost increased the local fibrosis rate in CF, but not in mHF. This might explain the subjectively reported better cosmetic outcomes in patients receiving mHF and reinforces the rationale for favouring mHF as the standard of care.
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Affiliation(s)
| | - Alina Abramian
- Department of Gynaecology, Division of Senology, University Hospital Bonn, 53127 Bonn, Germany
| | - Kira Lindner
- Department of Gynaecology, Division of Senology, University Hospital Bonn, 53127 Bonn, Germany
| | - Anne Bachmann
- Department of Gynaecology, Division of Senology, University Hospital Bonn, 53127 Bonn, Germany
| | - Katharina Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Teresa Anzböck
- Department of Gynaecology, Division of Gynaecology and Gynaecological Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Julian Philipp Layer
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
- Institute of Experimental Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | | | - Davide Scafa
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Hospital Bonn, 53127 Bonn, Germany
| | - Christina Kaiser
- Department of Gynaecology, Division of Senology, University Hospital Bonn, 53127 Bonn, Germany
| | - Andree Faridi
- Department of Gynaecology, Division of Senology, University Hospital Bonn, 53127 Bonn, Germany
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4
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Günay S, Gökçek B, Kandemir Ö, Akan A, Yalçın O. Long-term results of breast cancer patients who received IOERT as boost during BCS: A single-institution retrospective analysis. Turk J Surg 2023; 39:115-120. [PMID: 38026906 PMCID: PMC10681109 DOI: 10.47717/turkjsurg.2023.5978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/23/2023] [Indexed: 12/01/2023]
Abstract
Objectives Intraoperative electron radiotherapy (IOERT) applied as boost to the tumor bed during breast conserving surgery is advantageous in terms of local recurrence in breast cancer patients. In addition, it has other advantages over the adjuvant boost RT such as no risk of tumor bed change, ease of sequencing radiotherapy chemotherapy, and reduced workload of the radiotherapy clinic. This study aimed to evaluate the long-term results of our patients who were treated with this method in our institution and are still being followed up. Material and Methods One hundred and three patients enrolled in this study received IOERT equivalent to 10 Gy as boost during BCS and were subsequently given adjuvant WBI according to the biological subtype of the tumor systemic therapy. These patients were analyzed using their files and hospital records. Patients were evaluated for overall survival, local recurrence, distant metastasis, and cosmetic outcome (using LENT-SOMA scale). Results Median age was 53,5 (27-74), mean follow-up time was 75 (48-106) months. Mean pathological tumor size was 18 mm (4-30), 90 of the patients had invasive ductal carcinoma, eight of them were lobular and five of them had mixed histological structure. Ninety-three of the patients presented histological grade II, 15 grade III; 74 patients were luminal A-like, 15 luminal B-like, eight HER2 positive and six triple negative breast cancer. According to the LENT-SOMA scale, 35 had grade 0, 42 each had grade I, 23 had grade II, and two had grade III. All patients underwent whole breast irradiation after surgery, 81 received chemotherapy and 90 endocrine therapy. There was one local recurrence, distant recurrence was seen in four patients and one patient died of non-breast cancer causes. Overall survival was %99, and event free survival %96. Conclusion IOERT for breast cancer treatment during BCS is a safe option with low chronic toxicity and the cosmetic outcome gets better over time.
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Affiliation(s)
- Semra Günay
- Clinic of Breast and Endocrine Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Berk Gökçek
- Clinic of General Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Özge Kandemir
- Clinic of Radiation Oncology, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Arzu Akan
- Clinic of Breast and Endocrine Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
| | - Orhan Yalçın
- Clinic of Breast and Endocrine Surgery, Prof. Dr. Cemil Taşcıoğlu City Hospital, Health Science University Faculty of Medicine, İstanbul, Türkiye
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5
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van Loevezijn AA, Geluk CS, van den Berg MJ, van Werkhoven ED, Vrancken Peeters MJTFD, van Duijnhoven FH, Hoornweg MJ. Immediate or delayed oncoplastic surgery after breast conserving surgery at the Netherlands Cancer Institute: a cohort study of 251 cases. Breast Cancer Res Treat 2023; 198:295-307. [PMID: 36690822 DOI: 10.1007/s10549-022-06841-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/03/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE Oncoplastic surgery (OPS) after breast conserving surgery is preferably performed during the same operation. Offering delayed OPS instead of mastectomy to patients with a high risk of tumor-positive margins allows breast conservation with the option of margin re-excision during OPS, without having to dismantle the reconstruction. We aimed to evaluate surgical outcomes after immediate and delayed OPS. METHODS We included early-stage breast cancer patients who underwent OPS at the Netherlands Cancer Institute between 2016 and 2019. Patients were selected for delayed OPS after multidisciplinary consultation if the risk of tumor-positive margins with immediate OPS was considered significant (> 30%). Groups were compared on baseline characteristics and short-term surgical outcomes. RESULTS Of 242 patients with 251 OPS, 130 (52%) OPS had neoadjuvant chemotherapy. Immediate OPS was performed in 176 (70%) cases and delayed OPS in 76 (30%). Selection for delayed OPS was associated with tumor size (OR 1.03, 95% CI 1.01-1.04), ILC (OR 2.61, 95% CI 1.10-6.20), DCIS (OR 3.45, 95% CI 1.42-8.34) and bra size (OR 0.76, 95% CI 0.62-0.94). Delayed and immediate OPS differed in tissue weight (54 vs. 67 g, p = 0.034), tissue replacement (51% vs. 26%, p < .001) and tumor-positive margins (66% vs. 18%, p < .001). Re-excision was performed in 48 (63%) delayed OPS and in 11 (6%) immediate OPS. Groups did not differ in complications (21% vs. 18%, p = 0.333). Breast conservation after immediate and delayed OPS was 98% and 93%, respectively. CONCLUSION Performing delayed OPS in selected cases facilitated simultaneous margin re-excision without increasing complications, and resulted in an excellent breast conservation rate.
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Affiliation(s)
- Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Charissa S Geluk
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marieke J van den Berg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgical Oncology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marije J Hoornweg
- Department of Plastic and Reconstructive Surgery, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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6
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He L, Zhou J, Qi Y, He D, Yuan C, Chang H, Wang Q, Li G, Shao Q. Comparison of the Oncological Efficacy Between Intraoperative Radiotherapy With Whole-Breast Irradiation for Early Breast Cancer: A Meta-Analysis. Front Oncol 2022; 11:759903. [PMID: 34976808 PMCID: PMC8718609 DOI: 10.3389/fonc.2021.759903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/29/2021] [Indexed: 01/09/2023] Open
Abstract
Background Intraoperative radiotherapy (IORT) and whole-breast irradiation (WBI) are both effective radiotherapeutic interventions for early breast cancer patients undergoing breast-conserving surgery; however, an issue on whether which one can entail the better prognosis is still controversial. Our study aimed to investigate the 5-year oncological efficacy of the IORT cohort and the WBI cohort, respectively, and compare the oncological efficacy between the cohorts. Materials and Methods We conducted a computerized retrieval to identify English published articles between 2000 and 2021 in the PubMed, the Web of Science, the Cochrane Library, and APA PsycInfo databases. Screening, data extraction, and quality assessment were performed in duplicate. Results A total of 38 studies were eligible, with 30,225 analyzed participants. A non-comparative binary meta-analysis was performed to calculate the weighted average 5-year local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS) in the two cohorts, respectively. The LRFS, DMFS, and OS (without restriction on the 5-year outcomes) between the two cohorts were further investigated by a comparative binary meta-analysis. The weighted average 5-year LRFS, DMFS, and OS in the IORT cohort were 96.3, 96.6, and 94.1%, respectively, and in the WBI cohort were 98.0, 94.9, and 94.9%, respectively. Our pooled results indicated that the LRFS in the IORT cohort was significantly lower than that in the WBI cohort (pooled odds ratio [OR] = 2.36; 95% confidential interval [CI], 1.66–3.36). Nevertheless, the comparisons of DMFS (pooled OR = 1.00; 95% CI, 0.76–1.31), and OS (pooled OR = 0.95; 95% CI, 0.79–1.14) between the IORT cohort with the WBI cohort were both not statistically significant. Conclusions Despite the drastically high 5-year oncological efficacy in both cohorts, the LRFS in the IORT cohort is significantly poorer than that in the WBI cohort, and DMFS and OS do not differ between cohorts.
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Affiliation(s)
- Lin He
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China.,Cancer Center, Faculty of Health Sciences, University of Macau, Macau, Macau SAR, China
| | - Jiejing Zhou
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Yuhong Qi
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Dongjie He
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Canliang Yuan
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Hao Chang
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Qiming Wang
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Gaiyan Li
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Qiuju Shao
- Department of Radiotherapy, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
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7
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Kaidar-Person O, Dahn HM, Nichol AM, Boersma LJ, de Ruysscher D, Meattini I, Pignol JP, Aristei C, Belkacemi Y, Benjamin D, Bese N, Coles CE, Franco P, Ho AY, Hol S, Jagsi R, Kirby AM, Marrazzo L, Marta GN, Moran MS, Nissen HD, Strnad V, Zissiadis Y, Poortmans PM, Offersen BV. A Delphi study and International Consensus Recommendations: The use of bolus in the setting of postmastectomy radiation therapy for early breast cancer. Radiother Oncol 2021; 164:115-121. [PMID: 34563607 DOI: 10.1016/j.radonc.2021.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 01/01/2023]
Abstract
Bolus serves as a tissue equivalent material that shifts the 95-100% isodose line towards the skin and subcutaneous tissue. The need for bolus for all breast cancer patients planned for postmastectomy radiation therapy (PMRT) has been questioned. The work was initiated by the faculty of the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer courses and represents a multidisciplinary international breast cancer expert collaboration to optimize PMRT. Due to the lack of randomised trials evaluating the benefits of bolus, we designed a stepwise project to evaluate the existing evidence about the use of bolus in the setting of PMRT to achieve an international consensus for the indications of bolus in PMRT, based on the Delphi method.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, at Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Developmental Biology (Maastro), Maastricht University, Maastricht, The Netherlands.
| | - Hannah M Dahn
- Department of Radiation Oncology, Dalhousie University, Halifax, Canada
| | - Alan M Nichol
- Department of Radiation Oncology, BC Cancer - Vancouver, Vancouver, Canada
| | - Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dirk de Ruysscher
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence; Radiation Oncology Unit, Azienda Ospedaliero-Universitaria Careggi; Florence, Italy
| | | | - Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Yazid Belkacemi
- Department of Radiation Oncology and Henri Mondor Breast Center, University of Paris-Est (UPEC), Creteil, France, INSERM Unit 955, Creteil, France
| | - Dori Benjamin
- Department of Physics, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Nuran Bese
- Acibadem Mehmet Ali Aydinlar University, Research Institute of Senology Istanbul, Turkey
| | | | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, University Hospital "Maggiore della Carità,", Novara, Italy
| | - Alice Y Ho
- Harvard Medical School, Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
| | - Sandra Hol
- Instituut Verbeeten, Tilburg, The Netherlands
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Anna M Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
| | - Livia Marrazzo
- Medical Physics Unit, Careggi University Hospital, Florence, Italy
| | - Gustavo N Marta
- Department of Radiation Oncology - Hospital Sírio-Libanês, São Paulo, Brazil
| | | | | | - Vratislav Strnad
- Dept. of Radiation Oncology, University Hospital Erlangen, Germany
| | | | | | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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8
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Lee DS, Lee YK, Kang YN, Won YG, Park SH, Kim YS, Kim JS, Won HS. Assessment of planning reproducibility in three-dimensional field-in-field radiotherapy technique for breast cancer: impact of surgery-simulation interval. Sci Rep 2021; 11:1556. [PMID: 33452292 PMCID: PMC7810888 DOI: 10.1038/s41598-020-78666-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022] Open
Abstract
The three-dimensional field-in-field (3-D FIF) technique for radiotherapy is an advanced, state-of-the-art method that uses multileaf collimators to generate a homogeneous and conformal dose distribution via segmental subfields. The purpose of this study is to evaluate the dosimetric reproducibility of 3-D FIF plans using the original simulation computed tomography (iCT) scans and re-simulation CT (rCT) scans for whole breast irradiation (WBI) schedule. This study enrolled a total of 34 patients. The study population underwent iCT scans for standard WBI and took rCT scans after 45 Gy of WBI for cone down boost plans. The dosimetric parameters (V105%, V103%, V100%, V98%, V95%, V90%, V50%), plan quality indices (conformity index, homogeneity index) and clinical parameters (isocenter-breast axis, isocenter-lung axis, soft tissue volumes within radiation field, lung volumes within radiation field) were assessed. The median time interval from surgery to iCT was 33 days and from iCT to rCT was 35 days. All dosimetric parameters exhibited statistically significant differences between iCT and rCT among cohorts with a surgery-iCT interval of < 60 days. Homogeneity index showed a statistically significant increase from iCT to rCT among all cohorts. Soft tissue volumes (p = 0.001) and isocenter-breast axis (p = 0.032) exhibited statistically significant differences among cohorts with surgery-iCT interval < 60 days. Regarding the reproducibility of the 3-D FIF WBI plans, significant changes were observed in dosimetric and clinical factors, particularly in study cohorts with a surgery-simulation interval < 60 days. The main contributing factor of these transitions seemed to be the changes in volume of the soft tissue within the WBI field. Further confirmative studies are necessary to determine the most suitable timing and technique for WBI.
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Affiliation(s)
- Dong Soo Lee
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Young Kyu Lee
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Proton Therapy Center, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Young Nam Kang
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Gyun Won
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,AbbVie Biopharmaceutical Company, Seoul, Republic of Korea
| | - Seung Hwan Park
- Department of Radiation Oncology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Seok Kim
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeong Soo Kim
- Department of Surgery, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Sung Won
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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9
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Xu HP, Bronsart E, Costa É, Krhili S, Logerot C, Bazire L, Fournier-Bidoz N, Belshi A, Fourquet A, Kirova YM. Patterns of locoregional failure in women with early-stage breast cancer treated by whole breast irradiation in the lateral isocentric decubitus position: Large-scale single-centre experience. Cancer Radiother 2019; 23:116-124. [PMID: 30935887 DOI: 10.1016/j.canrad.2018.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 08/01/2018] [Accepted: 08/10/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to evaluate locoregional control and describe the patterns of failure in patients with breast cancer receiving whole breast radiotherapy in the isocentric lateral decubitus position technique. PATIENTS AND METHODS In a series of 832 consecutive female patients with early-stage breast cancer including invasive and in situ tumours treated by breast-conserving surgery followed by three-dimensional conformal whole breast irradiation in the isocentric lateral decubitus position between 2005 and 2010, all patients who experienced locoregional recurrence were studied. Five-year recurrence-free and overall survival rates were calculated. Regional recurrence mapping patterns were also determined. RESULTS The median age of this series of 832 women was 61.5 years (range: 29-90 years). Various types of fractionation were used: 50Gy in 25 fractions (17.9%), 66Gy in 33 fractions (50Gy in 25 fractions to breast followed by sequential boost to tumour bed to a total dose 66Gy in 33 fractions.) (46.5%), 40Gy in 15 fractions or 41.6Gy in 13 fractions (26.1%) and 30Gy in 5 fractions (9.5%). With a median follow-up of 6.4 years, only 36 patients experienced locoregional recurrence and no association with the fractionation regimen was identified (P=0.2). In this population of 36 patients, 28 (3.3%) had "in-breast" local recurrences (77.8%), two had local recurrences and regional lymph node recurrence (5.6%), and six had regional lymph node recurrence only (in non-irradiated areas; 16.6%). The median time to recurrence was 50 months. Complete mapping of patterns of recurrences was performed and, in most cases, local recurrences were situated adjacent to the primary tumour bed. Cases of local recurrences presented a significantly lower distant metastasis rate (P<0.001) and had a significantly longer overall survival compared to patients with regional lymph node recurrence (P<0.001). However, multivariate Cox regression analysis showed that the site of recurrence had no significant impact on overall survival (P=0.14). CONCLUSION The results of this study indicate a low local recurrence rate. Further careful follow-up and recording of recurrences is needed to improve the understanding of patterns of recurrence.
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Affiliation(s)
- H-P Xu
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France; Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - E Bronsart
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - É Costa
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - S Krhili
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - C Logerot
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - L Bazire
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - N Fournier-Bidoz
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - A Belshi
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - A Fourquet
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - Y-M Kirova
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France.
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10
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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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11
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Ippolito E, Rinaldi CG, Silipigni S, Greco C, Fiore M, Sicilia A, Trodella L, D’Angelillo RM, Ramella S. Hypofractionated radiotherapy with concomitant boost for breast cancer: a dose escalation study. Br J Radiol 2019; 92:20180169. [PMID: 30433824 PMCID: PMC6541174 DOI: 10.1259/bjr.20180169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 10/04/2018] [Accepted: 11/02/2018] [Indexed: 12/25/2022] Open
Abstract
METHODS: Patients with breast cancer with pathological stage pT 1-2 and at least one risk factor for local recurrence such as N1 disease, lymphovascular invasion, extensive intraductal component, close margins, non-hormone sensitive disease, grading G3 were enrolled. Patients were treated with hypofractionated RT to whole breast with a dose of 40.05 Gy in 15 fractions. The dose was escalated to the tumour bed through a daily concomitant boost technique at three dose levels: 48 Gy (3.2 Gy/die), 50.25 Gy(3.35 Gy/die) and 52.5 Gy (3.5 Gy/die). Dose escalation to a higher step was carried out if all patients of the lower dose had completed the treatment without dose limiting toxicity (DLT). Skin toxicity, cosmetic evaluation and quality of life was evaluated at baseline, at treatment end and at 3 and 12 months after RT end. RESULTS: Three patients for each dose level were enrolled. No DLT occurred. The maximum toxicity collected during RT was G2 skin toxicity in 3 (33.3%) patients, one for each dose level. No G2 toxicity at 3 and 12 months was collected. At median follow up of 21.8 months (range: 13.5 - 40.9 months), no G2 late toxicity was recorded. CONCLUSION: The 3 week course of post-operative RT with dose escalation to the tumour bed to 52.5 Gy has been achieved without dose limiting toxicities and can be tested in Phase II trials. ADVANCES IN KNOWLEDGE: In our study, we tested the highest dose level to the tumour bed ever reported in studies using accelerated hypofractionation with concomitant boost in high risk patients.
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Affiliation(s)
- Edy Ippolito
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Sonia Silipigni
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Carlo Greco
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Michele Fiore
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Lucio Trodella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Sara Ramella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
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12
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Predictors for poor cosmetic outcome in patients with early stage breast cancer treated with breast conserving therapy: Results of the Young boost trial. Radiother Oncol 2018; 128:434-441. [DOI: 10.1016/j.radonc.2018.06.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/27/2018] [Accepted: 06/12/2018] [Indexed: 11/21/2022]
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13
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Evaluation of adaptive radiotherapy (ART) by use of replanning the tumor bed boost with repeated computed tomography (CT) simulation after whole breast irradiation (WBI) for breast cancer patients having clinically evident seroma. Jpn J Radiol 2018; 36:401-406. [PMID: 29623550 DOI: 10.1007/s11604-018-0735-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 03/30/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study is to evaluate adaptive radiotherapy (ART) by use of replanning the tumor bed boost with repeated computed tomography (CT) simulation after whole breast irradiation (WBI) for breast cancer patients having clinically evident seroma. MATERIALS AND METHODS Forty-eight patients with clinically evident seroma at the time of planning CT simulation for WBI were included. Two RT treatment plannings were generated for each patient based on the initial CT simulation and tumor bed boost CT simulation to assess seroma and boost target volume (BTV) changes during WBI. Also, dosimetric impact of ART was analyzed by comparative evaluation of critical organ doses in both RT treatment plannings. RESULTS Median time interval between the two CT simulations was 35 days. Statistically significant reduction was detected in seroma volume and BTV during the conventionally fractionated WBI course along with statistically significant reduction in critical organ doses with ART (p < 0.0001). CONCLUSION Our data suggest significant benefit of ART by use of replanning the tumor bed boost with repeated CT simulation after WBI for patients with clinically evident seroma.
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14
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Kindts I, Laenen A, Depuydt T, Weltens C. Tumour bed boost radiotherapy for women after breast-conserving surgery. Cochrane Database Syst Rev 2017; 11:CD011987. [PMID: 29105051 PMCID: PMC6486034 DOI: 10.1002/14651858.cd011987.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Breast-conserving therapy, involving breast-conserving surgery followed by whole-breast irradiation and optionally a boost to the tumour bed, is a standard therapeutic option for women with early-stage breast cancer. A boost to the tumour bed means that an extra dose of radiation is applied that covers the initial tumour site. The rationale for a boost of radiotherapy to the tumour bed is that (i) local recurrence occurs mostly at the site of the primary tumour because remaining microscopic tumour cells are most likely situated there; and (ii) radiation can eliminate these causative microscopic tumour cells. The boost continues to be used in women at high risk of local recurrence, but is less widely accepted for women at lower risk. Reasons for questioning the boost are twofold. Firstly, the boost brings higher treatment costs. Secondly, the potential adverse events are not negligible. In this Cochrane Review, we investigated the effect of the tumour bed boost on local control and side effects. OBJECTIVES To assess the effects of tumour bed boost radiotherapy after breast-conserving surgery and whole-breast irradiation for the treatment of breast cancer. SEARCH METHODS We searched the Cochrane Breast Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to 1 March 2017), Embase (1980 to 1 March 2017), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov on 1 March 2017. We also searched the European Society of Radiotherapy and Oncology Annual Meeting, the St Gallen Oncology Conferences, and the American Society for Radiation Oncology Annual Meeting for abstracts. SELECTION CRITERIA Randomised controlled trials comparing the addition and the omission of breast cancer tumour bed boost radiotherapy. DATA COLLECTION AND ANALYSIS Two review authors (IK and CW) performed data extraction and assessed risk of bias using Cochrane's 'Risk of bias' tool, resolving any disagreements through discussion. We entered data into Review Manager 5 for analysis and applied GRADE to assess the quality of the evidence. MAIN RESULTS We included 5 randomised controlled trials analysing a total of 8325 women.Local control appeared to be better for women receiving a tumour bed boost compared to no tumour bed boost (hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.55 to 0.75; 5 studies, 8315 women, low-quality evidence). Overall survival did not differ with or without a tumour bed boost (HR 1.04, 95% CI 0.94 to 1.14; 2 studies, 6342 women, moderate-quality evidence). Disease-free survival did not differ with or without a tumour bed boost (HR 0.94, 95% CI 0.87 to 1.02; 3 studies, 6549 women, low-quality evidence). Late toxicity scored by means of percentage of breast retraction assessment did not differ with or without a tumour bed boost (mean difference 0.38, 95% CI -0.18 to 0.93; 2 studies, 1526 women, very low-quality evidence). Cosmesis scored by a panel was better (i.e. excellent or good compared to fair or poor) in the no-boost group (odds ratio (OR) 1.41, 95% CI 1.07 to 1.85; 2 studies, 1116 women, low-quality evidence). Cosmesis scored by a physician did not differ with or without a tumour bed boost (OR 1.58, 95% CI 0.93 to 2.69; 2 studies, 592 women, very low-quality evidence).We excluded two studies in a sensitivity analysis of local recurrence (because the biological equivalent dose (BED) to the tumour bed was lower, in situ tumours were included, or there was a high risk of selective reporting bias or blinding of outcome assessment bias), which resulted in a HR of 0.62 (95% CI 0.52 to 0.73; 3 studies, 6963 women, high-quality evidence). Subgroup analysis including women older than 40 years of age yielded a HR of 0.65 (95% CI 0.53 to 0.81; 2 studies, 5058 women, high-quality evidence).We found no data for the outcomes of acute toxicity, quality of life, or costs. AUTHORS' CONCLUSIONS It appears that local control rates are increased with the boost to the tumour bed, but we found no evidence of a benefit for other oncological outcomes. Subgroup analysis including women older than 40 years of age yielded similarly significant results. Objective percentage of breast retraction assessment appears similar between groups. It appears that the cosmetic outcome is worse with the boost to the tumour bed, but only when measured by a panel, not when assessed by a physician.
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Affiliation(s)
- Isabelle Kindts
- University Hospitals LeuvenDepartment of Radiation OncologyLeuvenBelgium3000
| | - Annouschka Laenen
- KULeuvenLeuven Biostatistics and Statistical Bioinformatices CentreLeuvenBelgium3500
| | - Tom Depuydt
- University Hospitals LeuvenDepartment of Radiation OncologyLeuvenBelgium3000
| | - Caroline Weltens
- University Hospitals LeuvenDepartment of Radiation OncologyLeuvenBelgium3000
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15
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Photobiomodulation therapy for the management of radiation-induced dermatitis. Strahlenther Onkol 2017; 193:491-498. [DOI: 10.1007/s00066-017-1117-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 02/07/2017] [Indexed: 12/16/2022]
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16
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Herskind C, Ma L, Liu Q, Zhang B, Schneider F, Veldwijk MR, Wenz F. Biology of high single doses of IORT: RBE, 5 R's, and other biological aspects. Radiat Oncol 2017; 12:24. [PMID: 28107823 PMCID: PMC5251326 DOI: 10.1186/s13014-016-0750-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 12/21/2016] [Indexed: 01/14/2023] Open
Abstract
Intraoperative radiotherapy differs from conventional, fractionated radiotherapy in several aspects that may influence its biological effect. The radiation quality influences the relative biologic effectiveness (RBE), and the role of the five R’s of radiotherapy (reassortment, repair, reoxygenation, repopulation, radiosensitivity) is different. Furthermore, putative special biological effects and the small volume receiving a high single dose may be important. The present review focuses on RBE, repair, and repopulation, and gives an overview of the other factors that potentially contribute to the efficacy. The increased RBE should be taken into account for low-energy X-rays while evidence of RBE < 1 for high-energy electrons at higher doses is presented. Various evidence supports a hypothesis that saturation of the primary DNA double-strand break (DSB) repair mechanisms leads to increasing use of an error-prone backup repair system leading to genomic instability that may contribute to inactivate tumour cells at high single doses. Furthermore, the elimination of repopulation of residual tumour cells in the tumour bed implies that some patients are likely to have very few residual tumour cells which may be cured even by low doses to the tumour bed. The highly localised dose distribution of IORT has the potential to inactivate tumour cells while sparing normal tissue by minimising the volume exposed to high doses. Whether special effects of high single doses also contribute to the efficacy will require further experimental and clinical studies.
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Affiliation(s)
- Carsten Herskind
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Lin Ma
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Present Address: Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Qi Liu
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Present Address: Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Bo Zhang
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Present Address: Department of Oncology at No. 2 Hospital Anhui Medical University, and School of Life Sciences, Anhui Medical University, Hefei, Anhui, China
| | - Frank Schneider
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marlon R Veldwijk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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17
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Patient-reported Long-term Cosmetic Outcomes Following Short Fractionation Whole Breast Radiotherapy With Boost. Am J Clin Oncol 2016; 39:473-8. [DOI: 10.1097/coc.0000000000000084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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18
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van der Leij F, van Werkhoven E, Bosma S, Linn SC, Rutgers EJ, van de Vijver MJ, Bartelink H, Elkhuizen PHM, Scholten A. Low risk of recurrence in elderly patients treated with breast conserving therapy in a single institute. Breast 2016; 30:19-25. [PMID: 27587341 DOI: 10.1016/j.breast.2016.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To guide decision making in preventing over- or under-treatment in older breast cancer patients who have undergone breast conserving surgery, we analyzed prognostic factors and risk of recurrence in a consecutive series of patients ≥ 65 years old with breast cancer and identified subgroups that may benefit or not from more intensive treatment. METHODS Patients ≥65 years of age with breast cancer (pT1-2/pN0-2) treated with breast conserving surgery and postoperative radiation therapy at the Netherlands Cancer Institute (NKI) between 1980 and 2008 were identified. Endpoints were locoregional recurrence (LRR), distant metastasis (DM) and overall survival (OS). Multivariable analyses were performed using Cox proportional hazards models. RESULTS 1922 patients with a median age of 70 years were analyzed. The 5- and 10- years LRR rates were 2% and 3% respectively. In multivariable analysis there was no significant factor influencing LRR risk. Patients with low risk tumors (node negative patients with T1 and ER positive, grade 1 or 2) had lower risk of DM (HR 0.26) and better OS (HR 0.65) compared to patients with higher risk tumors (grade 3 and/or node positive). CONCLUSION In elderly breast cancer patients the risk of LRR and DM is low. In patients with less favorable characteristics the risk of LRR is equally low, with a higher risk to develop DM and worse OS. Treatment in the low risk group may be minimized, while for the higher risk group adjuvant treatment could be intensified.
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Affiliation(s)
- Femke van der Leij
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Erik van Werkhoven
- Statistics Department, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Sophie Bosma
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Sabine C Linn
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands; Department of Pathology, University Medical Center, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Emiel J Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marc J van de Vijver
- Department of Pathology, Academical Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Astrid Scholten
- Department of Radiation Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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19
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Vaidya JS, Wenz F, Bulsara M, Tobias JS, Joseph DJ, Saunders C, Brew-Graves C, Potyka I, Morris S, Vaidya HJ, Williams NR, Baum M. An international randomised controlled trial to compare TARGeted Intraoperative radioTherapy (TARGIT) with conventional postoperative radiotherapy after breast-conserving surgery for women with early-stage breast cancer (the TARGIT-A trial). Health Technol Assess 2016; 20:1-188. [PMID: 27689969 DOI: 10.3310/hta20730] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Based on our laboratory work and clinical trials we hypothesised that radiotherapy after lumpectomy for breast cancer could be restricted to the tumour bed. In collaboration with the industry we developed a new radiotherapy device and a new surgical operation for delivering single-dose radiation to the tumour bed - the tissues at highest risk of local recurrence. We named it TARGeted Intraoperative radioTherapy (TARGIT). From 1998 we confirmed its feasibility and safety in pilot studies. OBJECTIVE To compare TARGIT within a risk-adapted approach with whole-breast external beam radiotherapy (EBRT) over several weeks. DESIGN The TARGeted Intraoperative radioTherapy Alone (TARGIT-A) trial was a pragmatic, prospective, international, multicentre, non-inferiority, non-blinded, randomised (1 : 1 ratio) clinical trial. Originally, randomisation occurred before initial lumpectomy (prepathology) and, if allocated TARGIT, the patient received it during the lumpectomy. Subsequently, the postpathology stratum was added in which randomisation occurred after initial lumpectomy, allowing potentially easier logistics and a more stringent case selection, but which needed a reoperation to reopen the wound to give TARGIT as a delayed procedure. The risk-adapted approach meant that, in the experimental arm, if pre-specified unsuspected adverse factors were found postoperatively after receiving TARGIT, EBRT was recommended. Pragmatically, this reflected how TARGIT would be practised in the real world. SETTING Thirty-three centres in 11 countries. PARTICIPANTS Women who were aged ≥ 45 years with unifocal invasive ductal carcinoma preferably ≤ 3.5 cm in size. INTERVENTIONS TARGIT within a risk-adapted approach and whole-breast EBRT. MAIN OUTCOME MEASURES The primary outcome measure was absolute difference in local recurrence, with a non-inferiority margin of 2.5%. Secondary outcome measures included toxicity and breast cancer-specific and non-breast-cancer mortality. RESULTS In total, 3451 patients were recruited between March 2000 and June 2012. The following values are 5-year Kaplan-Meier rates for TARGIT compared with EBRT. There was no statistically significant difference in local recurrence between TARGIT and EBRT. TARGIT was non-inferior to EBRT overall [TARGIT 3.3%, 95% confidence interval (CI) 2.1% to 5.1% vs. EBRT 1.3%, 95% CI 0.7% to 2.5%; p = 0.04; Pnon-inferiority = 0.00000012] and in the prepathology stratum (n = 2298) when TARGIT was given concurrently with lumpectomy (TARGIT 2.1%, 95% CI 1.1% to 4.2% vs. EBRT 1.1%, 95% CI 0.5% to 2.5%; p = 0.31; Pnon-inferiority = 0.0000000013). With delayed TARGIT postpathology (n = 1153), the between-group difference was larger than 2.5% and non-inferiority was not established for this stratum (TARGIT 5.4%, 95% CI 3.0% to 9.7% vs. EBRT 1.7%, 95% CI 0.6% to 4.9%; p = 0.069; Pnon-inferiority = 0.06640]. The local recurrence-free survival was 93.9% (95% CI 90.9% to 95.9%) when TARGIT was given with lumpectomy compared with 92.5% (95% CI 89.7% to 94.6%) for EBRT (p = 0.35). In a planned subgroup analysis, progesterone receptor (PgR) status was found to be the only predictor of outcome: hormone-responsive patients (PgR positive) had similar 5-year local recurrence with TARGIT during lumpectomy (1.4%, 95% CI 0.5% to 3.9%) as with EBRT (1.2%, 95% CI 0.5% to 2.9%; p = 0.77). Grade 3 or 4 radiotherapy toxicity was significantly reduced with TARGIT. Overall, breast cancer mortality was much the same between groups (TARGIT 2.6%, 95% CI 1.5% to 4.3% vs. EBRT 1.9%, 95% CI 1.1% to 3.2%; p = 0.56) but there were significantly fewer non-breast-cancer deaths with TARGIT (1.4%, 95% CI 0.8% to 2.5% vs. 3.5%, 95% CI 2.3% to 5.2%; p = 0.0086), attributable to fewer deaths from cardiovascular causes and other cancers, leading to a trend in reduced overall mortality in the TARGIT arm (3.9%, 95% CI 2.7% to 5.8% vs. 5.3%, 95% CI 3.9% to 7.3%; p = 0.099]. Health economic analyses suggest that TARGIT was statistically significantly less costly than EBRT, produced similar quality-adjusted life-years, had a positive incremental net monetary benefit that was borderline statistically significantly different from zero and had a probability of > 90% of being cost-effective. There appears to be little uncertainty in the point estimates, based on deterministic and probabilistic sensitivity analyses. If TARGIT were given instead of EBRT in suitable patients, it might potentially reduce costs to the health-care providers in the UK by £8-9.1 million each year. This does not include environmental, patient and societal costs. LIMITATIONS The number of local recurrences is small but the number of events for local recurrence-free survival is not as small (TARGIT 57 vs. EBRT 59); occurrence of so few events (< 3.5%) also implies that both treatments are effective and any difference is unlikely to be large. Not all 3451 patients were followed up for 5 years; however, more than the number of patients required to answer the main trial question (n = 585) were followed up for > 5 years. CONCLUSIONS For patients with breast cancer (women who are aged ≥ 45 years with hormone-sensitive invasive ductal carcinoma that is up to 3.5 cm in size), TARGIT concurrent with lumpectomy within a risk-adapted approach is as effective as, safer than and less expensive than postoperative EBRT. FUTURE WORK The analyses will be repeated with longer follow-up. Although this may not change the primary result, the larger number of events may confirm the effect on overall mortality and allow more detailed subgroup analyses. The TARGeted Intraoperative radioTherapy Boost (TARGIT-B) trial is testing whether or not a tumour bed boost given intraoperatively (TARGIT) boost is superior to a tumour bed boost given as part of postoperative EBRT. TRIAL REGISTRATION Current Controlled Trials ISRCTN34086741 and ClinicalTrials.gov NCT00983684. FUNDING University College London Hospitals (UCLH)/University College London (UCL) Comprehensive Biomedical Research Centre, UCLH Charities, Ninewells Cancer Campaign, National Health and Medical Research Council and German Federal Ministry of Education and Research (BMBF). From September 2009 this project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 73. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jayant S Vaidya
- Division of Surgery and Interventional Science, University College London, London, UK.,Department of Surgery, Whittington Hospital, Royal Free Hospital and University College London Hospital, London, UK
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Max Bulsara
- Department of Biostatistics, University of Notre Dame, Fremantle, WA, Australia
| | - Jeffrey S Tobias
- Department of Clinical Oncology, University College London Hospitals, London, UK
| | - David J Joseph
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Christobel Saunders
- Department of Surgery, University of Western Australia, Perth, WA, Australia
| | - Chris Brew-Graves
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Ingrid Potyka
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Stephen Morris
- Health Economics Group, Department of Biomedical Engineering, University College London, London, UK
| | | | - Norman R Williams
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Michael Baum
- Division of Surgery and Interventional Science, University College London, London, UK
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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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Hickey BE, James ML, Lehman M, Hider PN, Jeffery M, Francis DP, See AM. Fraction size in radiation therapy for breast conservation in early breast cancer. Cochrane Database Syst Rev 2016; 7:CD003860. [PMID: 27425588 PMCID: PMC6457862 DOI: 10.1002/14651858.cd003860.pub4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Shortening the duration of radiation therapy would benefit women with early breast cancer treated with breast conserving surgery. It may also improve access to radiation therapy by improving efficiency in radiation oncology departments globally. This can only happen if the shorter treatment is as effective and safe as conventional radiation therapy. This is an update of a Cochrane Review first published in 2008 and updated in 2009. OBJECTIVES To assess the effect of altered radiation fraction size for women with early breast cancer who have had breast conserving surgery. SEARCH METHODS We searched the Cochrane Breast Cancer Specialised Register (23 May 2015), CENTRAL (The Cochrane Library 2015, Issue 4), MEDLINE (Jan 1996 to May 2015), EMBASE (Jan 1980 to May 2015), the WHO International Clinical Trials Registry Platform (ICTRP) search portal (June 2010 to May 2015) and ClinicalTrials.gov (16 April 2015), reference lists of articles and relevant conference proceedings. No language or publication constraints were applied. SELECTION CRITERIA Randomised controlled trials of altered fraction size versus conventional fractionation for radiation therapy in women with early breast cancer who had undergone breast conserving surgery. DATA COLLECTION AND ANALYSIS Two authors performed data extraction independently, with disagreements resolved by discussion. We sought missing data from trial authors. MAIN RESULTS We studied 8228 women in nine studies. Eight out of nine studies were at low or unclear risk of bias. Altered fraction size (delivering radiation therapy in larger amounts each day but over fewer days than with conventional fractionation) did not have a clinically meaningful effect on: local recurrence-free survival (Hazard Ratio (HR) 0.94, 95% CI 0.77 to 1.15, 7095 women, four studies, high-quality evidence), cosmetic outcome (Risk ratio (RR) 0.90, 95% CI 0.81 to 1.01, 2103 women, four studies, high-quality evidence) or overall survival (HR 0.91, 95% CI 0.80 to 1.03, 5685 women, three studies, high-quality evidence). Acute radiation skin toxicity (RR 0.32, 95% CI 0.22 to 0.45, 357 women, two studies) was reduced with altered fraction size. Late radiation subcutaneous toxicity did not differ with altered fraction size (RR 0.93, 95% CI 0.83 to 1.05, 5130 women, four studies, high-quality evidence). Breast cancer-specific survival (HR 0.91, 95% CI 0.78 to 1.06, 5685 women, three studies, high quality evidence) and relapse-free survival (HR 0.93, 95% CI 0.82 to 1.05, 5685 women, three studies, moderate-quality evidence) did not differ with altered fraction size. We found no data for mastectomy rate. Altered fraction size was associated with less patient-reported (P < 0.001) and physician-reported (P = 0.009) fatigue at six months (287 women, one study). We found no difference in the issue of altered fractionation for patient-reported outcomes of: physical well-being (P = 0.46), functional well-being (P = 0.38), emotional well-being (P = 0.58), social well-being (P = 0.32), breast cancer concerns (P = 0.94; 287 women, one study). We found no data with respect to costs. AUTHORS' CONCLUSIONS We found that using altered fraction size regimens (greater than 2 Gy per fraction) does not have a clinically meaningful effect on local recurrence, is associated with decreased acute toxicity and does not seem to affect breast appearance, late toxicity or patient-reported quality-of-life measures for selected women treated with breast conserving therapy. These are mostly women with node negative tumours smaller than 3 cm and negative pathological margins.
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Affiliation(s)
- Brigid E Hickey
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
- The University of QueenslandSchool of MedicineBrisbaneAustralia
| | - Melissa L James
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
| | - Margot Lehman
- The University of QueenslandSchool of MedicineBrisbaneAustralia
- Princess Alexandra HospitalRadiation Oncology UnitGround Floor, Outpatients FIpswich Road, WoollangabbaBrisbaneQueenslandAustralia4102
| | - Phil N Hider
- University of Otago, ChristchurchDepartment of Population HealthPO Box 4345ChristchurchNew Zealand8140
| | - Mark Jeffery
- Christchurch HospitalCanterbury Regional Cancer and Haematology ServicePrivate Bag 4710ChristchurchNew Zealand8140
| | - Daniel P Francis
- Queensland University of TechnologySchool of Public Health and Social WorkVictoria Park RoadBrisbaneQueenslandAustralia4059
| | - Adrienne M See
- Princess Alexandra HospitalRadiation Oncology Mater Service31 Raymond TerraceBrisbaneQueenslandAustralia4101
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Verhoeven K, Peeters S, Erven K, Kindts I, Van Limbergen E, Janssen H, Laenen A, Petillion S, Weltens C. Is the use of a preoperative computed tomography beneficial to reduce the interobserver variability of the CTV boost delineation for breast radiation therapy? Pract Radiat Oncol 2016; 6:376-382. [PMID: 27156427 DOI: 10.1016/j.prro.2016.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/29/2016] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine whether the use of a preoperative (preop) computed tomography (CT) reduces (1) the clinical target volume boost (CTVboost) and (2) the interobserver variability (IOV) of the delineated CTVboost in breast radiation therapy. METHODS AND MATERIALS In patients treated with breast-conserving therapy, 3 CT scans in treatment position were performed: (1) preop; (2) after surgery, prechemotherapy (postop); and (3) postchemotherapy (postchemo). Six radiation-oncologists delineated the tumor bed and CTVboost before and after fusion of the preop CT. To assess the IOV, the Jaccard index was used. Linear mixed models were performedfor all analyses. RESULTS Eighty-two lumpectomy cavities were evaluated in 22 patients. No difference in CTVboost using the fusion of the preop CT (50.0 cm3; 95% confidence interval [CI], 35.6-64.4) compared with no fusion (49.0 cm3; 95% CI, 34.6-63.4) (P = .6) was observed. A significant increase in IOV was shown with the fusion of the preop CT; the mean Jaccard index of the CTVboost delineation of postop and postchemo CT together without the fusion of the preop CT was 0.53 (95% CI, 0.49-0.57) versus 0.50 (95% CI, 0.46-0.53) with fusion (P < .0001). CONCLUSIONS There is no benefit of using a preop CT to reduce the volume or the interobserver variability of the delineated CTVboost for breast radiation therapy.
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Affiliation(s)
- Karolien Verhoeven
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium.
| | - Stéphanie Peeters
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium
| | - Katrien Erven
- Iridium kankernetwerk Wilrijk, Department of Radiation-Oncology, Belgium
| | - Isabelle Kindts
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium
| | - Erik Van Limbergen
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium
| | - Hilde Janssen
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium
| | | | - Saskia Petillion
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium
| | - Caroline Weltens
- University Hospitals Leuven/KU Leuven, Department of Radiation-Oncology, Belgium
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Falco M, Masojć B, Rolla M, Czekała A, Pietruszewska J, Rubik-Leszczyńska A, Lewocki M, Łukowiak M, Kram A. Risk factors for seroma evacuation in breast cancer patients treated with intraoperative radiotherapy. Rep Pract Oncol Radiother 2016; 21:225-31. [PMID: 27601955 PMCID: PMC5002024 DOI: 10.1016/j.rpor.2016.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/04/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Novel techniques in oncology provide new treatment opportunities but also introduce different patterns of side effects. Intraoperative radiotherapy (IORT) allows a shortened overall treatment time for early breast cancer either combined with whole breast radiotherapy (WBRT), or alone. Although the early side effects of IORT are well known, data on clinically important late side effects, which require medical intervention, are scarce. AIM In this study, we analyze risk factors for seroma evacuation more than 6 months after IORT. MATERIALS AND METHODS We evaluated 120 patients with a mean follow-up of 27.8 months (range: 7-52 months). Fifty-one patients received IORT only and 69 were additionally treated with WBRT. RESULTS Seroma evacuation was performed 6-38 months after IORT. Two (3.9%) events were observed in the IORT group and 14 (20%) in the IORT + WBRT group. Univariate (Kaplan-Meier) analysis showed that addition of WBRT to IORT increased the risk of seroma evacuation [hazard ratio = 5.5, 95% confidence interval: 2.0-14.7, P = 0.011]. In a multivariate analysis (Cox proportional hazards regression), WBRT and axillary lymph node dissection were significant risk factors for seroma evacuation (model P value = 0.0025). CONCLUSIONS WBRT applied after IORT is associated with increased risk of seroma evacuation, which might be considered as a late side effect.
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Affiliation(s)
- Michał Falco
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Bartłomiej Masojć
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Rolla
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Agnieszka Czekała
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Jolanta Pietruszewska
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | | | - Mirosław Lewocki
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Łukowiak
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Andrzej Kram
- Pathology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
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Cost-effectiveness assessment of lumpectomy cavity boost in elderly women with early stage estrogen receptor positive breast cancer receiving adjuvant radiotherapy. Radiother Oncol 2016; 119:52-6. [DOI: 10.1016/j.radonc.2016.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/21/2016] [Accepted: 01/31/2016] [Indexed: 10/22/2022]
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Very low local recurrence rates after breast-conserving therapy: analysis of 8485 patients treated over a 28-year period. Breast Cancer Res Treat 2016; 156:391-400. [DOI: 10.1007/s10549-016-3732-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 01/02/2023]
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Abstract
Breast cancer is the most commonly diagnosed malignancy in young women in the USA. Although breast cancer mortality has decreased overall, survival rates in young women remain lower than those in older women. Young women with breast cancer comprise a special population due to the aggressive biology of their tumors as well as their unique psychosocial concerns. Although general treatment principles are similar regardless of age, recent developments from research focused on younger women have provided new insights to guide treatment of this special population. This article will focus on these new developments in areas including endocrine therapy and fertility preservation as well as the unique treatment-related sequelae and psychosocial concerns among young women with breast cancer face.
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Nitsche M, Dunst J, Carl UM, Hermann RM. Emerging Role of Hypofractionated Radiotherapy with Simultaneous Integrated Boost in Modern Radiotherapy of Breast Cancer. Breast Care (Basel) 2015; 10:320-4. [PMID: 26688679 DOI: 10.1159/000436951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Hypofractionated radiotherapy for breast cancer is becoming increasingly important. The scientific background of this development as well as the introduction of the simultaneous integrated boost to the primary tumor region in this context are discussed here.
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Affiliation(s)
- Mirko Nitsche
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Juergen Dunst
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Ulrich M Carl
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany
| | - Robert M Hermann
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Abteilung Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Germany
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Recommendations from GEC ESTRO Breast Cancer Working Group (I): Target definition and target delineation for accelerated or boost Partial Breast Irradiation using multicatheter interstitial brachytherapy after breast conserving closed cavity surgery. Radiother Oncol 2015; 115:342-8. [DOI: 10.1016/j.radonc.2015.06.010] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 06/08/2015] [Accepted: 06/08/2015] [Indexed: 11/18/2022]
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Quality of life and cosmesis after breast cancer: whole breast radiotherapy vs partial breast high-dose-rate brachytherapy. TUMORI JOURNAL 2015; 101:161-7. [PMID: 25768319 DOI: 10.5301/tj.5000233] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2014] [Indexed: 12/24/2022]
Abstract
AIM AND BACKGROUND Conservative surgery and radiotherapy for early breast cancer offers a better quality of life than mastectomy. As 80-85% of breast relapses develop close to the tumour bed, partial breast irradiation was developed to overcome drawbacks with standard radiotherapy. This study compares quality of life and cosmesis after partial breast multi-catheter high-dose rate interstitial brachytherapy or standard radiotherapy. METHODS A questionnaire, exploring body image, fear of recurrence, satisfaction with treatment and cosmesis, was administered to 39 partial and 78 whole breast patients at a median of 20 and 80 months after radiotherapy. Patients' and physicians' cosmetic assessments were compared. RESULTS Groups were well-matched, except for: a higher percentage of chemotherapy-treated patients in the whole breast group and a older median age and a higher percentage of infiltrating ductal carcinoma G1 in partial breast group. At first and second analysis no significant inter-group difference emerged on body image and fear of recurrence, while partial breast patients were more satisfied with cosmetic outcome and at first analysis with treatment. Comparing results from first and second analysis into each treatment group, body image was significantly better at the first analysis in both groups. Fear of recurrence was unchanged. No differences were found in cosmesis as assessed by patients. At first and second analyses physicians' assessment of cosmesis was significantly better in the partial breast group. CONCLUSIONS Even at longer follow-up, quality of life is similar after partial or whole breast irradiation. Cosmesis is better after partial breast irradiation.
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Breast cancer in young women in southern Tunisia: Anatomical study and clinical prognostic factors: About a series of 83 patients. Rep Pract Oncol Radiother 2015; 20:155-60. [PMID: 25949218 DOI: 10.1016/j.rpor.2015.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 08/06/2014] [Accepted: 01/28/2015] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To define epidemiological, clinical, therapeutic and prognostic factors influencing survival of breast cancer in young women younger than 35 in southern Tunisia. MATERIAL AND METHODS This is a retrospective study of 83 patients younger than 35 years and treated within tumors mammary committee of Sfax. RESULTS The mean age was 31.7 years. T2 stage, high grade with positive node tumors were frequent. Breast surgery was performed for 73 patients. Chemotherapy was neo-adjuvant, adjuvant and palliative for respectively 10, 62 and 13 patients. Radiotherapy was delivered for 65 patients with curative intent and for 8 metastatic patients. Endocrine therapy was adjuvant in 38 patients and palliative in 6 cases. The overall survival (OS) at 5 years was 66.8%. Pejorative prognostic factors in uni-variate analysis were clinical T stage (T3, T4), and the number of involved lymph nodes. CONCLUSION Despite adequate treatment, the prognosis of breast cancer in young women remains worse. Early diagnosis is necessary to promote outcome.
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Novel 10-fraction Breast Irradiation in Prone and Supine Position: Technical, Dosimetric and Clinical Evaluation. TUMORI JOURNAL 2015; 101:154-60. [DOI: 10.5301/tj.5000232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2014] [Indexed: 12/25/2022]
Abstract
Background The aim of this study was to evaluate retrospectively the planned dose distribution and acute toxicity of adjuvant hypofractionated whole breast radiotherapy (RT) delivered in the prone vs. supine position. Methods Twenty-four patients were enrolled; 12 underwent adjuvant RT with a supine setup and 12 with a prone setup. We included patients according to breast volume (≥500 mL), disease stage (≤pT2/pN1), and clinical/biological features. Patients received a regimen of 35 Gy in 10 fractions for 2.5 weeks, and a concomitant boost of 3/4 Gy in 1 fraction/week. Target coverage was assessed by volume, V90, V95, V100, V103 and V105. Heart, LADCA and ipsilateral lung doses were evaluated according to volume, maximum dose, mean dose, V14, V10 and V5. We evaluated acute skin toxicity during RT, at the end of treatment, and after 1 month according to RTOG scales. Results Radiobiological equivalence was warranted with satisfactory BED values: considering α/β = 4 for breast cancer, the 10-fraction schedule equaled 74 or 77 Gy depending on the boost dose (3 Gy vs. 4 Gy, respectively). Toxicity was low and similar for supine and prone treatments. Dose sparing was significant in the ipsilateral lung in the prone position (median Dmax: 28.7 Gy vs. 38.4 Gy; median Dmean: 0.8 Gy vs. 6.3 Gy; median V14:0.6% vs. 13.5%; median V5: 0 vs. 19.3%, p<0.001). Conclusions This novel 10-fraction schedule is feasible and well tolerated; the prone position allows better saving of OARs, with a statistically significant value for the ipsilateral lung.
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Fernandez J, Montaudié H, Courdi A, Georgiou C, Camuzard O, Chignon-Sicard B. [Breast lesions of a metastatic melanoma on a radiotherapy territory: Treatment by vemurafenib and carcinologic surgery]. ANN CHIR PLAST ESTH 2014; 61:69-75. [PMID: 25446470 DOI: 10.1016/j.anplas.2014.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Accepted: 09/25/2014] [Indexed: 01/26/2023]
Abstract
INTRODUCTION This article describes the unique case of a female patient who presented distant melanoma metastasis on the breast while having irradiation therapy for breast cancer. This happened eight months after the initial treatment for a melanoma of the back (under the right scapula). Furthermore, this case report demonstrates the efficiency of Vemurafenib® as a treatment for late stage melanomas. CASE REPORT The patient was a 47-year-old female that had a superficial spreading melanoma under the right scapula (Breslow 1.02mm) that was treated with 2cm skin excision and sentinel lymph node sampling that was negative. The melanoma was positive for the BRAF600E mutation. One month after this incident, the patient developed breast cancer that was treated with conservative surgery and radiotherapy. Three months after the end of the irradiation treatment, she developed multiple melanoma metastasis on the skin of the breast. Our multidisciplinary team decided to initiate a treatment with vemurafenib. The patient showed an excellent response, so the surgical team completed the treatment with a radical mastectomy and immediate reconstruction with a pedicled latissimus dorsi flap. The histologic report of the mastectomy specimen showed no sign of melanocytic proliferation, that demonstrates the efficacy of vemurafenib. The patient showed no relapse after two years of follow-up. DISCUSSION The speed of development and location of cutaneous metastases in this case brought us to think about the effects of radiation therapy on the skin. Radiation therapy causes acute complications (radiodermatitis) by cellular and molecular mechanisms. Moreover, depressed immunity is found after irradiation. Association of these mecanisms could explain the appearance of these metastases in irradiation field. The efficiency of vemurafenib found in our case is consistent with what is described in literature, especially with the improvement in median overall survival. CONCLUSION This case demonstrates a unique case of distant melanoma metastasis on the irradiation field of a breast cancer. It also demonstrates the efficacy of vemurafenib as well as the efficacy of a radical complementary surgical treatment in these patients.
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Affiliation(s)
- J Fernandez
- Service de chirurgie plastique, réparatrice et esthétique, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06000 Nice, France.
| | - H Montaudié
- Service de dermatologie, hôpital de l'Archet 2, CHU de Nice, 151, route de Saint-Antoine, 06200 Nice, France
| | - A Courdi
- Pôle de radiothérapie, centre Antoine-Lacassagne, 31, avenue de Valombrose, 06103 Nice, France
| | - C Georgiou
- Service de chirurgie plastique, réparatrice et esthétique, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06000 Nice, France
| | - O Camuzard
- Service de chirurgie plastique, réparatrice et esthétique, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06000 Nice, France
| | - B Chignon-Sicard
- Service de chirurgie plastique, réparatrice et esthétique, hôpital Saint-Roch, CHU de Nice, 5, rue Pierre-Dévoluy, 06000 Nice, France
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Petillion S, Swinnen A, Defraene G, Verhoeven K, Weltens C, Van den Heuvel F. The photon dose calculation algorithm used in breast radiotherapy has significant impact on the parameters of radiobiological models. J Appl Clin Med Phys 2014; 15:259–269. [PMID: 25207416 PMCID: PMC5875495 DOI: 10.1120/jacmp.v15i4.4853] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 03/19/2014] [Accepted: 03/12/2014] [Indexed: 11/23/2022] Open
Abstract
The comparison of the pencil beam dose calculation algorithm with modified Batho heterogeneity correction (PBC-MB) and the analytical anisotropic algorithm (AAA) and the mutual comparison of advanced dose calculation algorithms used in breast radiotherapy have focused on the differences between the physical dose distributions. Studies on the radiobiological impact of the algorithm (both on the tumor control and the moderate breast fibrosis prediction) are lacking. We, therefore, investigated the radiobiological impact of the dose calculation algorithm in whole breast radiotherapy. The clinical dose distributions of 30 breast cancer patients, calculated with PBC-MB, were recalculated with fixed monitor units using more advanced algorithms: AAA and Acuros XB. For the latter, both dose reporting modes were used (i.e., dose-to-medium and dose-to-water). Next, the tumor control probability (TCP) and the normal tissue complication probability (NTCP) of each dose distribution were calculated with the Poisson model and with the relative seriality model, respectively. The endpoint for the NTCP calculation was moderate breast fibrosis five years post treatment. The differences were checked for significance with the paired t-test. The more advanced algorithms predicted a significantly lower TCP and NTCP of moderate breast fibrosis then found during the corresponding clinical follow-up study based on PBC calculations. The differences varied between 1% and 2.1% for the TCP and between 2.9% and 5.5% for the NTCP of moderate breast fibrosis. The significant differences were eliminated by determination of algorithm-specific model parameters using least square fitting. Application of the new parameters on a second group of 30 breast cancer patients proved their appropriateness. In this study, we assessed the impact of the dose calculation algorithms used in whole breast radiotherapy on the parameters of the radiobiological models. The radiobiological impact was eliminated by determination of algorithm specific model parameters.
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Influence of boost radiotherapy in patients with ductal carcinoma in situ breast cancer: a multicenter, retrospective study in Korea (KROG 11-04). Breast Cancer Res Treat 2014; 146:341-5. [PMID: 24939061 DOI: 10.1007/s10549-014-3025-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
To estimate the effect of boost radiotherapy on local recurrence-free survival (LRFS) in patients with ductal carcinoma in situ (DCIS) breast cancer. We included patients from nine institutions who met the following criteria: having Tis, age 18 years or older, having breast conserving surgery (BCS) and radiotherapy within 12 weeks after surgery. From 1995 through 2006, 728 patients were analyzed retrospectively by the Korean Radiation Oncology Group. All patients received whole-breast radiation therapy (WBRT) after BCS. 232 patients (31.9 %) also received boost radiation therapy (RT) (median 10 Gy). After median follow-up of 82 months, 5-year LRFS was 98.4 % and 10-year LRFS was 95.8 % for all patients. There was no statistically significant difference of LRFS between the boost and no-boost groups. Nineteen (2.6 %) patients had ipsilateral breast recurrences, including 12 of invasive recurrence and 7 DCIS. The presence of the HER2 receptor was associated with more invasive recurrences. Nine (1.2 %) patients developed contralateral breast cancer, including six invasive breast cancer and three DCIS. In the multivariate analysis, only the margin status was a significant prognostic factor for LRFS. Boost RT was not associated with further improvement of local control in DCIS after BCS and WBRT. HER2 receptor-positive patients may need further treatment with the anti-HER2 agents.
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First international consensus guidelines for breast cancer in young women (BCY1). Breast 2014; 23:209-20. [PMID: 24767882 DOI: 10.1016/j.breast.2014.03.011] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 03/25/2014] [Accepted: 03/25/2014] [Indexed: 01/23/2023] Open
Abstract
The 1st International Consensus Conference for Breast Cancer in Young Women (BCY1) took place in November 2012, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for management of breast cancer in young women were developed and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).
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The use of radiotherapy for early breast cancer in woman at different ages. Clin Transl Oncol 2014; 16:680-5. [DOI: 10.1007/s12094-014-1164-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 02/12/2014] [Indexed: 10/25/2022]
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Hepel JT. Late toxicity and cosmetic outcomes related to interstitial multicatheter brachytherapy for partial breast irradiation. Brachytherapy 2014; 13:23-6. [DOI: 10.1016/j.brachy.2013.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 09/05/2013] [Indexed: 11/25/2022]
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Michalski A, Atyeo J, Cox J, Rinks M, Morgia M, Lamoury G. A dosimetric comparison of 3D-CRT, IMRT, and static tomotherapy with an SIB for large and small breast volumes. Med Dosim 2014; 39:163-8. [DOI: 10.1016/j.meddos.2013.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 11/25/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
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Rabinovitch R, Winter K, Kuske R, Bolton J, Arthur D, Scroggins T, Vicini F, McCormick B, White J. RTOG 95-17, a Phase II trial to evaluate brachytherapy as the sole method of radiation therapy for Stage I and II breast carcinoma--year-5 toxicity and cosmesis. Brachytherapy 2013; 13:17-22. [PMID: 24041956 DOI: 10.1016/j.brachy.2013.08.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 01/19/2023]
Abstract
PURPOSE Radiation Therapy Oncology Group (RTOG) 95-17, a Phase II trial to evaluate multicatheter brachytherapy (mCathBrachy) as the sole method of radiation therapy for Stage I-II breast cancer (BrCa), was the first cooperative group trial in North America to evaluate accelerated partial breast irradiation (APBI) and include patient-reported outcomes (PROs). This report presents the year-5 toxicity and cosmesis data. METHODS AND MATERIALS After lumpectomy and axillary dissection for invasive BrCa (tumor size <3cm with zero to three positive lymph nodes), 100 patients (pts), 98 evaluable, were treated (txed) with mCathBrachy from 1997 to 2000 with 34Gy administered twice daily in 10 high-dose-rate fractions or 45Gy in 3.5-6 days as a low-dose-rate implant to 1-2cm beyond the lumpectomy bed. The PROs and physician-reported outcomes of toxicity, cosmesis, and tx satisfaction at year-5 are reported here, defined as data submitted 54-78 months after tx. RESULTS Grade (G) 1-2 skin toxicity developed in 78% of the pts and G3 in 13% (no G4). The tx effects included skin dimpling/indentation (37%), fibrosis (45%), telangiectasias (45%), skin catheter marks (54%), and symptomatic fat necrosis (15%). Breast asymmetry was reported in 73%. Rates of excellent-to-good cosmesis were similar between PROs (66%) and radiation oncologists (68%). The PROs of tx satisfaction at year-5 was 75%. CONCLUSIONS RTOG 95-17 documents the year-5 skin toxicity and tx effects of mCathBrachy APBI, which are associated with PROs of good-to-excellent cosmesis and high tx satisfaction. This emphasizes the importance of PROs when assessing BrCa tx. National Surgical Adjuvant Breast and Bowel Project B39/RTOG 0413 will allow for definitive comparisons between APBI and whole breast radiation therapy.
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Affiliation(s)
- Rachel Rabinovitch
- Department of Radiation Oncology, University of Colorado Hospital, Aurora, CO.
| | - Kathryn Winter
- Department of Statistics, Radiation Therapy Oncology Group, Philadelphia, PA
| | - Robert Kuske
- Department of Radiation Oncology, AZ Oncology Services, Scottsdale, AZ; Radiation Oncology, Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - John Bolton
- Department of Surgery, Ochsner Clinic, New Orleans, LA
| | - Doug Arthur
- Department of Radiation Oncology, Medical College of Virginia, Richmond, VA
| | - Troy Scroggins
- Department of Radiation Oncology, Ochsner Baptist Medical Center, New Orleans, LA
| | - Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI; Radiation Oncology, Michigan HealthCare Professionals/21st Century Oncology, Farmington Hills, MI
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Julia White
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI; Department of Radiation Oncology, Ohio State University Medical Center, Columbus, OH
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Kreienberg R, Albert US, Follmann M, Kopp IB, Kühn T, Wöckel A. Interdisciplinary GoR level III Guidelines for the Diagnosis, Therapy and Follow-up Care of Breast Cancer: Short version - AWMF Registry No.: 032-045OL AWMF-Register-Nummer: 032-045OL - Kurzversion 3.0, Juli 2012. Geburtshilfe Frauenheilkd 2013; 73:556-583. [PMID: 24771925 PMCID: PMC3963234 DOI: 10.1055/s-0032-1328689] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | - U.-S. Albert
- Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg, Klinik
für Gynäkologie, Gynäkologische Endokrinologie und Onkologie,
Marburg
| | - M. Follmann
- Deutsche Krebsgesellschaft e. V., Bereich Leitlinien,
Berlin
| | - I. B. Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, c/o
Philipps-Universität, Marburg
| | - T. Kühn
- Klinikum Esslingen, Klinik für Frauenheilkunde und Geburtshilfe,
Esslingen
| | - A. Wöckel
- Universitätsklinikum Ulm, Klinik für Frauenheilkunde und Geburtshilfe,
Ulm
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Livi L, Meattini I, Franceschini D, Saieva C, Meacci F, Marrazzo L, Gerlain E, Desideri I, Scotti V, Nori J, Sanchez LJ, Orzalesi L, Bonomo P, Greto D, Bianchi S, Biti G. Radiotherapy boost dose-escalation for invasive breast cancer after breast-conserving surgery: 2093 patients treated with a prospective margin-directed policy. Radiother Oncol 2013; 108:273-8. [PMID: 23490271 DOI: 10.1016/j.radonc.2013.02.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 02/16/2013] [Accepted: 02/17/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the outcome of invasive early breast cancer patients that underwent breast-conserving surgery and adjuvant radiotherapy (RT), treated with a prospective margin-directed institutional policy for RT boost dose, based on final margins status (FMS). METHODS AND MATERIALS A total of 2093 patients were treated between 2000 and 2008. 10 Gy boost was prescribed in case of FMS>5mm; 16 Gy boost with FMS between 2 and 5mm; 20 Gy boost in case of FMS<2mm or positive. RESULTS After a median follow up of 5.2 years, we recorded 41 local relapse (LR, 2%). Concerning LR free survival, age at diagnosis, nuclear grade, hormonal status, T-stage, adjuvant hormonal therapy and adjuvant chemotherapy emerged as significant parameters (p-values from log rank test <0.05). FMS, that directed the RT boost dose, did not have significant impact on LRFS (p=0.46). LR rates were 2.3% for FMS<2mm, 2.6% for 2-5mm FMS and 1.8% for FMS>5mm. At multivariate analysis, higher nuclear grade (p=0.045), triple negative subtype (p=0.036) and higher T-stage (p=0.02) resulted as the independent predictors of LR occurrence. CONCLUSIONS Our experience showed that a margin-directed policy of RT boost dose-escalation seems to reduce the negative impact of FMS on LR, but it is not able to overcome the unfavorable effect of higher nuclear grade, higher T stage and triple negative subtype.
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Affiliation(s)
- Lorenzo Livi
- Radiotherapy Unit, University of Florence, Italy
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Lyngholm CD, Christiansen PM, Damsgaard TE, Overgaard J. Long-term follow-up of late morbidity, cosmetic outcome and body image after breast conserving therapy. A study from the Danish Breast Cancer Cooperative Group (DBCG). Acta Oncol 2013; 52:259-69. [PMID: 23215829 DOI: 10.3109/0284186x.2012.744469] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The Danish Breast Cancer Cooperative Group (DBCG) introduced BCT as a standard treatment in Denmark in 1990. The aim of this study was to investigate late morbidity, cosmetic outcome, and body image after BCT and to associate these outcome variables with patient, tumor, and treatment characteristics. MATERIAL AND METHODS A total of 214 patients treated with BCT from 1989-2002 participated in a long-term follow-up visit comprising an interview, clinical examination, photos of the breast region and completion of a questionnaire on Body Image. RESULTS Median follow-up time was 12 years (range 7-20). Moderate to severe fibrosis was found in 23% of patients and was associated with chemotherapy [OR 2.6, CI (1.1; 5.9), p = 0.02], large breast size [OR 3.2, CI (1.6; 6.4), p = 0.001], and smoking [OR 2.4, CI (1.1; 4.9), p = 0.02]. Patients with a satisfactory cosmetic outcome, when assessed by a clinician, were characterized by small tumors [OR 3.2, CI (1.5; 6.8), p = 0.003] and small to medium sized breasts [OR 2.0, CI (1.1; 3.5), p = 0.002]. Fifty percent of patients scored good or excellent when assessed by a clinician compared to 88% when reported by the patients themselves. Patients satisfied with their own cosmetic outcome were the younger patients [< 50 years; OR 3.2, CI (1.1; 8.6), p = 0.03] with no postoperative complications [OR 3.3, CI (1.2; 9.2), p = 0.02]. Regarding body image 15% felt less feminine, 25% felt less sexually attractive, and 28% of patients had changed their clothing habits as a result of the disease or treatment. CONCLUSION The majority of patients were satisfied with their cosmetic outcome after BCT, whereas only half of the patients were found to have a good or excellent cosmetic outcome when assessed by the clinician. Body image was found to be only minimally disturbed in the majority of patients. The level of moderate to severe fibrosis was acceptable compared to both national and international studies with similar patient compositions.
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Affiliation(s)
- Christina D Lyngholm
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark.
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Cancer du sein traité exclusivement par l’association d’une irradiation externe et d’une curiethérapie exclusive : résultats à long terme. Cancer Radiother 2012; 16:674-80. [DOI: 10.1016/j.canrad.2012.07.187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Revised: 07/17/2012] [Accepted: 07/18/2012] [Indexed: 11/24/2022]
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Atean I, Pointreau Y, Barillot I, Kirova YM. [Organs at risk and target volumes: definition for conformal radiation therapy in breast cancer]. Cancer Radiother 2012; 16:485-92. [PMID: 22925488 DOI: 10.1016/j.canrad.2012.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 06/16/2012] [Indexed: 12/14/2022]
Abstract
Adjuvant radiotherapy is a standard component of breast cancer treatment. The addition of radiotherapy after breast conserving surgery has been shown to reduce local recurrence rate and improve long-term survival. Accurate delineation of target volumes and organs at risk is crucial to the quality of treatment planning and delivered accomplished with innovate technologies in radiation therapy. This allows the radiation beam to be shaped specifically to each individual patient's anatomy. Target volumes include the mammary gland and surgical bed in case of breast conserving surgery, the chest wall in case of mastectomy, and if indicated, regional lymph nodes (axillary, supra- and infraclavicular and internal mammary). Organs at risk include lungs, thyroid, brachial plexus, heart, spinal cord and oesophagus. The aim of this article is to encourage the use of conformal treatment and delineation of target volumes and organs at risk and to describe specifically the definition of these volumes.
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Affiliation(s)
- I Atean
- Service de radiothérapie, centre régional universitaire de cancérologie Henry-S.-Kaplan, hôpital Bretonneau, CHRU de Tours, France.
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45
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A Multi-Institutional Study of Feasibility, Implementation, and Early Clinical Results With Noninvasive Breast Brachytherapy for Tumor Bed Boost. Int J Radiat Oncol Biol Phys 2012; 83:1374-80. [DOI: 10.1016/j.ijrobp.2011.10.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Revised: 09/29/2011] [Accepted: 10/04/2011] [Indexed: 11/18/2022]
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Peebles DD, Soref CM, Copp RR, Thunberg AL, Fahl WE. ROS-scavenger and radioprotective efficacy of the new PrC-210 aminothiol. Radiat Res 2012; 178:57-68. [PMID: 22702647 DOI: 10.1667/rr2806.1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
To identify new aminothiol radioprotectors that are active when applied topically and have fewer side effects when administered systemically, a new family of aminothiol radioprotectors was designed and synthesized. Three key elements in the aminothiol design were, (1) small size for efficient transmembrane diffusion, (2) positive charged amines in alkyl backbone for strong ionic interaction with DNA backbone, and (3) a perpendicular, alkyl side-chain with a terminal thiol that is projected away from the DNA backbone to enable reactive oxygen species scavenging around DNA. Several in vitro assays were used to characterize the prototype aminothiol, PrC-210, for efficacy: protection against reactive oxygen species-induced plasmid DNA nicking, mass spectrometry to detect aminothiol-reactive oxygen species by-products, S. typhimurium mutagenesis, human cell growth inhibition, Western blot for p21 expression, and FACS analysis. Additionally, two in vivo assays were used to assess radioprotective efficacy; a Sprague-Dawley rat dorsal skin radiodermatitis assay was developed to screen for aminothiol efficacy when topically applied, and ICR mouse survival was scored after systemic PrC-210 administration and whole-body radiation. PrC-210 efficiently scavenged reactive oxygen species and completely protected supercoiled plasmid DNA against reactive oxygen species-induced damage. Neither PrC-210 nor its analog PrC-211 were bacterial mutagens. In cell culture, PrC-210 application to diploid human fibroblasts showed: (1) inhibition of cell growth with an IC(70) of 4.1 mM, (2) induced levels of p21 expression, and (3) a G(1)/S-cell cycle block that was reversed after washout of PrC-210-containing medium. In rodents, PrC-210 was an effective radioprotector showing: (1) complete prevention of Grade 2-3 radiodermatitis when applied topically (370 mM in ethanol:propylene glycol:water solution) prior to skin irradiation, (2) complete prevention of Grade 2-3 radiodermatitis when administered by i.p. injection (200 μg/g of body weight) before skin irradiation, (3) 100% survival of mice from an otherwise 100% lethal dose of whole-body radiation (8.75 Gy) when administered by i.p. injection (252 μg/g of body weight = 0.5 × maximum tolerated dose) before irradiation, and (4) a dose reduction factor of 1.6, the same as amifostine. These data suggest that the PrC-210 aminothiol is a plausible candidate for drug development as a human pre-exposure radioprotector.
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Affiliation(s)
- Daniel D Peebles
- McArdle Laboratory for Cancer Research, University of Wisconsin Carbone Comprehensive Cancer Center, Madison, Wisconsin, USA
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Raza S, Lymberis SC, Ciervide R, Axelrod D, Fenton-Kerimian M, Magnolfi C, Rosenstein B, Dewyngaert JK, Formenti SC. Comparison of Acute and Late Toxicity of Two Regimens of 3- and 5-Week Concomitant Boost Prone IMRT to Standard 6-Week Breast Radiotherapy. Front Oncol 2012; 2:44. [PMID: 22649788 PMCID: PMC3355878 DOI: 10.3389/fonc.2012.00044] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 04/16/2012] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Limited information is available comparing toxicity of accelerated radiotherapy (RT) to that of standard fractionation RT for early stage breast cancer. We report early and late toxicities of two prone regimens of accelerated intensity-modulated radiation therapy (IMRT) with a concomitant boost (CB) to the tumor bed delivered over 3 or 5 weeks as compared to standard 6 week RT with a sequential electron boost. METHODS From 2/2003 to 12/2007, 169 consecutive patients with Stage I-II breast cancer were offered the choice to undergo prone RT with either: a 6-week standard RT regimen of 46 Gy/23 fractions (fx) to the whole breast (WB), followed by a14 Gy sequential boost (SB) to the tumor bed (6wSB), a 5-week regimen of 50 Gy to WB with an IMRT CB of 6.25 Gy in 25 fx (5wCB); or a 3-week protocol of 40.5 Gy to WB with an IMRT CB of 7.5 Gy in 15 fx (3wCB). These regimens were estimated as biologically equivalent, based on alpha/beta = 4 for tumor control. Toxicities were reported using RTOG and LENT/SOMA scoring. RESULTS 51/169 patients chose standard 6wSB, 28 selected 5wCB, and 90 enrolled in 3wCB protocol. Maximum acute toxicity was Grade 3 dermatitis in 4% of the patients in the 6wSB compared 1% in 3wCB. In general, acute complications (breast pain, fatigue, and dermatitis) were significantly less in the 3wCB than in the other schedules (P < 0.05). With a median follow-up of 61 months, the only Grade 3 late toxicity was telangiectasia in two patients: one in 3wCB and one in 5wCB group. Notably, fibrosis was comparable among the three groups (P = NS). CONCLUSION These preliminary data suggest that accelerated regimens of breast RT over 3 or 5 weeks in the prone position, with an IMRT tumor bed CB, result in comparable late toxicity to standard fractionation with a sequential tumor boost delivered over 6 weeks. As predicted by radiobiological modeling the shorter regimen was associated with less acute effects.
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Affiliation(s)
- Shahzad Raza
- Department of Radiation Oncology and Surgery, New York University School of Medicine, New York University Langone Medical Center New York, NY, USA
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Vivekanandan S, Mhlanga J, Launders D, Przeslak A, Morgan DAL. Beam angle manipulation to reduce cardiac dose during breast radiotherapy. Br J Radiol 2012; 85:265-71. [PMID: 21750129 PMCID: PMC3473992 DOI: 10.1259/bjr/58636261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 02/15/2011] [Accepted: 02/22/2011] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Standard tangential radiotherapy techniques after breast conservative surgery (BCS) often results in the irradiation of the tip of the left ventricle and the left anterior descending coronary artery (LAD), potentially increasing cardiovascular morbidity. The importance of minimising radiation dose to these structures has attracted increased interest in recent years. We tested a hypothesis that in some cases, by manipulating beam angles and accepting lower-than-prescribed doses of radiation in small parts of the breast distant from the surgical excision site, significant cardiac sparing can be achieved compared with more standard plans. METHODS A sample of 12 consecutive patients undergoing radiotherapy after left-sided BCS was studied. All patients were planned with a 6 MV tangential beam, beam angles were manipulated carefully and if necessary lower doses were given to small parts of the breast distant from the surgical excision site to minimise cardiac irradiation ("institutional" plan). Separate "hypothetical standard" plans were generated for seven patients using set field margins that met published guidelines. RESULTS In seven patients, the institutional plans resulted in lower doses to the LAD and myocardium than the hypothetical standard plans. In the other five patients, LAD and myocardial doses were deemed minimal using the hypothetical standard plan, which in these patients corresponded to the institutional plan (the patients were actually treated using the institutional plans). CONCLUSION Much attention has been devoted to ways of minimising cardiac radiation dose. This small sample demonstrates that careful manipulation of beam angles can often be a simple, but effective technique to achieve this.
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Affiliation(s)
- S Vivekanandan
- Department of Clinical Oncology, Nottingham University Hospitals, Nottingham, UK.
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Barnett GC, West CML, Coles CE, Pharoah PDP, Talbot CJ, Elliott RM, Tanteles GA, Symonds RP, Wilkinson JS, Dunning AM, Burnet NG, Bentzen SM. Standardized Total Average Toxicity score: a scale- and grade-independent measure of late radiotherapy toxicity to facilitate pooling of data from different studies. Int J Radiat Oncol Biol Phys 2012; 82:1065-74. [PMID: 21605943 DOI: 10.1016/j.ijrobp.2011.03.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 03/15/2011] [Accepted: 03/18/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE The search for clinical and biologic biomarkers associated with late radiotherapy toxicity is hindered by the use of multiple and different endpoints from a variety of scoring systems, hampering comparisons across studies and pooling of data. We propose a novel metric, the Standardized Total Average Toxicity (STAT) score, to try to overcome these difficulties. METHODS AND MATERIALS STAT scores were derived for 1010 patients from the Cambridge breast intensity-modulated radiotherapy trial and 493 women from the University Hospitals of Leicester. The sensitivity of the STAT score to detect differences between patient groups, stratified by factors known to influence late toxicity, was compared with that of individual endpoints. Analysis of residuals was used to quantify the effect of these covariates. RESULTS In the Cambridge cohort, STAT scores detected differences (p < 0.00005) between patients attributable to breast volume, surgical specimen weight, dosimetry, acute toxicity, radiation boost to tumor bed, postoperative infection, and smoking (p < 0.0002), with no loss of sensitivity over individual toxicity endpoints. Diabetes (p = 0.017), poor postoperative surgical cosmesis (p = 0.0036), use of chemotherapy (p = 0.0054), and increasing age (p = 0.041) were also associated with increased STAT score. When the Cambridge and Leicester datasets were combined, STAT was associated with smoking status (p < 0.00005), diabetes (p = 0.041), chemotherapy (p = 0.0008), and radiotherapy boost (p = 0.0001). STAT was independent of the toxicity scale used and was able to deal with missing data. There were correlations between residuals of the STAT score obtained using different toxicity scales (r > 0.86, p < 0.00005 for both datasets). CONCLUSIONS The STAT score may be used to facilitate the analysis of overall late radiation toxicity, from multiple trials or centers, in studies of possible genetic and nongenetic determinants of radiotherapy toxicity.
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Affiliation(s)
- Gillian C Barnett
- University of Cambridge Department of Oncology, Oncology Centre, Cambridge, UK.
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50
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Abstract
The foregoing, it is hoped, has provided at least a taste of the past, present, and future in the use of RT for the elderly population. Based on many ongoing studies, it becomes clear that the radiation oncology world has come to recognize the geriatric population’s ability to tolerate, and perhaps even thrive from, a course of RT, when it is offered appropriately. In the final analysis, it has become clear that no simple age cutoff can substitute for clinical acumen and a thorough assessment of patients’ general health before the best treatment regimen can be chosen. One need only follow the trend both in American and in European trials (the RTOG and the EORTC) to appreciate the acceptance that has taken hold that there need not be an age cutoff so much as a set of clinical criteria, including performance status and other assessments of function and comorbidity, prior to patient enrollment in anational trial. With such an outlook, we eagerly anticipate the results from these trials and look forward to implementing them in our treatment of young and old patients alike.
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Affiliation(s)
- Benjamin Rosenbluth
- Department of Radiation Oncology, Holy Name Medical Center, Teaneck, NJ 07666, USA.
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