1
|
Hassan AM, Asaad M, Morris N, Kumar S, Liu J, Mitchell MP, Shuck JW, Clemens MW, Butler CE, Selber JC. Subpectoral Implant Placement Is Not Protective against Postmastectomy Radiotherapy-Related Complications Compared to Prepectoral Placement. Plast Reconstr Surg 2024; 153:24-33. [PMID: 37010459 DOI: 10.1097/prs.0000000000010489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Postmastectomy radiotherapy (PMRT) is associated with altered cosmetic outcomes and higher complication rates in implant-based breast reconstruction (IBR). Conventional wisdom suggests that muscle coverage is somewhat protective against PMRT-related complications. In this study, the authors compared surgical outcomes in patients who underwent two-stage prepectoral versus subpectoral IBR in the setting of PMRT. METHODS The authors performed a retrospective cohort study of patients who underwent mastectomy and PMRT with two-stage IBR from 2016 to 2019. The primary outcome was breast-related complications, including device infection; the secondary outcome was device explantation. RESULTS The authors identified 179 reconstructions (101 prepectoral and 78 subpectoral) in 172 patients with a mean follow-up time of 39.7 ± 14.4 months. There were no differences between the prepectoral and subpectoral reconstructions in rates of breast-related complications (26.7% and 21.8%, respectively; P = 0.274), device infection (18.8% and 15.4%, respectively; P = 0.307), skin flap necrosis (5.0% and 1.3%, respectively; P = 0.232), or device explantation (20.8% and 14.1%, respectively; P = 0.117). In adjusted models, compared with prepectoral device placement, subpectoral device placement was not associated with a lower risk of breast-related complications [hazard ratio (HR), 0.75; 95% confidence interval (CI), 0.41 to 1.36], device infection (HR, 0.73; 95% CI, 0.35 to 1.49), or device explantation (HR, 0.58; 95% CI, 0.28 to 1.19). CONCLUSIONS Device placement plane was not predictive of complication rates in IBR in the setting of PMRT. Two-stage prepectoral IBR provides safe long-term outcomes with acceptable postoperative complication rates comparable to those with subpectoral IBR, even in the setting of PMRT. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
Affiliation(s)
- Abbas M Hassan
- From the Departments of Plastic and Reconstructive Surgery
| | - Malke Asaad
- From the Departments of Plastic and Reconstructive Surgery
| | | | | | - Jun Liu
- From the Departments of Plastic and Reconstructive Surgery
| | | | - John W Shuck
- From the Departments of Plastic and Reconstructive Surgery
| | - Mark W Clemens
- From the Departments of Plastic and Reconstructive Surgery
| | | | - Jesse C Selber
- From the Departments of Plastic and Reconstructive Surgery
| |
Collapse
|
2
|
Tumor Response After Neoadjuvant Magnetic Resonance Guided Single Ablative Dose Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2020; 106:821-829. [DOI: 10.1016/j.ijrobp.2019.11.406] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/14/2019] [Accepted: 11/17/2019] [Indexed: 12/12/2022]
|
3
|
Oultram S, Dempsey S, Greer P, Clapham M. Comparing Breast Conservation Surgery Seromas Contoured by Radiation Therapists versus those Contoured by a Radiation Oncologist in Radiation Therapy Planning for Early-Stage Breast Cancer. J Med Imaging Radiat Sci 2020; 51:108-116. [PMID: 31983574 DOI: 10.1016/j.jmir.2019.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION In the management of early-stage breast cancer using radiation therapy, computed tomography (CT) simulation is used to identify the breast conservation surgery (BCS) seroma as a proxy for the tumour bed. The delineation or contouring of the seroma is generally a task performed by a radiation oncologist (RO). With increasing patient numbers and other demands placed on ROs, the scope of practice for radiation therapists (RTs) is continually expanding, and the need for skills transfer from one profession to another has been investigated in recent years. This study aims to compare the BCS seroma volumes contoured by RTs with those contoured by ROs to add evidence in support of expanding the RTs' role in the treatment planning process in the management of early-stage breast cancer. METHODS A study was undertaken using the CT-simulation (CT-sim) data sets of patients with early-stage breast cancer treated in 2013. The CT-sim data sets had BCS seromas contoured by 1 of 5 ROs as part of routine clinical management. This study involved 4 RTs who each used the patient information to identify and contour breast seromas on 50 deidentified CT-sim data sets. Metrics used to compare RT versus RO contours included volume size, overlap between volumes, and geographical distance from the centre of volumes. RESULTS There were 50 CT-sim data sets with 1 RO contour and 4 RT contours analysed. The contour volumes of the 4 RTs and the ROs were assessed. Although there were 50 CT-sim data sets presented to each RT, analysis was carried out on 45, 43, 46, and 45 CT-sim data sets. There were no comparisons made where contours were not delineated. The contour volumes of the 4 RTs and the ROs were assessed with an interclass correlation coefficient, with a result of excellent reliability (0.975, 95% [0.963, 0.985]). The DICE similarity coefficient was used to compare the overlap of each RT contour with the RO contour; the results were favourable with mean (95% CI) DSCs 0.685, 0.640, 0.678, and 0.681, respectively. Comparing the RT and RO geographical centre of the seroma volumes, good to excellent reliability between the RTs and ROs was demonstrated (95% CI mean RO vs RT distances (mm): 3.75, 4.99, 7.71, and 3.39). There was no statistically significant difference between the distances (P = 0.65). CONCLUSION BCS seromas contoured by RTs compared well with those contoured by an RO. This research has provided further evidence to support RTs in assuming additional contouring responsibilities in radiation therapy planning for patients with early-stage breast cancer.
Collapse
Affiliation(s)
- Sharon Oultram
- Senior Clinical Radiation Therapy Educator, MPhil (Research) Candidate, Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia.
| | - Shane Dempsey
- Head of School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Peter Greer
- Department of Radiation Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Matthew Clapham
- Clinical Research Design, IT, and Statistical Support (CReDITTS), Hunter Medical Research Institute, Lot 1 Kookaburra Circuit, New Lambton Heights, New South Wales, Australia
| |
Collapse
|
4
|
Fhoghlú MN, Barrett S. A Review of Radiation-Induced Lymphocyte Apoptosis as a Predictor of Late Toxicity After Breast Radiotherapy. J Med Imaging Radiat Sci 2019; 50:337-344. [PMID: 31176443 DOI: 10.1016/j.jmir.2019.02.004] [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] [Received: 08/31/2018] [Revised: 01/28/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improved survivorship in patients with breast cancer means many are currently living with the late effects of radiotherapy, particularly fibrosis. Personalized treatment is not currently considered for patients with breast cancer. Radiation-induced lymphocyte apoptosis (RILA), a predictive assay, could offer a novel approach in predicting patients at a higher risk of developing this late toxicity and therefore improving informed decision-making. MATERIALS AND METHODS A systematic search of PubMed and Embase was performed and eight clinical trials were identified that investigate RILA as a predictor of late breast fibrosis after radiotherapy. RESULTS Median RILA scores were lower in patients who experienced ≥ grade 2 fibrosis than in patients who experienced ≥ grade 1. A clear inverse relationship between RILA scores and late toxicity was reported in the literature; however, there were several other confounding factors involved in the development of fibrosis. CD8 lymphocytes were reported to have superior sensitivity and specificity over CD4 lymphocytes. CONCLUSION RILA was reported to be an effective biomarker in predicting fibrosis in breast cancer but other factors also need to be considered before clinical implementation.
Collapse
Affiliation(s)
- Meadhbh Ní Fhoghlú
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Sarah Barrett
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| |
Collapse
|
5
|
Miranda FA, Vieira MTL, Moraes FYD, Marta GN, Carvalho HDA, Hanna SA. Cosmesis in patients with breast neoplasia submitted to the hypofractionated radiotherapy with of intensity-modulated beam. ACTA ACUST UNITED AC 2019; 64:1023-1030. [PMID: 30570055 DOI: 10.1590/1806-9282.64.11.1023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/05/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the cosmetic satisfaction of patients diagnosed with breast cancer submitted to the hypofractionated radiotherapy with IMRT (hIMRT) technique and its correlation with dosimetric data of the radiotherapy planning. METHODS The retrospective cohort study that assessed women with a diagnosis of malignant breast neoplasia submitted to the conservative treatment or radical mastectomy and treated with hIMRT. In the period between August 2007 to December 2014, in a philanthropic / private institution, 170 records were selected. The cosmetic assessment was carried out by means of the Harvard/RTOG/NSABP scale with one-year minimum range after treatment. The collected dosimetric data were: breast / chest wall volume, volume that received 95% (V95%) and 107% (V107%) of the prescribed dose. RESULTS The volume of the treated breasts ranged from 169 to 2.103 ml (median = 702; IQR: 535 to 914 ml). Median V95% was 86.7% (54.6-96.6%; IQR: 80.0% to 90.6%); eight (5.7%) patients had V95% higher than 95%. Median V107% was 0% (0%-16.3%; IQR: 0.0% to 0.3% and 13); 9.3% patients had V107% higher than 2%. One hundred and thirty-three (78.2%) patients responded to the cosmetic assessment: 99 (74.4%) considered the cosmetic results excellent. Significant associations between cosmetic assessment and breast volume (p=0.875), V95% (p=0.294) e V107% (p=0.301) were not found. CONCLUSION The cosmetic results showed favorable when using hIMRT, and the lack of correlation with usual the dosimetric data illustrates the capacity of hIMRT to minimize the heterogeneity of the dose in this endpoint, even in voluminous breasts.
Collapse
Affiliation(s)
| | | | - Fabio Ynoe de Moraes
- Radiation Medicine Program, Princess Margaret Hospital University of Toronto, Toronto, Ontario, Canada
| | - Gustavo Nader Marta
- Radiation Oncologist of Hospital Sírio-Libanês - SP and Instituto do Câncer do Estado de São Paulo, São Paulo (SP), Brasil
| | - Heloísa de Andrade Carvalho
- Radiation Oncologist of Hospital Sírio-Libanês - SP and Instituto de Radiologia (InRad) - SP, São Paulo (SP), Brasil
| | | |
Collapse
|
6
|
Thompson MK, Poortmans P, Chalmers AJ, Faivre-Finn C, Hall E, Huddart RA, Lievens Y, Sebag-Montefiore D, Coles CE. Practice-changing radiation therapy trials for the treatment of cancer: where are we 150 years after the birth of Marie Curie? Br J Cancer 2018; 119:389-407. [PMID: 30061587 PMCID: PMC6117262 DOI: 10.1038/s41416-018-0201-z] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 06/22/2018] [Accepted: 06/22/2018] [Indexed: 12/18/2022] Open
Abstract
As we mark 150 years since the birth of Marie Curie, we reflect on the global advances made in radiation oncology and the current status of radiation therapy (RT) research. Large-scale international RT clinical trials have been fundamental in driving evidence-based change and have served to improve cancer management and to reduce side effects. Radiation therapy trials have also improved practice by increasing quality assurance and consistency in treatment protocols across multiple centres. This review summarises some of the key RT practice-changing clinical trials over the last two decades, in four common cancer sites for which RT is a crucial component of curative treatment: breast, lung, urological and lower gastro-intestinal cancer. We highlight the global inequality in access to RT, and the work of international organisations, such as the International Atomic Energy Agency (IAEA), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the United Kingdom National Cancer Research Institute Clinical and Translational Radiotherapy Research Working Group (CTRad), that aim to improve access to RT and facilitate radiation research. We discuss some emerging RT technologies including proton beam therapy and magnetic resonance linear accelerators and predict likely future directions in clinical RT research.
Collapse
Affiliation(s)
- Mareike K Thompson
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | | | - Anthony J Chalmers
- Institute of Cancer Sciences, University of Glasgow, Glasgow, G61 1QH, UK
| | - Corinne Faivre-Finn
- Division of Cancer Sciences, University of Manchester; The Christie NHS Foundation Trust, Manchester, M20 4BX, UK
| | - Emma Hall
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, Sutton, London, SM2 5NG, UK
| | - Robert A Huddart
- Section of Radiotherapy and Imaging, The Institute of Cancer Research, London, SM2 5NG, UK
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital and Ghent University, C. Heymanslaan, 9000, Ghent, Belgium
| | - David Sebag-Montefiore
- Radiotherapy Research Group, Leeds Institute of Cancer and Pathology, University of Leeds; Leeds Cancer Centre, St James's University Hospitals, Leeds, LS9 7TF, UK
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, CB2 0QQ, UK.
| |
Collapse
|
7
|
Oultram S, Dempsey S. A Feasibility Study on the Identification of Postlumpectomy Seromas by a Radiation Therapist Compared with That by Radiation Oncologists in Radiation Therapy Planning for Early Stage Breast Cancer. J Med Imaging Radiat Sci 2018; 49:173-178. [DOI: 10.1016/j.jmir.2018.02.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 02/03/2018] [Accepted: 02/22/2018] [Indexed: 11/17/2022]
|
8
|
Meade AD, Maguire A, Bryant J, Cullen D, Medipally D, White L, McClean B, Shields L, Armstrong J, Dunne M, Noone E, Bradshaw S, Finn M, Shannon AM, Howe O, Lyng FM. Prediction of DNA damage and G2 chromosomal radio-sensitivity ex vivo in peripheral blood mononuclear cells with label-free Raman micro-spectroscopy. Int J Radiat Biol 2018. [DOI: 10.1080/09553002.2018.1451006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Aidan D. Meade
- School of Physics, Dublin Institute of Technology, Dublin, Ireland
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
| | - Adrian Maguire
- School of Physics, Dublin Institute of Technology, Dublin, Ireland
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
| | - Jane Bryant
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
| | - Daniel Cullen
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
- School of Biological Sciences, Dublin Institute of Technology, Dublin, Ireland
| | - Dinesh Medipally
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
- School of Biological Sciences, Dublin Institute of Technology, Dublin, Ireland
| | - Lisa White
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
- School of Biological Sciences, Dublin Institute of Technology, Dublin, Ireland
| | - Brendan McClean
- Department of Medical Physics, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
| | - Laura Shields
- Department of Medical Physics, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
| | - John Armstrong
- Department of Radiation Oncology, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
- Cancer Trials Ireland, Dublin, Ireland
| | - Mary Dunne
- Department of Radiation Oncology, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
| | - Emma Noone
- Department of Radiation Oncology, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
| | - Shirley Bradshaw
- Department of Radiation Oncology, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
| | - Marie Finn
- Department of Radiation Oncology, Saint Luke's Radiation Oncology Network, St Luke's Hospital, Dublin, Ireland
| | | | - Orla Howe
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
- School of Biological Sciences, Dublin Institute of Technology, Dublin, Ireland
| | - Fiona M. Lyng
- School of Physics, Dublin Institute of Technology, Dublin, Ireland
- DIT Centre for Radiation and Environmental Science, Focas Research Institute, Dublin Institute of Technology, Dublin, Ireland
| |
Collapse
|
9
|
Immediate Breast Reconstruction with Abdominal Free Flap and Adjuvant Radiotherapy. Plast Reconstr Surg 2017; 140:681-690. [DOI: 10.1097/prs.0000000000003664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Ricci JA, Epstein S, Momoh AO, Lin SJ, Singhal D, Lee BT. A meta-analysis of implant-based breast reconstruction and timing of adjuvant radiation therapy. J Surg Res 2017; 218:108-116. [PMID: 28985836 DOI: 10.1016/j.jss.2017.05.072] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/25/2017] [Accepted: 05/19/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implant-based breast reconstruction is the most common type of reconstruction after postmastectomy radiation therapy (PMRT). The impact of the timing of PMRT to a tissue expander or permanent implant is not well understood. The purpose of this systematic review was to evaluate outcomes in implant-based reconstruction and the timing of PMRT. METHODS A review of the English literature in the PubMed/MEDLINE database (2000-2016) was performed to identify all articles on implant-based breast reconstruction and PMRT. Cases from each study were grouped by PMRT to a tissue expander or PMRT to a permanent implant. Outcomes of interest included reconstructive failure and capsular contracture as overall rates and associations were pooled. Effect sizes (z values), risk ratios (RRs), and heterogeneity scores (I2) were calculated on meta-analysis. RESULTS There were 20 studies meeting inclusion criteria with 2348 patients identified. Pooled analysis revealed an overall rate of reconstructive failure of 17.6% and Baker grade III/IV capsular contracture of 37.5%. PMRT applied to tissue expanders resulted in higher rates of reconstructive failure compared with PMRT applied to permanent silicone implants (20% versus 13.4%, RR = 2.33, P = 0.0083, 95% confidence interval 1.24-4.35), but lower rates of capsular contracture (24.5% versus 49.4%, RR = 0.53, P = 0.083, 95% confidence interval 0.26-1.09). CONCLUSIONS Regardless of timing, PMRT applied to implant-based breast reconstruction was associated with high risk of reconstructive failure and capsular contracture. Surgeons should consider alternative strategies, such as autologous tissue reconstructions, in patients requiring PMRT.
Collapse
Affiliation(s)
- Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sherise Epstein
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
11
|
Short tangential arcs in VMAT based breast and chest wall radiotherapy lead to conformity of the breast dose with lesser cardiac and lung doses: a prospective study of breast conservation and mastectomy patients. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:729-736. [DOI: 10.1007/s13246-017-0558-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
|
12
|
Juneja P, Evans P, Windridge D, Harris E. Classification of fibroglandular tissue distribution in the breast based on radiotherapy planning CT. BMC Med Imaging 2016; 16:6. [PMID: 26762357 PMCID: PMC4712590 DOI: 10.1186/s12880-016-0107-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/05/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Accurate segmentation of breast tissues is required for a number of applications such as model based deformable registration in breast radiotherapy. The accuracy of breast tissue segmentation is affected by the spatial distribution (or pattern) of fibroglandular tissue (FT). The goal of this study was to develop and evaluate texture features, determined from planning computed tomography (CT) data, to classify the spatial distribution of FT in the breast. METHODS Planning CT data of 23 patients were evaluated in this study. Texture features were derived from the radial glandular fraction (RGF), which described the distribution of FT within three breast regions (posterior, middle, and anterior). Using visual assessment, experts grouped patients according to FT spatial distribution: sparse or non-sparse. Differences in the features between the two groups were investigated using the Wilcoxon rank test. Classification performance of the features was evaluated for a range of support vector machine (SVM) classifiers. RESULTS Experts found eight patients and 15 patients had sparse and non-sparse spatial distribution of FT, respectively. A large proportion of features (>9 of 13) from the individual breast regions had significant differences (p <0.05) between the sparse and non-sparse group. The features from middle region had most significant differences and gave the highest classification accuracy for all the SVM kernels investigated. Overall, the features from middle breast region achieved highest accuracy (91%) with the linear SVM kernel. CONCLUSION This study found that features based on radial glandular fraction provide a means for discriminating between fibroglandular tissue distributions and could achieve a classification accuracy of 91%.
Collapse
Affiliation(s)
- Prabhjot Juneja
- />North Sydney Cancer Center, Royal North Shore Hospital, Sydney, Australia
- />Institute of Medical Physics, School of Physics, University of Sydney, Sydney, Australia
- />Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| | - Philip Evans
- />Centre for Vision Speech and Signal Processing, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, UK
| | - David Windridge
- />Centre for Vision Speech and Signal Processing, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, UK
| | - Emma Harris
- />Joint Department of Physics, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, London, UK
| |
Collapse
|
13
|
Dosimetric comparison for volumetric modulated arc therapy and intensity-modulated radiotherapy on the left-sided chest wall and internal mammary nodes irradiation in treating post-mastectomy breast cancer. Radiol Oncol 2015; 49:91-8. [PMID: 25810708 PMCID: PMC4362613 DOI: 10.2478/raon-2014-0033] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 07/07/2014] [Indexed: 01/22/2023] Open
Abstract
Background The aim of the study was to evaluate the dosimetric benefit of applying volumetric modulated arc therapy (VMAT) on the post-mastectomy left-sided breast cancer patients, with the involvement of internal mammary nodes (IMN). Patients and methods The prescription dose was 50 Gy delivered in 25 fractions, and the clinical target volume included the left chest wall (CW) and IMN. VMAT plans were created and compared with intensity-modulated radiotherapy (IMRT) plans on Pinnacle treatment planning system. Comparative endpoints were dose homogeneity within planning target volume (PTV), target dose coverage, doses to the critical structures including heart, lungs and the contralateral breast, number of monitor units and treatment delivery time. Results VMAT and IMRT plans showed similar PTV dose homogeneity, but, VMAT provided a better dose coverage for IMN than IMRT (p = 0.017). The mean dose (Gy), V30 (%) and V10 (%) for the heart were 13.5 ± 5.0 Gy, 9.9% ± 5.9% and 50.2% ± 29.0% by VMAT, and 14.0 ± 5.4 Gy, 10.6% ± 5.8% and 55.7% ± 29.6% by IMRT, respectively. The left lung mean dose (Gy), V20 (%), V10 (%) and the right lung V5 (%) were significantly reduced from 14.1 ± 2.3 Gy, 24.2% ± 5.9%, 42.4% ± 11.9% and 41.2% ± 12.3% with IMRT to 12.8 ± 1.9 Gy, 21.0% ± 3.8%, 37.1% ± 8.4% and 32.1% ± 18.2% with VMAT, respectively. The mean dose to the contralateral breast was 1.7 ± 1.2 Gy with VMAT and 2.3 ± 1.6 Gy with IMRT. Finally, VMAT reduced the number of monitor units by 24% and the treatment time by 53%, as compared to IMRT. Conclusions Compared to 5-be am step-and-shot IMRT, VMAT achieves similar or superior target coverage and a better normal tissue sparing, with fewer monitor units and shorter delivery time.
Collapse
|
14
|
Interventional oncology in multidisciplinary cancer treatment in the 21(st) century. Nat Rev Clin Oncol 2014; 12:105-13. [PMID: 25445561 DOI: 10.1038/nrclinonc.2014.211] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Interventional oncology is an evolving branch of interventional radiology, which relies on rapidly evolving, highly sophisticated treatment tools and precise imaging guidance to target and destroy malignant tumours. The development of this field has important potential benefits for patients and the health-care system, but as a new discipline, interventional oncology has not yet fully established its place in the wider field of oncology; its application does not have a comprehensive evidence base, or a clinical or quality-assurance framework within which to operate. In this regard, radiation oncology, a cornerstone of modern cancer care, has a lot of important information to offer to interventional oncologists. A strong collaboration between radiation oncology and interventional oncology, both of which aim to cure or control tumours or to relieve symptoms with as little collateral damage to normal tissue as possible, will have substantial advantages for both disciplines. A close relationship with radiation oncology will help facilitate the development of a robust quality-assurance framework and accumulation of evidence to support the integration of interventional oncology into multidisciplinary care. Furthermore, collaboration between interventional oncology and radiation oncology fields will have great benefits to practitioners, people affected by cancer, and to the wider field of oncology.
Collapse
|
15
|
Lin Y, Wang B. Dosimetric absorption of intensity-modulated radiotherapy compared with conventional radiotherapy in breast-conserving surgery. Oncol Lett 2014; 9:9-14. [PMID: 25435927 PMCID: PMC4246647 DOI: 10.3892/ol.2014.2704] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 07/01/2014] [Indexed: 01/29/2023] Open
Abstract
The aim of this study was to investigate the dosimetric benefits between intensity-modulated radiotherapy (IMRT) and conventional radiotherapy (CR) among patients receiving breast-conserving surgery. A dosimetric comparison of IMRT and CR was evaluated in 20 patients with early-stage breast cancer using a three-dimensional treatment planning system. The prescribed mammary gland dose was completed in 25 fractions with a total dose of 5,000 cGy. Homogeneity of the planning target volume (PTV), irradiation dose and volume of organs at risk (OARs) were evaluated through a dose-volume histogram. For the homogeneity of PTV, the average volume receiving 95% of the prescribed dose in the IMRT plan was similar to that in the CR plan (97 vs. 96%, respectively). With regard to normal tissue sparing in OARs, the ipsilateral lung V20 in the IMRT and CR plans was 27.8 and 20.8%, respectively. The mean dose and V30 of the heart for five patients were 598.4 versus 348.3 cGy and 10.06 versus 5.3%, respectively. The mean dose sparing the heart or lung was markedly reduced in the IMRT plan compared with the CR plan. The results of the current study demonstrated that whole breast IMRT improves PTV dose distribution and improves normal tissue sparing in OARs.
Collapse
Affiliation(s)
- Yang Lin
- Department of Radiation Oncology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Benzhong Wang
- Department of Breast Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| |
Collapse
|
16
|
Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: A review. Crit Rev Oncol Hematol 2012; 81:1-20. [PMID: 21376625 DOI: 10.1016/j.critrevonc.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 01/03/2011] [Accepted: 01/25/2011] [Indexed: 01/03/2023] Open
|
17
|
Henríquez-Hernández LA, Carmona-Vigo R, Pinar B, Bordón E, Lloret M, Núñez MI, Rodríguez-Gallego C, Lara PC. Combined low initial DNA damage and high radiation-induced apoptosis confers clinical resistance to long-term toxicity in breast cancer patients treated with high-dose radiotherapy. Radiat Oncol 2011; 6:60. [PMID: 21645372 PMCID: PMC3117708 DOI: 10.1186/1748-717x-6-60] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 06/06/2011] [Indexed: 11/18/2022] Open
Abstract
Background Either higher levels of initial DNA damage or lower levels of radiation-induced apoptosis in peripheral blood lymphocytes have been associated to increased risk for develop late radiation-induced toxicity. It has been recently published that these two predictive tests are inversely related. The aim of the present study was to investigate the combined role of both tests in relation to clinical radiation-induced toxicity in a set of breast cancer patients treated with high dose hyperfractionated radical radiotherapy. Methods Peripheral blood lymphocytes were taken from 26 consecutive patients with locally advanced breast carcinoma treated with high-dose hyperfractioned radical radiotherapy. Acute and late cutaneous and subcutaneous toxicity was evaluated using the Radiation Therapy Oncology Group morbidity scoring schema. The mean follow-up of survivors (n = 13) was 197.23 months. Radiosensitivity of lymphocytes was quantified as the initial number of DNA double-strand breaks induced per Gy and per DNA unit (200 Mbp). Radiation-induced apoptosis (RIA) at 1, 2 and 8 Gy was measured by flow cytometry using annexin V/propidium iodide. Results Mean DSB/Gy/DNA unit obtained was 1.70 ± 0.83 (range 0.63-4.08; median, 1.46). Radiation-induced apoptosis increased with radiation dose (median 12.36, 17.79 and 24.83 for 1, 2, and 8 Gy respectively). We observed that those "expected resistant patients" (DSB values lower than 1.78 DSB/Gy per 200 Mbp and RIA values over 9.58, 14.40 or 24.83 for 1, 2 and 8 Gy respectively) were at low risk of suffer severe subcutaneous late toxicity (HR 0.223, 95%CI 0.073-0.678, P = 0.008; HR 0.206, 95%CI 0.063-0.677, P = 0.009; HR 0.239, 95%CI 0.062-0.929, P = 0.039, for RIA at 1, 2 and 8 Gy respectively) in multivariate analysis. Conclusions A radiation-resistant profile is proposed, where those patients who presented lower levels of initial DNA damage and higher levels of radiation induced apoptosis were at low risk of suffer severe subcutaneous late toxicity after clinical treatment at high radiation doses in our series. However, due to the small sample size, other prospective studies with higher number of patients are needed to validate these results.
Collapse
|
18
|
Computer simulation of pectoralis major muscle strain to guide exercise protocols for patients after breast cancer surgery. J Orthop Sports Phys Ther 2011; 41:417-26. [PMID: 21628825 DOI: 10.2519/jospt.2011.3358] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN Descriptive study. OBJECTIVES To quantify and rank the order of strain (length change in proportion to the resting length) of 3 portions of the pectoralis major (PM) muscle during various exercises. BACKGROUND A biomechanical foundation on which to base exercise prescriptions for patients after breast cancer surgery is lacking. METHODS An interactive, 3-D, computer graphic simulation system, developed to study biomechanical properties of the musculoskeletal system, was used to simulate movements of the glenohumeral, scapulothoracic, and scapuloclavicular joints of the shoulder, and to estimate strain in 3 portions of the pectoralis major (PM) muscle throughout the motions. The computed tomography scans of 2 male cadavers and literature review formed the basis for the estimations used in the model. Strains in the clavicular, midsternum, and abdominal regions of the PM were expressed as percent strain: [(change in muscle length/resting length) × 100]. Exercise motions were based on PM muscle anatomy and published breast cancer rehabilitation protocols. RESULTS Strains of the PM regions ranged from -21% shortening of the clavicular region during flexion to 55% lengthening of the abdominal region during the overhead stretch. Strain between adjacent regions was most uniform for the movement of abduction with external rotation, and least uniform with flexion. CONCLUSION PM muscle lengthening estimates were not linearly proportioned to shoulder joint motions, and varied for 3 portions of the PM. This information may help clinicians and researchers to estimate lengthening of PM portions throughout measurable shoulder motions.
Collapse
|
19
|
Abstract
Radiotherapy has undergone significant technological advances during the last 20 years, although their use in breast cancer was relatively limited until recently. The major recent changes in the use of radiotherapy for breast cancer have been the following: the establishment of partial breast irradiation (PBI) as an option for therapy in early stage disease; the revival of hypofractionated therapies for breast only therapy; the clearer definition of the role of post-mastectomy irradiation; and the continuing investigation as to which patients having conservative surgery do not need radiation therapy. Intensity-modulated radiotherapy is still not widely accepted to be medically necessary in breast cancer, but ongoing studies may demonstrate that it will prove to be useful in treating node-positive breast cancer when wide-field nodal targets need to be included in the treatment volume. Image-guided radiotherapy will prove to be necessary for PBI by external beam to keep the irradiated treatment volumes within long-term tolerance. The optimum dose and delivery schedule for PBI is yet to be finalized. Overall, the local control rates for all breast cancer treatment scenarios are generally good, and therefore, the emphasis is now on maintaining local control while reducing toxicities from treatment. The long-term risks of breast cancer radiotherapy on subsequent cancer induction are subject to ongoing studies. Biological enhancement of the effect of radiotherapy could allow dose reduction, with presumed reductions in the toxicity of treatment. In conclusion, breast cancer radiotherapy has much to understand and optimize in the 21st Century.
Collapse
Affiliation(s)
- Simon Powell
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
| |
Collapse
|
20
|
Morganti AG, Cilla S, de Gaetano A, Panunzi S, Digesù C, Macchia G, Massaccesi M, Deodato F, Ferrandina G, Cellini N, Scambia G, Piermattei A, Valentini V. Forward planned intensity modulated radiotherapy (IMRT) for whole breast postoperative radiotherapy. Is it useful? When? J Appl Clin Med Phys 2011; 12:3451. [PMID: 21587195 PMCID: PMC5718668 DOI: 10.1120/jacmp.v12i2.3451] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 12/10/2010] [Accepted: 01/10/2011] [Indexed: 11/23/2022] Open
Abstract
The purpose was to compare the dosimetric results observed in 201 breast cancer patients submitted to tangential forward intensity-modulated radiation therapy (IMRT) with those observed in 131 patients treated with a standard wedged 3D technique for postoperative treatment of whole breast, according to breast size and supraclavicular node irradiation. Following dosimetric parameters were used for the comparison: D(max), D(min), D(mean), V(95%) and V(107%) for the irradiated volume; D(max), D(mean), V(80%) and V(95%) for the ipsilateral lung; D(max), D(mean), V(80%) and V(95%) for the heart. Stratification was made according to breast size and supraclavicular (SCV) nodal irradiation. As respect to irradiated volume, a significant reduction of V(107%) (mean values: 7.0 ± 6.6 versus 2.4 ± 3.7, p < 0.001) and D(max) (mean % values: 111.2 ± 2.7 versus 107.7 ± 6.3, p < 0.001), and an increase of D(min) (mean % values: 65.0 ± 17.4 versus 74.9 ± 12.9, p < 0.001) were observed with forward IMRT. The homogeneity of dose distribution to target volume significantly improved with forward IMRT in all patient groups, irrespective of breast size or supraclavicular nodal irradiation. When patients treated with supraclavicular nodal irradiation were excluded from the analysis, forward IMRT slightly reduced V(80%) (mean values: 3.7 ± 2.6 versus 3.0 ± 2.4, p = 0.03) and V(95%) (mean values 1.9 ± 1.8 versus 1.2%± 1.5; p = 0.001) of the ipsilateral lung. The dose to the heart tended to be lower with IMRT but this difference was not statistically significant. Tangential forward IMRT in postoperative treatment of whole breast improved dosimetric parameters in terms of homogeneity of dose distribution to the target in a large sample of patients, independent of breast size or supraclavicular nodal irradiation. Lung irradiation was slightly reduced in patients not undergoing to supraclavicular irradiation.
Collapse
Affiliation(s)
- Alessio G. Morganti
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Savino Cilla
- Medical Physics UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Andrea de Gaetano
- CNR‐Institute of Systems Analysis and Computer Science (IASI)BioMathLabRome
| | - Simona Panunzi
- CNR‐Institute of Systems Analysis and Computer Science (IASI)BioMathLabRome
| | - Cinzia Digesù
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Gabriella Macchia
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Mariangela Massaccesi
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Francesco Deodato
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Gabriella Ferrandina
- Gynaecology Oncology UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Numa Cellini
- Department of RadiotherapyPoliclinico Universitario “Agostino Gemelli”, Catholic UniversityRomeItaly
| | - Giovanni Scambia
- Gynecology Oncology DepartmentPoliclinico Universitario “Agostino Gemelli”, Catholic UniversityRomeItaly
| | - Angelo Piermattei
- Medical Physics UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Vincenzo Valentini
- Department of RadiotherapyPoliclinico Universitario “Agostino Gemelli”, Catholic UniversityRomeItaly
| |
Collapse
|
21
|
Kirova YM, Castro Pena P, Hijal T, Fournier-Bidoz N, Laki F, Sigal-Zafrani B, Dendale R, Bollet MA, Campana F, Fourquet A. Improving the definition of tumor bed boost with the use of surgical clips and image registration in breast cancer patients. Int J Radiat Oncol Biol Phys 2010; 78:1352-5. [PMID: 20381975 DOI: 10.1016/j.ijrobp.2009.10.049] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 09/10/2009] [Accepted: 10/13/2009] [Indexed: 12/22/2022]
Abstract
PURPOSE To evaluate the accuracy of a boost technique. METHODS AND MATERIALS Twenty-two patients underwent tumorectomy with placement of two or more clips in the surgical cavity before breast remodeling. Preoperative and postoperative computed tomography scans, with match-point registration, were performed on all patients. The relationship between the location of the gross tumor volume (GTV), defined on the preoperative scan, and clip clinical target volume (CTV) (clips with a 5-mm margin on the postoperative scan) was then studied, by use of commercial volume analysis software. RESULTS Of the patients, 4 had two clips, 2 had three clips, 8 had four clips, and 8 had five clips. The median GTV was 1.06 mL (range, 0.2-5.3 mL); clip CTV ranged from 2.4 to 21.5 mL. Volumetric analysis showed that in 7 cases (32%), there was no intersection between the GTV and the clip CTV, with the following distribution: 4 patients with two clips, 1 patient with three clips, 1 patient with four clips, and 1 patient with five clips. The common contoured volume was defined as the percent ratio between the intersection of the GTV and clip CTV and the GTV. It was found to be significantly increased if three or more clips were used vs. only two clips (common contoured volume, 35.45% vs. 0.73%; p = 0.028). Finally, the GTV and clip CTV volume relationship can be presented as follows: 12.5% to 33% overlap in 8 patients (36.4%), 50% to 75% in 5 patients (22.7%), and greater than 90% in 2 patients (9%). CONCLUSIONS The use of three or more clips during tumorectomy increases the accuracy of tumor bed delineation.
Collapse
Affiliation(s)
- Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Chanda N, Kan P, Watkinson LD, Shukla R, Zambre A, Carmack TL, Engelbrecht H, Lever JR, Katti K, Fent GM, Casteel SW, Smith CJ, Miller WH, Jurisson S, Boote E, Robertson JD, Cutler C, Dobrovolskaia M, Kannan R, Katti KV. Radioactive gold nanoparticles in cancer therapy: therapeutic efficacy studies of GA-198AuNP nanoconstruct in prostate tumor–bearing mice. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2010; 6:201-9. [DOI: 10.1016/j.nano.2009.11.001] [Citation(s) in RCA: 159] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 10/18/2009] [Accepted: 11/03/2009] [Indexed: 11/24/2022]
|
23
|
Dedicated Magnetic Resonance Imaging in the Radiotherapy Clinic. Int J Radiat Oncol Biol Phys 2009; 74:644-51. [DOI: 10.1016/j.ijrobp.2009.01.065] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Revised: 01/09/2009] [Accepted: 01/14/2009] [Indexed: 11/21/2022]
|
24
|
Moon SH, Shin KH, Kim TH, Yoon M, Park S, Lee DH, Kim JW, Kim DW, Park SY, Cho KH. Dosimetric comparison of four different external beam partial breast irradiation techniques: three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, helical tomotherapy, and proton beam therapy. Radiother Oncol 2008; 90:66-73. [PMID: 18992950 DOI: 10.1016/j.radonc.2008.09.027] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Revised: 09/11/2008] [Accepted: 09/13/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND PURPOSE As an alternative to whole breast irradiation in early breast cancer, a variety of accelerated partial breast irradiation (APBI) techniques have been investigated. The purpose of our study is to compare the dosimetry of four different external beam APBI (EB-APBI) plans: three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), helical tomotherapy (TOMO), and proton beam therapy (PBT). METHODS AND MATERIALS Thirty patients were included in the study, and plans for four techniques were developed for each patient. A total dose of 30Gy in 6Gy fractions once daily was prescribed in all treatment plans. RESULTS In the analysis of the non-PTV breast volume that was delivered 50% of the prescribed dose (PD), PBT (mean: 16.5%) was superior to TOMO (mean: 22.8%), IMRT (mean: 33.3%), and 3D-CRT (mean: 40.9%) (p<0.001). The average ipsilateral lung volume percentage receiving 20% of the PD was significantly lower in PBT (0.4%) and IMRT (2.3%) compared with 3D-CRT (6.0%) and TOMO (14.2%) (p<0.001). The average heart volume percentage receiving 20% and 10% of the PD in left-sided breast cancer (N=19) was significantly larger with TOMO (8.0%, 19.4%) compared to 3D-CRT (1.5%, 3.1%), IMRT (1.2%, 4.0%), and PBT (0%, 0%) (p<0.001). CONCLUSIONS All four EB-APBI techniques showed acceptable coverage of the PTV. However, effective non-PTV breast sparing was achieved at the cost of considerable dose exposure to the lung and heart in TOMO.
Collapse
Affiliation(s)
- Sung Ho Moon
- Proton Therapy Center, National Cancer Center, Gyeonggi-do, Republic of Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Kirova YM, Fournier-Bidoz N, Servois V, Laki F, Pollet GA, Salmon R, Thomas A, Dendale R, Bollet MA, Campana F, Fourquet A. How to boost the breast tumor bed? A multidisciplinary approach in eight steps. Int J Radiat Oncol Biol Phys 2008; 72:494-500. [PMID: 18374516 DOI: 10.1016/j.ijrobp.2007.12.059] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Revised: 12/18/2007] [Accepted: 12/19/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE To describe a new procedure for breast radiotherapy that will improve tumor bed localization and radiotherapy treatment using a multidisciplinary approach. PATIENTS AND METHODS This pilot study was conducted by departments of radiation oncology, surgery, and radiology. A new procedure has been implemented, summarized as eight steps: from pre-surgery contrast CT to surgery, tumor bed planning target volume (PTV) determination, and finally breast and tumor bed irradiation. RESULTS Twenty patients presenting with T1N0M0 tumors were enrolled in the study. All patients underwent lumpectomy with the placement of surgical clips in the tumor bed region. During surgery, 1 to 5 clips were placed in the lumpectomy cavity before the plastic procedure. All patients underwent pre- and postoperative CT scans in the treatment position. The two sets of images were registered with a match-point registration. All volumes were contoured and the results evaluated. The PTV included the clips region, the gross tumor volume, and the surgical scar, with an overall margin of 5-10 mm in all directions, corresponding to localization and setup uncertainties. For each patient the boost PTV was discussed and compared with our standard forward-planned PTV. CONCLUSIONS We demonstrate the feasibility of a tumor bed localization and treatment procedure that seems adaptable to routine practice. Our study shows the advantages of a multidisciplinary approach for tumor bed localization and treatment. The use of more than 1 clip associated with pre- to postoperative CT image registration allows better definition of the PTV boost volume.
Collapse
Affiliation(s)
- Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Jalali R, Singh S, Budrukkar A. Techniques of tumour bed boost irradiation in breast conserving therapy: current evidence and suggested guidelines. Acta Oncol 2008; 46:879-92. [PMID: 17851869 DOI: 10.1080/02841860701441798] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Breast conservation surgery followed by external beam radiotherapy to breast has become the standard of care in management of early carcinoma breast. A boost to the tumour bed after whole breast radiotherapy is employed in view of the pattern of tumour bed recurrences in the index quadrant and was particularly considered in patients with some adverse histopathological characteristics such as positive margins, extensive intraductal carcinoma (EIC), lymphovascular invasion dose in patients even without such factors and for all age groups. The maximum absolute reduction of local recurrences by the addition of boost is especially seen in young premenopausal patients. At the same time, the addition of boost is associated with increased risk of worsening of cosmesis and no clear cut survival advantage. Radiological modalities such as fluoroscopy, ultrasound and CT scan have aided in accurate delineation of tumour bed with increasing efficacy. A widespread application of these techniques might ultimately translate into improved local control with minimal cosmetic deficit. The present article discusses the role of radiotherapy boost and the means to delineate and deliver the same, identify the high risk group, optimal technique and the doses and fractionations to be used. It also discusses the extent of adverse cosmetic outcome after boost delivery, means to minimise it and relevance of tumour bed in present day scenario of advanced radiotherapy delivery techniques like Intensity modulated radiation therapy (IMRT).
Collapse
|
27
|
Ahmed RS, De Los Santos JF, Fiveash JB, Keene KS, Popple RA. An imrt technique to increase therapeutic ratio of breast irradiation in patients with early-stage left breast cancer: limiting second malignancies. Med Dosim 2008; 33:71-7. [DOI: 10.1016/j.meddos.2007.10.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 07/25/2007] [Accepted: 10/01/2007] [Indexed: 12/11/2022]
|
28
|
A treatment planning study using non-coplanar static fields and coplanar arcs for whole breast radiotherapy of patients with concave geometry. Radiother Oncol 2007; 85:346-54. [DOI: 10.1016/j.radonc.2007.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 09/21/2007] [Accepted: 10/06/2007] [Indexed: 11/21/2022]
|
29
|
Pinar B, Lara PC, Lloret M, Bordón E, Núñez MI, Villalobos M, Guerrero R, Luna JD, Ruiz de Almodóvar JM. Radiation-induced DNA damage as a predictor of long-term toxicity in locally advanced breast cancer patients treated with high-dose hyperfractionated radical radiotherapy. Radiat Res 2007; 168:415-22. [PMID: 17903032 DOI: 10.1667/rr0746.1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 05/18/2007] [Indexed: 11/03/2022]
Abstract
This 14-year-long study makes a novel contribution to the debate on the relationship between the in vitro radiosensitivity of peripheral blood lymphocytes and normal tissue reactions after radiation therapy. The aims were (1) to prospectively assess the degree and time of onset of skin side effects in 40 prospectively recruited consecutive patients with locally advanced breast cancer treated with a hyperfractionated dose-escalation radiotherapy schedule and (2) to assess whether initial radiation-induced DNA damage in peripheral blood lymphocytes of these patients could be used to determine their likelihood of suffering severe late damage to normal tissue. Initial radiation-induced DNA double-strand breaks (DSBs) were assessed in peripheral blood lymphocytes of these patients by pulsed-field electrophoresis. Acute and late cutaneous and subcutaneous toxicity was evaluated using the Radiation Therapy Oncology Group morbidity score. A wide interindividual variation was observed in toxicity grades and in radiation-induced DNA DSBs in peripheral blood lymphocytes (mean 1.61 +/- 0.76 DSBs/Gy per 200 MBp, range 0.63- 4.08), which were not correlated. Multivariate analysis showed a correlation (P < 0.008) between late toxicity and higher prescribed protocol dose (81.6 Gy). Analysis of the 29 patients referred to 81.6 Gy revealed significantly (P < 0.031) more frequent late subcutaneous toxicity in those with intrinsic sensitivity to radiation-induced DNA DSBs of >1.69 DSBs/Gy per DNA unit. Our demonstration of a relationship between the sensitivity of in vitro-irradiated peripheral blood lymphocytes and the risk of developing late toxic effects opens up the possibility of predicting normal tissue response to radiation in individual patients, at least in high-dose non-conventional radiation therapy regimens.
Collapse
Affiliation(s)
- Beatriz Pinar
- Instituto Canario de Investigación del Cáncer (ICIC), Gran Canaria, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Coles CE, Cash CJC, Treece GM, Miller FNAC, Hoole ACF, Gee AH, Prager RW, Sinnatamby R, Britton P, Wilkinson JS, Purushotham AD, Burnet NG. High definition three-dimensional ultrasound to localise the tumour bed: a breast radiotherapy planning study. Radiother Oncol 2007; 84:233-41. [PMID: 17714816 DOI: 10.1016/j.radonc.2007.06.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2007] [Accepted: 06/19/2007] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Complex radiation techniques, such as conformal radiotherapy for partial breast irradiation, require accurate localisation of the tumour bed. This study investigated high definition 3D ultrasound for breast tumour bed localisation. Study aims were: firstly, to determine how easily a tumour cavity could be visualised with 3D ultrasound; secondly, to determine the accuracy of computed tomography (CT) and 3D ultrasound co-registration; thirdly, to compare 3D ultrasound with other methods of localisation. MATERIALS AND METHODS 3D ultrasound examinations were carried out in 40 women attending for breast radiotherapy. 3D position data were co-registered with the radiotherapy planning CT. 2D ultrasound and CT, surgical clips and CT, and CT alone were also used to localise the tumour bed in 32/40, 14/40 and 5/40 patients, respectively. Tumour bed volume and centre of gravity measurements for all methods of localisation were compared. RESULTS Mean surgery to imaging interval was 44 days (range 23-86 days). The post-operative cavity was seen in all cases using the 3D ultrasound, and was graded as highly visible, visible and subtle in 21/40 (53%), 12/40 (30%) and 7/40 (17%) cases, respectively. There was a statistically significant improvement in the ability of 3D ultrasound to localise the tumour bed compared with 2D ultrasound. CT-ultrasound registration was achieved in all cases. Two-dimensional and 3D ultrasound showed smaller tumour bed volumes than clips. CONCLUSIONS Three-dimensional ultrasound localisation of the tumour bed appears superior to 2D ultrasound. It can also be co-registered with a planning CT, thus allowing additional information on the size and location of the tumour bed to be integrated into complex radiotherapy planning.
Collapse
|
31
|
Poortmans P. Evidence based radiation oncology: Breast cancer. Radiother Oncol 2007; 84:84-101. [PMID: 17599597 DOI: 10.1016/j.radonc.2007.06.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Radiotherapy is, similar to surgery, a local treatment. In the case of breast cancer, it is generally given after conservative or after more extensive, tumour and patient adapted, surgery. The target volumes can be the breast and/or the thoracic wall and/or the regional lymph node areas. The integration and the extent of radiotherapy as part of the comprehensive treatment of the breast cancer patient, including the amount of surgery and the sequencing with the systemic treatments, has to be well discussed with all medical specialists involved in treating breast cancer on a multidisciplinary basis. Guidelines for the appropriate prescription and execution of radiotherapy are of utmost importance. However, individualisation based on the individual patients' and tumours' characteristics should always be envisaged. MATERIALS AND METHODS Based on a review of the literature the level of evidence that is available for the indications for radiotherapy is summarised, as well as the main clinical questions that are unanswered today. An overview of the recent and ongoing clinical trails in breast cancer will highlight some of the current ongoing debates. CONCLUSIONS In the case of breast cancer, radiotherapy, given after as well conservative as extensive risk-adapted surgery, significantly reduces the risk of local and regional recurrences. Especially for patients with an intermediate to high absolute risk for local recurrences, a positive influence on overall survival has been shown, notably when appropriate radiotherapy techniques are used. Most important is that the best results that we can offer to our breast cancer patients for all clinical endpoints (local and regional control; quality of life; cosmetic results; survival) can be obtained by a multidisciplinary and patient-oriented approach, involving all those involved in the treatment of breast cancer patients.
Collapse
Affiliation(s)
- Philip Poortmans
- Dr. Bernard Verbeeten Instituut, Radiotherapy, Tilburg, Netherlands.
| |
Collapse
|
32
|
Stelzer KJ, Bailey B, Davidson M, Dugick S, Mullins M. Determination of critical dosimetric parameters for breast radiation using forward-planned segmented fields for intensity modulation. Med Dosim 2007; 32:23-32. [PMID: 17317532 DOI: 10.1016/j.meddos.2006.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2006] [Accepted: 10/16/2006] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to determine factors associated with acute skin toxicity from breast radiation for optimizing forward-planned intensity modulation. Treatment plans in 100 patients who received breast radiation using three-dimensional treatment planning were analyzed. Fifty-two patients were treated with tangent fields using wedges (nonsegmented), and 48 patients were treated with forward-planned fields segmented by a multileaf collimator to modulate intensity. Clinical and dosimetric variables were recorded. Acute skin toxicity was prospectively documented using a standard scale. Body weight, breast target volume, maximum body dose (encompassing 10 mL), and volume of body receiving >50 Gy and 55 Gy (V50Gy, and V55Gy) were associated with acute toxicity. Patients treated with segmented plans had significantly larger breast targets and were treated to lower prescription isodoses, confounding comparison with nonsegmented plans. Consequently, datasets from patients treated with segmented plans were used to design new nonsegmented plans for paired comparison. Segmented plans were superior with respect to dosimetric endpoints predictive of toxicity in this paired comparison. Limitations of 55 Gy for maximum body dose and 1100 mL for V50Gy appeared to be appropriate values to guide forward treatment planning of segmented fields.
Collapse
Affiliation(s)
- Keith J Stelzer
- Celilo Radiation Therapy, Mid-Columbia Medical Center, The Dalles, OR 97058, USA.
| | | | | | | | | |
Collapse
|
33
|
Palazzi M, Tomatis S, Valli MC, Guzzetti R, Tonoli S, Bertoni F, Magrini SM, Meregalli S, Asnaghi D, Arienti V, Pradella R, Cafaro I. Impact of radiotherapy technique on the outcome of early breast cancer treated with conservative surgery: A multicenter observational study on 1,176 patients. Int J Radiat Oncol Biol Phys 2006; 65:1361-7. [PMID: 16750324 DOI: 10.1016/j.ijrobp.2006.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 03/16/2006] [Accepted: 03/16/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE To quantify the impact of radiotherapy technique on cosmetic outcome and on 5-year local control rate of early breast cancer treated with conservative surgery and adjuvant radiation. METHODS AND MATERIALS A total of 1,176 patients irradiated to the breast in 1997 were entered by eight centers into a prospective, observational study. Surgical procedure was quadrantectomy in 97% of patients, with axillary dissection performed in 96%; pT-stage was T1 in 81% and T2 in 19% of cases; pN-stage was N0 in 71%, N + (1-3) in 21%, and N + (>3) in 8% of cases. An immobilization device was used in 17% of patients; external contour-based and computed tomography-based treatment planning were performed in 20% and 72% of cases, respectively; 37% of patients were treated with a telecobalt unit and 63% with a linear accelerator; portal verification was used in 55% of patients; a boost dose to the tumor bed was delivered in 60% of cases. RESULTS With a median follow-up of 6.2 years, local, regional, and distant control rates at 5 years are 98%, 99%, and 92%, respectively. Use of less sophisticated treatment technique was associated with a less favorable cosmetic outcome. Local control was comparable between centers despite substantial technical differences. In a multivariate analysis including clinical and technical factors, only older age and prescription of medical adjuvant treatment significantly predicted for better local control, whereas use of portal verification was of borderline significance. CONCLUSIONS Radiation technical factors impacted negatively on cosmetic outcome, but had relatively small effects on local control compared with other clinical factors.
Collapse
|
34
|
Williams MV, James ND, Summers ET, Barrett A, Ash DV. National survey of radiotherapy fractionation practice in 2003. Clin Oncol (R Coll Radiol) 2006; 18:3-14. [PMID: 16477914 DOI: 10.1016/j.clon.2005.10.002] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIMS To document UK practice in radiotherapy fractionation. METHODS All radiotherapy centres in the UK participated in a 1-week audit from 29 September 2003. Fractionation data were collected for all patients starting external beam radiotherapy. This included 2498 patients who were prescribed 32 547 fractions. RESULTS For the radical treatment of non-skin malignancy (n = 708), the prescribed dose ranged from a single fraction of 8 Gy for total-body irradiation to 75 Gy in 43 fractions for prostate cancer. Postoperative treatment for breast cancer was dominated by three regimens: 40 Gy in 15 fractions; 45 Gy in 20 fractions; and 50 Gy in 25 fractions. Palliative treatment was given in a single fraction to 393 patients (36%) with doses of up to 15 Gy. Three hundred and ninety patients (36%) received four to seven fractions delivering 20-25 Gy. Only 89 patients (8%) received more than 10 fractions with palliative intent but used 29% of such fractions. In the treatment of bone metastases, the most common prescriptions were 8-10 Gy in a single fraction and 20 Gy in five fractions. CONCLUSION UK radiotherapy practice has become more uniform and moved closer to practice in North America and Europe over the past 15 years. For radical radiotherapy, 54% of prescriptions were for a fraction size of 1.8-2.0 Gy but the distribution was bi-modal and 20% of patients were prescribed fraction sizes of 2.7-3.0 Gy. Evidence-based practice now supports hypo-fractionated palliative treatment favouring single fractions for bone metastases and one or two fractions for many patients with advanced lung cancer. Two fractions are advised for some patients with brain metastasis. If these guidelines had been applied uniformly, then the number of treatments prescribed for palliation could have fallen by 36% from 5197 to 3313. This would have represented a 6% reduction in the overall radiotherapy workload. Not all patients are suitable for such hypo-fractionated treatments, but this is an area in which resource use can be improved. In the postoperative management of breast cancer, a change in practice to use 15 fractions uniformly would reduce overall radiotherapy workload by 4%. By contrast, a change to 25 fractions would increase overall workload by 7%.
Collapse
Affiliation(s)
- M V Williams
- Oncology Centre, Addenbrooke's NHS Trust, Cambridge, UK.
| | | | | | | | | |
Collapse
|
35
|
|