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Bonaccorsi SG, Tessonnier T, Hoeltgen L, Meixner E, Harrabi S, Hörner-Rieber J, Haberer T, Abdollahi A, Debus J, Mairani A. Exploring Helium Ions' Potential for Post-Mastectomy Left-Sided Breast Cancer Radiotherapy. Cancers (Basel) 2024; 16:410. [PMID: 38254899 PMCID: PMC10814201 DOI: 10.3390/cancers16020410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
Proton therapy presents a promising modality for treating left-sided breast cancer due to its unique dose distribution. Helium ions provide increased conformality thanks to a reduced lateral scattering. Consequently, the potential clinical benefit of both techniques was explored. An explorative treatment planning study involving ten patients, previously treated with VMAT (Volumetric Modulated Arc Therapy) for 50 Gy in 25 fractions for locally advanced, node-positive breast cancer, was carried out using proton pencil beam therapy with a fixed relative biological effectiveness (RBE) of 1.1 and helium therapy with a variable RBE described by the mMKM (modified microdosimetric kinetic model). Results indicated that target coverage was improved with particle therapy for both the clinical target volume and especially the internal mammary lymph nodes compared to VMAT. Median dose value analysis revealed that proton and helium plans provided lower dose on the left anterior descending artery (LAD), heart, lungs and right breast than VMAT. Notably, helium therapy exhibited improved ipsilateral lung sparing over protons. Employing NTCP models as available in the literature, helium therapy showed a lower probability of grade ≤ 2 radiation pneumonitis (22% for photons, 5% for protons and 2% for helium ions), while both proton and helium ions reduce the probability of major coronary events with respect to VMAT.
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Affiliation(s)
| | - Thomas Tessonnier
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Line Hoeltgen
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Eva Meixner
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Semi Harrabi
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Thomas Haberer
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Amir Abdollahi
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Jürgen Debus
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), 69120 Heidelberg, Germany
| | - Andrea Mairani
- Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Division of Molecular and Translational Radiation Oncology, National Center for Tumor Diseases (NCT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Centro Nazionale di Adroterapia Oncologica (CNAO), 27100 Pavia, Italy
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Chakraborty MA, Khan AJ, Cahlon O, Xu AJ, Braunstein LZ, Powell SN, Choi JI. Proton Reirradiation for High-Risk Recurrent or New Primary Breast Cancer. Cancers (Basel) 2023; 15:5722. [PMID: 38136268 PMCID: PMC10742022 DOI: 10.3390/cancers15245722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Radiotherapy is an integral component of multidisciplinary breast cancer care. Given how commonly radiotherapy is used in the treatment of breast cancer, many patients with recurrences have received previous radiotherapy. Patients with new primary breast cancer may also have received previous radiotherapy to the thoracic region. Curative doses and comprehensive field photon reirradiation (reRT) have often been avoided in these patients due to concerns for severe toxicities to organs-at-risk (OARs), such as the heart, lungs, brachial plexus, and soft tissue. However, many patients may benefit from definitive-intent reRT, such as patients with high-risk disease features such as lymph node involvement and dermal/epidermal invasion. Proton therapy is a potentially advantageous treatment option for delivery of reRT due to its lack of exit dose and greater conformality that allow for enhanced non-target tissue sparing of previously irradiated tissues. In this review, we discuss the clinical applications of proton therapy for patients with breast cancer requiring reRT, the currently available literature and how it compares to historical photon reRT outcomes, treatment planning considerations, and questions in this area warranting further study. Given the dosimetric advantages of protons and the data reported to date, proton therapy is a promising option for patients who would benefit from the added locoregional disease control provided by reRT for recurrent or new primary breast cancer.
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Affiliation(s)
- Molly A. Chakraborty
- Rutgers New Jersey Medical School, Newark, NJ 07103, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Atif J. Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Oren Cahlon
- Department of Radiation Oncology, New York University, New York, NY 10016, USA
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - J. Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
- New York Proton Center, New York, NY 10035, USA
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Holt F, Probert J, Darby SC, Haviland JS, Coles CE, Kirby AM, Liu Z, Dodwell D, Ntentas G, Duane F, Taylor C. Proton Beam Therapy for Early Breast Cancer: A Systematic Review and Meta-analysis of Clinical Outcomes. Int J Radiat Oncol Biol Phys 2023; 117:869-882. [PMID: 36868521 PMCID: PMC7615202 DOI: 10.1016/j.ijrobp.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/06/2023] [Accepted: 02/11/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE Adjuvant proton beam therapy (PBT) is increasingly available to patients with breast cancer. It achieves better planned dose distributions than standard photon radiation therapy and therefore may reduce the risks. However, clinical evidence is lacking. METHODS AND MATERIALS A systematic review of clinical outcomes from studies of adjuvant PBT for early breast cancer published in 2000 to 2022 was undertaken. Early breast cancer was defined as when all detected invasive cancer cells are in the breast or nearby lymph nodes and can be removed surgically. Adverse outcomes were summarized quantitatively, and the prevalence of the most common ones were estimated using meta-analysis. RESULTS Thirty-two studies (1452 patients) reported clinical outcomes after adjuvant PBT for early breast cancer. Median follow-up ranged from 2 to 59 months. There were no published randomized trials comparing PBT with photon radiation therapy. Scattering PBT was delivered in 7 studies (258 patients) starting 2003 to 2015 and scanning PBT in 22 studies (1041 patients) starting 2000 to 2019. Two studies (123 patients) starting 2011 used both PBT types. For 1 study (30 patients), PBT type was unspecified. Adverse events were less severe after scanning than after scattering PBT. They also varied by clinical target. For partial breast PBT, 498 adverse events were reported (8 studies, 358 patients). None were categorized as severe after scanning PBT. For whole breast or chest wall ± regional lymph nodes PBT, 1344 adverse events were reported (19 studies, 933 patients). After scanning PBT, 4% (44/1026) of events were severe. The most prevalent severe outcome after scanning PBT was dermatitis, which occurred in 5.7% (95% confidence interval, 4.2-7.6) of patients. Other severe adverse outcomes included infection, pain, and pneumonitis (each ≤1%). Of the 141 reconstruction events reported (13 studies, 459 patients), the most prevalent after scanning PBT was prosthetic implant removal (34/181, 19%). CONCLUSIONS This is a quantitative summary of all published clinical outcomes after adjuvant PBT for early breast cancer. Ongoing randomized trials will provide information on its longer-term safety compared with standard photon radiation therapy.
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Affiliation(s)
- Francesca Holt
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
| | - Jake Probert
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Sarah C Darby
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Joanne S Haviland
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Anna M Kirby
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, United Kingdom
| | - Zulian Liu
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Georgios Ntentas
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Department of Medical Physics, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Frances Duane
- St. Luke's Radiation Oncology Network and Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Carolyn Taylor
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Kang Y, Bues M, Halyard MY, McGee LA, Vern-Gross TZ, Wong WW, Keole SR, Vargas C, James SE, Ahmed SK, Archuleta JP, Ridgway AK, Lara PR, Fatyga M. Dose delivery reproducibility for PBS proton treatment of breast cancer patients with and without mask immobilization. Radiat Oncol 2023; 18:157. [PMID: 37736727 PMCID: PMC10515054 DOI: 10.1186/s13014-023-02323-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Setup reproducibility of the tissue in the proton beam path is critical in maintaining the planned clinical target volume (CTV) dose coverage and sparing the organs at risk (OAR). In this study, we retrospectively evaluated radiation therapy dose reproducibility for proton pencil beam scanning (PBS) treatment of breast cancer patients with and without mask immobilization. METHODS Ninety-four patients treated between January 2019 and September 2022 with at least one verification CT scan (V-CT) in treatment position were included for this study. All patients were set up with arms up using the Orfit AIO patient positioning system, with (69 patients) or without (25 patients) mask immobilization in chin, neck, shoulder, upper arm, and chest areas. Two to three enface or near enface single field uniform dose PBS beams were optimized using a commercial treatment planning system. Prescription doses were 25 to 60 GyRBE in 5 to 45 fractions. Treatment plan doses re-calculated on V-CTs were compared to the corresponding planned doses. Cumulative doses were also calculated for patients with at least 3 V-CTs by deform and weighted sum doses from V-CTs to corresponding P-CTs. CTV D95%, ipsilateral-lung V40%, esophagus D0.01cc, and heart mean dose were evaluated and reported as percentages of prescription doses. Differences were large dose deteriorations (LDD) if: (1) CTV (V-CT/cumulative D95%) - (Planned D95%) < - 5%; or (2) Ipsilateral-lung (V-CT/cumulative V40%) - (Planned V40%) > 5%; or (3) Esophagus (V-CT/cumulative D0.01cc) - (Planned D0.01cc) > 10%; or (4) Heart (V-CT/cumulative mean) - (Planned mean) > 1.5%. RESULTS On average, V-CT/cumulative and planned CTV/OAR dose parameter differences were less than 2.2%/1.7% and 3.4%/3.7% for masked and maskless patients, respectively. The percentages of patients with at least one CTV or OAR V-CT/cumulative dose LDD were 20.3%/25.0% and 72.0%/54.0% for masked and maskless patients, respectively. CONCLUSIONS On average, masked/maskless setups achieved delivered and planned CTV/OAR dose parameters agreed within 2.2%/3.7% for PBS treatment of breast cancer patients in this study. Maskless patients had higher rate of CTV/OAR LDDs compared to masked patients. Dosimetric differences large enough to raise clinical concerns in either group were able to be addressed with replannings.
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Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Tamara Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sarah E James
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - James P Archuleta
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Ana K Ridgway
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Pedro R Lara
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
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Kirby AM, Holt F, Taylor CW, Haviland JS, MacKenzie M, Coles CE. Should patients requiring radiotherapy for breast cancer be treated with proton beam therapy? BMJ 2023; 381:e072896. [PMID: 37295798 DOI: 10.1136/bmj-2022-072896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Anna M Kirby
- Royal Marsden NHS Foundation Trust & Institute of Cancer Research, Sutton, UK
| | - Francesca Holt
- Nuffield Department of Population Health, University of Oxford, UK
| | - Carolyn W Taylor
- Nuffield Department of Population Health, University of Oxford, UK
| | - Joanne S Haviland
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, UK
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Nangia S, Burela N, Noufal MP, Patro K, Wakde MG, Sharma DS. Proton therapy for reducing heart and cardiac substructure doses in Indian breast cancer patients. Radiat Oncol J 2023; 41:69-80. [PMID: 37403349 DOI: 10.3857/roj.2023.00073] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/10/2023] [Indexed: 07/06/2023] Open
Abstract
PURPOSE Indians have a higher incidence of cardiovascular diseases, often at a younger age, than other ethnic groups. This higher baseline risk requires consideration when assessing additional cardiac morbidity of breast cancer treatment. Superior cardiac sparing is a critical dosimetric advantage of proton therapy in breast cancer radiotherapy. We report here the heart and cardiac-substructure doses and early toxicities in breast cancer patients treated post-operatively with proton therapy in India's first proton therapy center. MATERIALS AND METHODS We treated twenty breast cancer patients with intensity-modulated proton therapy (IMPT) from October 2019 to September 2022, eleven after breast conservation, nine following mastectomy, and appropriate systemic therapy, when indicated. The most prescribed dose was 40 GyE to the whole breast/chest wall and 48 GyE by simultaneous integrated boost to the tumor bed and 37.5 GyE to appropriate nodal volumes, delivered in 15 fractions. RESULTS Adequate coverage was achieved for clinical target volume (breast/chest wall), i.e., CTV40, and regional nodes, with 99% of the targets receiving 95% of the prescribed dose (V95% > 99%). The mean heart dose was 0.78 GyE and 0.87 GyE for all and left breast cancer patients, respectively. The mean left anterior descending artery (LAD) dose, LAD D0.02cc, and left ventricle dose were 2.76, 6.46, and 0.2 GyE, respectively. Mean ipsilateral lung dose, V20Gy, V5Gy, and contralateral breast dose (Dmean) were 6.87 GyE, 14.6%, 36.4%, and 0.38 GyE, respectively. CONCLUSION The dose to heart and cardiac substructures is lower with IMPT than published photon therapy data. Despite the limited access to proton therapy at present, given the higher cardiovascular risk and coronary artery disease prevalence in India, the cardiac sparing achieved using this technique merits consideration for wider adoption in breast cancer treatment.
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Affiliation(s)
- Sapna Nangia
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Nagarjuna Burela
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - M P Noufal
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Kartikeswar Patro
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Manoj Gulabrao Wakde
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
| | - Dayanada S Sharma
- Department of Medical Physics, Apollo Proton Cancer Centre, Chennai, Tamil Nadu, India
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Oymak E, Bozca R, Guler OC, Onal C. Contralateral breast radiation doses in breast cancer patients treated with helical tomotherapy. Med Dosim 2022; 48:61-66. [PMID: 36572598 DOI: 10.1016/j.meddos.2022.11.002] [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: 04/11/2022] [Revised: 11/27/2022] [Accepted: 11/30/2022] [Indexed: 12/25/2022]
Abstract
We aimed to evaluate contralateral breast doses calculated with a Treatment Planning System (TPS) and verified with metal oxide semiconductor field effect transistor (MOSFET) detectors in patients with early-stage breast cancer (BC) who received helical tomotherapy (HT) after breast-conserving surgery. The dosimetric data of 30 patients (15 left-sided and 15 right-sided) with BC treated with 50.4 Gy to the whole breast and 64.4 Gy to the tumor bed in 28 fractions were analyzed. TPS doses were calculated and MOSFET doses were measured in the contralateral breast (CB) at cranial, caudal, and midpoint and 2 cm lateral to the central point. TPS and MOSFET doses were compared in the entire cohort as well as by tumor location (inner vs outer quadrant) and planning target volume of the breast (<1200 cc vs ≥1200 cc). The average doses at superior, inferior, central, and lateral points calculated with the TPS were 0.26 ± 0.15 cGy, 0.21 ± 0.09 cGy, 0.65 ± 0.14 cGy, and 0.50 ± 0.11 cGy, respectively, and were 0.37 ± 0.16 cGy, 0.34 ± 0.12 cGy, 0.60 ± 0.18 cGy, and 0.34 ± 0.15 cGy, respectively in MOSFET readings. Except for the central point, TPS-calculated doses and MOSFET readings were differed. The doses to the CB in patients with inner and outer quadrant tumors were not significantly different. In patients with large breasts, MOSFET doses were higher at superior and lateral points than TPS doses, but TPS doses were greater at inferior points. MOSFET readings were higher than TPS calculated doses in patients with inner or outer quadrant tumors in small or large breast volumes. The dose calculated by the TPS and that measured by MOSFET differed by a very small amount. The maximum dose to the CB administered at the midpoint was 1.8 Gy, as calculated using the TPS and confirmed using MOSFET detectors, in patients with early-stage BC undergoing breast-only radiotherapy with HT.
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Affiliation(s)
- Ezgi Oymak
- Division of Radiation Oncology, Iskenderun Gelisim Hospital, Hatay, Turkey
| | - Recep Bozca
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
| | - Ozan Cem Guler
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey
| | - Cem Onal
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Turkey; Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Turkey.
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Lin H, Dong L, Jimenez RB. Emerging Technologies in Mitigating the Risks of Cardiac Toxicity From Breast Radiotherapy. Semin Radiat Oncol 2022; 32:270-281. [DOI: 10.1016/j.semradonc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fuglsang Jensen M, Stick LB, Høyer M, Kronborg CJS, Lorenzen EL, Mortensen HR, Nyström PW, Petersen SE, Randers P, Thai LMH, Yates ES, Offersen BV. Proton therapy for early breast cancer patients in the DBCG proton trial: planning, adaptation, and clinical experience from the first 43 patients. Acta Oncol 2022; 61:223-230. [PMID: 34632922 DOI: 10.1080/0284186x.2021.1986229] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Danish Breast Cancer Group (DBCG) Proton Trial randomizes breast cancer patients selected on high mean heart dose (MHD) or high lung dose (V20Gy/V17Gy) in the photon plan between photon and proton therapy. This study presents the proton plans and adaptation strategy for the first 43 breast cancer patients treated with protons in Denmark. MATERIAL AND METHODS Forty-four proton plans (one patient with bilateral cancer) were included; 2 local and 42 loco-regional including internal mammary nodes (IMN). Nineteen patients had a mastectomy and 25 a lumpectomy. The prescribed dose was either 50 Gy in 25 fractions (n = 30) or 40 Gy in 15 fractions (n = 14) wherefrom five received simultaneous integrated boost to the tumor bed. Using 2-3 en face proton fields, single-field optimization, robust optimization and a 5 cm range shifter ensured robustness towards breathing motion, setup- and range uncertainties. An anatomical evaluation was performed by evaluating the dose after adding/removing 3 mm and 5 mm tissue to/from the body-outline and used to define treatment tolerances for anatomical changes. RESULTS The nominal and robust criteria were met for all patients except two. The median MHD was 1.5 Gy (0.5-3.4 Gy, 50 Gy) and 1.1 Gy (0.0-1.5 Gy, 40 Gy). The anatomical evaluations showed how 5 mm shrinkage approximately doubled the MHD while 5 mm swelling reduced target coverage of the IMN below constraints. Ensuring 3-5 mm robustness toward swelling was prioritized but not always achieved by robust optimization alone emphasizing the need for a distal margin. Twenty-eight patients received plan adaptation, eight patients received two, and one received five. CONCLUSION This proton planning strategy ensured robust treatment plans within a pre-defined level of acceptable anatomical changes that fulfilled the planning criteria for most of the patients and ensured low MHD.
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Affiliation(s)
| | | | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Petra Witt Nyström
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Uppsala University Hospital, Uppsala, Sweden
| | | | - Pia Randers
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Linh My Hoang Thai
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
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Stick LB, Jensen MF, Bentzen SM, Kamby C, Lundgaard AY, Maraldo MV, Offersen BV, Yu J, Vogelius IR. Radiation-Induced Toxicity Risks in Photon Versus Proton Therapy for Synchronous Bilateral Breast Cancer. Int J Part Ther 2021; 8:1-13. [PMID: 35530186 PMCID: PMC9009461 DOI: 10.14338/ijpt-21-00023.1] [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: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study compares photon and proton therapy plans for patients with synchronous bilateral early breast cancer and estimates risks of early and late radiation-induced toxicities. Materials and Methods Twenty-four patients with synchronous bilateral early breast cancer receiving adjuvant radiation therapy using photons, 3-dimensional conformal radiation therapy or volumetric modulated arc therapy, were included and competing pencil beam scanning proton therapy plans were created. Risks of dermatitis, pneumonitis, acute esophageal toxicity, lung and breast fibrosis, hypothyroidism, secondary lung and esophageal cancer and coronary artery events were estimated using published dose-response relationships and normal tissue complication probability (NTCP) models. Results The primary clinical target volume V95% and/or nodal clinical target volume V90% were less than 95% in 17 photon therapy plans and none of the proton plans. Median NTCP of radiation dermatitis ≥ grade 2 was 18.3% (range, 5.4-41.7) with photon therapy and 58.4% (range, 31.4-69.7) with proton therapy. Median excess absolute risk (EAR) of secondary lung cancer at age 80 for current and former smokers was 4.8% (range, 0.0-17.0) using photons and 2.7% (range, 0.0-13.6) using protons. Median EAR of coronary event at age 80, assuming all patients have preexisting cardiac risk factors, was 1.0% (range, 0.0-5.6) with photons and 0.2% (range, 0.0-1.3) with protons. Conclusion Proton therapy plans improved target coverage and reduced risk of coronary artery event and secondary lung cancer while increasing the risk of radiation dermatitis.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren M. Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public, Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claus Kamby
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anni Young Lundgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja Vestmø Maraldo
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Vrou Offersen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Target motion management in breast cancer radiation therapy. Radiol Oncol 2021; 55:393-408. [PMID: 34626533 PMCID: PMC8647788 DOI: 10.2478/raon-2021-0040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 08/04/2021] [Indexed: 12/25/2022] Open
Abstract
Background Over the last two decades, breast cancer remains the main cause of cancer deaths in women. To treat this type of cancer, radiation therapy (RT) has proved to be efficient. RT for breast cancer is, however, challenged by intrafractional motion caused by respiration. The problem is more severe for the left-sided breast cancer due to the proximity to the heart as an organ-at-risk. While particle therapy results in superior dose characteristics than conventional RT, due to the physics of particle interactions in the body, particle therapy is more sensitive to target motion. Conclusions This review highlights current and emerging strategies for the management of intrafractional target motion in breast cancer treatment with an emphasis on particle therapy, as a modern RT technique. There are major challenges associated with transferring real-time motion monitoring technologies from photon to particles beams. Surface imaging would be the dominant imaging modality for real-time intrafractional motion monitoring for breast cancer. The magnetic resonance imaging (MRI) guidance and ultra high dose rate (FLASH)-RT seem to be state-of-the-art approaches to deal with 4D RT for breast cancer.
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Kang Y, Shen J, Bues M, Hu Y, Liu W, Ding X. Technical Note: Clinical modeling and validation of breast tissue expander metallic ports in a commercial treatment planning system for proton therapy. Med Phys 2021; 48:7512-7525. [PMID: 34519357 DOI: 10.1002/mp.15225] [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: 03/16/2021] [Revised: 08/20/2021] [Accepted: 09/05/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To validate breast tissue expander metallic port (MP) models in a commercial treatment planning system (TPS) in proton pencil beam scanning (PBS) treatments for breast cancer patients with breast tissue expanders. METHODS AND MATERIALS Three types of MPs taken out of a Mentor CPX4, a Natrelle 133, and a PMT Integra breast tissue expanders and a 650 cc saline filled Mentor CPX4 expander were placed on top of acrylic slabs, and scanned using a Siemens Somatom Definition AS Open RT CT scanner. Structure templates for each of the MPs were designed within Eclipse TPS. The CT numbers for the metallic parts were overridden to reflect measured or calculated relative proton stopping powers (RPSPs). Mock targets were contoured in acrylic to represent postmastectomy chest-wall radiation therapy (PMRT) targets. Plans with different beam incident angles were optimized using the Eclipse TPS to deliver uniform prescription dose to the target using Hitachi Probeat-V PBS beams. Eclipse calculated doses and an in-house Monte Carlo (MC) code calculated doses were compared to the measured Gafchromic EBT3 film doses in acrylic. RESULTS TPS/MC and film dose comparison results showed that (1) 3%/2 mm/10% threshold Gamma pass rates were better than 90.8% in the acrylic target region for all plans; (2) comparing TPS and film doses for the individual beam plans in the MP dose shadow areas, the area with dose difference above 5% ([ΔA] 5%) ranged from 1.1 to 5.0 cm2 , and the maximum dose difference ([ΔD] 0.01 cm2 ) ranged from 12.5% to 25.0%; (3) comparing MC and film doses for the individual beam plans in the MP dose shadow areas, the (ΔA) 5% varied from 1.1 to 2.9 cm2 and (ΔD) 0.01 cm2 varied from 8.5% to 24.2%; (4) for a plan composed of three individual beams treating through the Mentor CPX4 expander, the TPS (ΔA) 5% was less than 0.13 cm2 , and the (ΔD) 0.01 cm2 was less than 6% in the MP dose shadow areas. CONCLUSIONS It is feasible to treat patients with tissue expanders using multiple PBS beams using a structure template with CT number overridden to represent the measured/calculated RPSP for MPs for PBS treatment planning. MC dose was more accurate than analytical dose in the areas with high dose gradient caused by the density heterogeneity of the breast tissue expander MPs.
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Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Xiaoning Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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Musielak M, Suchorska WM, Fundowicz M, Milecki P, Malicki J. Future Perspectives of Proton Therapy in Minimizing the Toxicity of Breast Cancer Radiotherapy. J Pers Med 2021; 11:jpm11050410. [PMID: 34068305 PMCID: PMC8153289 DOI: 10.3390/jpm11050410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/16/2022] Open
Abstract
The toxicity of radiotherapy is a key issue when analyzing the eligibility criteria for patients with breast cancer. In order to obtain better results, proton therapy is proposed because of the more favorable distribution of the dose in the patient’s body compared with photon radiotherapy. Scientific groups have conducted extensive research into the improved efficacy and lower toxicity of proton therapy for breast cancer. Unfortunately, there is no complete insight into the potential reasons and prospects for avoiding undesirable results. Cardiotoxicity is considered challenging; however, researchers have not presented any realistic prospects for preventing them. We compared the clinical evidence collected over the last 20 years, providing the rationale for the consideration of proton therapy as an effective solution to reduce cardiotoxicity. We analyzed the parameters of the dose distribution (mean dose, Dmax, V5, and V20) in organs at risk, such as the heart, blood vessels, and lungs, using the following two irradiation techniques: whole breast irradiation and accelerated partial breast irradiation. Moreover, we presented the possible causes of side effects, taking into account biological and technical issues. Finally, we collected potential improvements in higher quality predictions of toxic cardiac effects, like biomarkers, and model-based approaches to give the full background of this complex issue.
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Affiliation(s)
- Marika Musielak
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
- Correspondence: ; Tel.: +48-505372290
| | - Wiktoria M. Suchorska
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
| | | | - Piotr Milecki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiotherapy Ward I, 61-866 Poznan, Poland;
| | - Julian Malicki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Medical Physics Department, 61-866 Poznan, Poland
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Friedrich T, Henthorn N, Durante M. Modeling Radioimmune Response-Current Status and Perspectives. Front Oncol 2021; 11:647272. [PMID: 33796470 PMCID: PMC8008061 DOI: 10.3389/fonc.2021.647272] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/25/2021] [Indexed: 12/13/2022] Open
Abstract
The combination of immune therapy with radiation offers an exciting and promising treatment modality in cancer therapy. It has been hypothesized that radiation induces damage signals within the tumor, making it more detectable for the immune system. In combination with inhibiting immune checkpoints an effective anti-tumor immune response may be established. This inversion from tumor immune evasion raises numerous questions to be solved to support an effective clinical implementation: These include the optimum immune drug and radiation dose time courses, the amount of damage and associated doses required to stimulate an immune response, and the impact of lymphocyte status and dynamics. Biophysical modeling can offer unique insights, providing quantitative information addressing these factors and highlighting mechanisms of action. In this work we review the existing modeling approaches of combined ‘radioimmune’ response, as well as associated fields of study. We propose modeling attempts that appear relevant for an effective and predictive model. We emphasize the importance of the time course of drug and dose delivery in view to the time course of the triggered biological processes. Special attention is also paid to the dose distribution to circulating blood lymphocytes and the effect this has on immune competence.
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Affiliation(s)
- Thomas Friedrich
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany
| | - Nicholas Henthorn
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom.,The Christie NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Marco Durante
- Biophysics Department, GSI Helmholtz Center for Heavy Ion Research, Darmstadt, Germany.,Institute for Solid State Physics, Technical University Darmstadt, Darmstadt, Germany
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Stick LB, Lorenzen EL, Yates ES, Anandadas C, Andersen K, Aristei C, Byrne O, Hol S, Jensen I, Kirby AM, Kirova YM, Marrazzo L, Matías-Pérez A, Nielsen MMB, Nissen HD, Oliveros S, Verhoeven K, Vikström J, Offersen BV. Selection criteria for early breast cancer patients in the DBCG proton trial - The randomised phase III trial strategy. Clin Transl Radiat Oncol 2021; 27:126-131. [PMID: 33659716 PMCID: PMC7892790 DOI: 10.1016/j.ctro.2021.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/27/2021] [Accepted: 01/31/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Adjuvant radiotherapy of internal mammary nodes (IMN) improves survival in high-risk early breast cancer patients but inevitably leads to more dose to heart and lung. Target coverage is often compromised to meet heart/lung dose constraints. We estimate heart and lung dose when target coverage is not compromised in consecutive patients. These estimates are used to guide the choice of selection criteria for the randomised Danish Breast Cancer Group (DBCG) Proton Trial. MATERIALS AND METHODS 179 breast cancer patients already treated with loco-regional IMN radiotherapy from 18 European departments were included. If the clinically delivered treatment plan did not comply with defined target coverage requirements, the plan was modified retrospectively until sufficient coverage was reached. The choice of selection criteria was based on the estimated number of eligible patients for different heart and lung dose thresholds in combination with proton therapy capacity limitations and dose-response relationships for heart and lung. RESULTS Median mean heart dose was 3.0 Gy (range, 1.1-8.2 Gy) for left-sided and 1.4 Gy (0.4-11.5 Gy) for right-sided treatment plans. Median V17Gy/V20Gy (hypofractionated/normofractionated plans) for ipsilateral lung was 31% (9-57%). The DBCG Radiotherapy Committee chose mean heart dose ≥ 4 Gy and/or lung V17Gy/V20Gy ≥ 37% as thresholds for inclusion in the randomised trial. Using these thresholds, we estimate that 22% of patients requiring loco-regional IMN radiotherapy will be eligible for the trial. CONCLUSION The patient selection criteria for the DBCG Proton Trial are mean heart dose ≥ 4 Gy and/or lung V17Gy/V20Gy ≥ 37%.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Carmel Anandadas
- Department of Clinical Oncology, The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Karen Andersen
- Department of Radiotherapy, Herlev & Gentofte Hospital, Herlev, Denmark
| | - Cynthia Aristei
- Department of Medicine and Surgery, Radiation Oncology Section, University of Perugia & Perugia General Hospital, Perugia, Italy
| | - Orla Byrne
- Department of Medical Physics, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, the Netherlands
| | - Ingelise Jensen
- Department of Medical Physics, Aalborg University Hospital, Aalborg, Denmark
| | - Anna M. Kirby
- Department of Radiotherapy, The Royal Marsden Hospital NHS Foundation Trust & Institute of Cancer Research, London, UK
| | | | - Livia Marrazzo
- Department of Medical Physics, Careggi University Hospital, Florence, Italy
| | | | | | | | - Sileida Oliveros
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karolien Verhoeven
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Johan Vikström
- Department of Radiotherapy, Stavanger University Hospital, Stavanger, Norway
| | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Santos AMC, Kotsanis A, Cunningham L, Penfold SN. Estimating the second primary cancer risk due to proton therapy compared to hybrid IMRT for left sided breast cancer. Acta Oncol 2021; 60:300-304. [PMID: 33345660 DOI: 10.1080/0284186x.2020.1862421] [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] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND PURPOSE Proton therapy has been proposed as a technique to improve the long-term quality of life of breast cancer patients. This is due to its ability to reduce the dose to healthy tissue compared to conventional X-ray therapy. The aim of this study was to investigate the risk of secondary carcinogenesis due to proton therapy compared to hybrid IMRT for breast treatments. MATERIAL AND METHODS In this study, the Pinnacle treatment planning system was used to simulate treatment plans for 15 female left-sided whole breast cancer patients with deep inspiration breath hold scans. Two treatment plans were generated for each patient: hybrid intensity modulated radiotherapy (h-IMRT) and intensity modulated proton therapy (IMPT). Using the dose-volume histograms (DVHs) from these plans, the mean lifetime attributed risk (LAR) for both lungs and the contralateral breast were evaluated using the BEIR VII and Schneider full risk models. RESULTS The results from both risk models show lower LAR estimates for the IMPT treatment plan compared to the h-IMRT treatment plan. This result was observed for all organs of interest and was consistent amongst the two separate risk models. For both treatment plans, the organs from most to least at risk were: ipsilateral lung, contralateral breast, and contralateral lung. In all cases, the risk estimated via the BEIR VII model was higher that the Schneider full risk model. CONCLUSION The use of proton therapy for breast treatments leads to reduced risk estimates for secondary carcinogenesis. Therefore, proton therapy shows promise in improving the long term treatment outcome of breast patients.
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Affiliation(s)
- Alexandre M. C. Santos
- School for Physical Sciences, University of Adelaide, Adelaide, Australia
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
| | - Andreas Kotsanis
- School for Physical Sciences, University of Adelaide, Adelaide, Australia
| | - Lisa Cunningham
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
- Allied Health and Human Performance, University of South Australia, Adelaide, Australia
| | - Scott N. Penfold
- School for Physical Sciences, University of Adelaide, Adelaide, Australia
- Department of Radiation Oncology, Royal Adelaide Hospital, Adelaide, Australia
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Paganetti H. “Cancer risk after breast proton therapy considering physiological and radiobiological uncertainties” by Raptis et al. (Physica Medica 76 (2020) 1–6). Phys Med 2020; 80:274-276. [DOI: 10.1016/j.ejmp.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/02/2020] [Accepted: 11/07/2020] [Indexed: 11/16/2022] Open
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Proton pencil beam scanning reduces secondary cancer risk in breast cancer patients with internal mammary chain involvement compared to photon radiotherapy. Radiat Oncol 2020; 15:228. [PMID: 33008412 PMCID: PMC7532613 DOI: 10.1186/s13014-020-01671-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 09/24/2020] [Indexed: 11/21/2022] Open
Abstract
Purpose Proton pencil beam scanning (PBS) represents an interesting option for the treatment of breast cancer (BC) patients with nodal involvement. Here we compare tangential 3D-CRT and VMAT to PBS proton therapy (PT) in terms of secondary cancer risk (SCR) for the lungs and for contralateral breast. Methods Five BC patients including supraclavicular (SVC) nodes in the target (Group 1) and five including SVC plus internal-mammary-nodes (IMNs, Group 2) were considered. The Group 1 patients were planned by PT versus tangential 3D-CRT in free-breathing (FB). The Group 2 patients were planned by PT versus VMAT considering both FB and deep-inspiration breath hold (DIBH) irradiation. The prescription dose to the target volume was 50 Gy (2 Gy/fraction). A constant RBE = 1.1 was assumed for PT. The SCR was evaluated with the excess absolute risk (EAR) formalism, considering also the age dependence. A cumulative EAR was finally computed. Results According to the linear, linear-exponential and linear-plateau dose response model, the cumulative EAR for Group 1 patients after PT was equal to 45 ± 10, 17 ± 3 and 15 ± 3, respectively. The corresponding relative increase for tangential 3D-CRT was equal to a factor 2.1 ± 0.5, 2.1 ± 0.4 and 2.3 ± 0.4. Group 2 patients showed a cumulative EAR after PT in FB equal to 65 ± 3, 21 ± 1 and 20 ± 1, according to the different models; the relative risk obtained with VMAT increased by a factor 3.5 ± 0.2, 5.2 ± 0.3 and 5.1 ± 0.3. Similar values emerge from DIBH plans. Contrary to photon radiotherapy, PT appears to be not sensitive to the age dependence due to the very low delivered dose. Conclusions PBS PT is associated to significant SCR reduction in BC patients compared to photon radiotherapy. The benefits are maximized for young patients with both SVC and IMNs involvement. When combined with the improved sparing of the heart, this might contribute to the establishment of effective patient-selection criteria for proton BC treatments.
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Paganetti H, Depauw N, Johnson A, Forman RB, Lau J, Jimenez R. The risk for developing a secondary cancer after breast radiation therapy: Comparison of photon and proton techniques. Radiother Oncol 2020; 149:212-218. [PMID: 32464163 DOI: 10.1016/j.radonc.2020.05.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE To compare secondary malignancy risks of modern proton and photon therapy techniques for locally advanced breast cancer. METHODS AND MATERIALS We utilized dosimetric data from 34 [10 photon-VMAT, 10 photon-3DCRT, 14 pencil beam scanning proton (PBS)] breast cancer patients who received comprehensive nodal irradiation. Employing a model based on organ equivalent dose to account for both inhomogeneous organ dose distributions and non-linear functional dose relationships, we estimated excess absolute risk, excess relative risk, and lifetime attributable risk (LAR) for secondary malignancies. The model uses dose distribution, number of fractions, age at exposure, attained age, the linear-quadratic dose response relationship for cell survival, repopulation factor, as well as gender specific age dependencies, and initial slopes of dose response curves. RESULTS The LAR for carcinoma at age 70 was estimated to be up to 3.64% for esophagus with an advantage of 3DCRT over PBS and VMAT. For the ipsilateral lung, risks were lowest for PBS (up to 5.56%), followed by 3DCRT (up to 6.54%) and VMAT (up to 7.7%). For the contralateral lung, there is a clear advantage of 3DCRT and PBS techniques (risk <0.86%) over VMAT (up to 4.4%). The risk for the contralateral breast is negligible for 3DCRT and PBS but was estimated as up to 1.2% for VMAT. Risks for the thyroid are overall negligible. Independently performed comparative treatment plans on 10 patients revealed that the risk for the contralateral lung and breast using VMAT can be more than an order of magnitude higher compared to PBS. Sarcoma risks were estimated as well showing similar trends but were overall lower compared to carcinoma. CONCLUSION Conventional (3DCRT) techniques led to the lowest estimated risks of, thyroid and esophageal secondary cancers while PBS demonstrated a benefit for secondary lung and contralateral breast cancer risks, with the highest risks overall associated with VMAT techniques.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Nicolas Depauw
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Andrew Johnson
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Beth Forman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Jackson Lau
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Cancer risk after breast proton therapy considering physiological and radiobiological uncertainties. Phys Med 2020; 76:1-6. [PMID: 32563956 DOI: 10.1016/j.ejmp.2020.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 06/04/2020] [Accepted: 06/06/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The reduced normal tissue dose burden from protons can reduce the risk of second cancer for breast cancer patients. Breathing motion and the impact of variable relative biological effectiveness (RBE) are however concerns for proton dose distributions. This study aimed to quantify the impact of these factors on risk predictions from proton and photon therapy. MATERIALS AND METHODS Twelve patients were planned in free breathing with protons and photons to deliver 50 Gy (RBE) in 25 fractions (assuming RBE = 1.1 for protons) to the left breast. Second cancer risk was evaluated with several models for the lungs, contralateral breast, heart and esophagus as organs at risk (OARs). Plans were recalculated on CT-datasets acquired in extreme phases to account for breathing motion. Proton plans were also recalculated assuming variable RBE for a range of radiobiological parameters. RESULTS The OARs received substantially lower doses from protons compared to photons. The highest risks were for the lungs (average second cancer risks of 0.31% and 0.12% from photon and proton plans, respectively). The reduced risk with protons was maintained, even when breathing and/or RBE variation were taken into account. Furthermore, while the total risks from the photon plans were seen to increase with the integral dose, no such correlation was observed for the proton plans. CONCLUSIONS Protons have an advantage over the photons with respect to the induction of cancer. Uncertainties in physiological movements and radiobiological parameters affected the absolute risk estimates, but not the general trend of lower risk associated with proton therapy.
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