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Schmitt M, Eber J, Antoni D, Noel G. Should the management of radiation therapy for breast cancer be standardized? Results of a survey on current French practices in breast radiotherapy. Rep Pract Oncol Radiother 2021; 26:814-826. [PMID: 34760316 DOI: 10.5603/rpor.a2021.0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022] Open
Abstract
Background Breast cancer is the most frequent cancer in women in France. Its management has evolved considerably in recent years with a focus on reducing iatrogenic toxicity. The radiotherapy indications are validated in multidisciplinary consultation meetings; however, questions remain outstanding, particularly regarding hypofractionated radiotherapy, partial breast irradiation, and irradiation of the internal mammary chain and axillary lymph node area. Materials and methods An online survey was sent to 47 heads of radiotherapy departments in France. The survey consisted of 22 questions concerning indications for irradiation of the supraclavicular, internal mammary and axillary lymph node areas; irradiation techniques and modalities; prescribed doses; and fractionation. Results Twenty-four out of 47 centers responded (response rate of 51%). This survey demonstrated a wide variation in the prescribed dose regimen, monoisocentric radiotherapy, and indications of irradiation of the lymph node areas. Conclusion This survey provides insight into the current radiotherapy practice for breast cancer in France. It shows the need to standardize practices.
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Affiliation(s)
- Martin Schmitt
- Radiotherapy Department, Institut du Cancer, Strasbourg, Europe, France
| | - Jordan Eber
- Radiotherapy Department, Institut du Cancer, Strasbourg, Europe, France
| | - Delphine Antoni
- Radiotherapy Department, Institut du Cancer, Strasbourg, Europe, France
| | - Georges Noel
- Radiotherapy Department, Institut du Cancer, Strasbourg, Europe, France
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[Diffusion prophylactic axillary irradiation in breast cancer - Literature review]. Cancer Radiother 2021; 25:191-199. [PMID: 33402287 DOI: 10.1016/j.canrad.2020.06.035] [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: 07/09/2019] [Revised: 12/24/2019] [Accepted: 06/16/2020] [Indexed: 11/21/2022]
Abstract
PURPOSE In breast cancer, radiotherapy is an essential component of the treatment. However, indications of irradiation of the internal mammary chain and axillary area are debatables. Axillary recurrence in patients with invasive breast carcinoma remains an issue. Currently, the substitution of axillary lymph node dissection by sentinel node biopsy leads to revisit the role of axillary irradiation. Breast irradiation including level I, II and III might decrease the risk of axillary recurrence. MATERIAL AND METHODS A literature search was performed in PubMed and the Cochrane library to identify articles publishing data regarding dose-volume analysis of axillary levels in breast irradiation aiming to determine the potential therapeutic implications. RESULTS Eleven articles were retained. A total of 375 treatment plans were analyzed. The results concerning the irradiation technique, initial dose prescribed to breast, delineated volumes and dose received at axillary levels were heterogeneous. The average dose delivered to axilla levels I-III with 3D-conformal radiotherapy using standard fields were between 24Gy and 43.5Gy, 3Gy and 32.5Gy and between 1.0Gy and 20.5Gy respectively. The average doses delivered to axilla levels I-III with 3D-conformal radiotherapy using high tangential fields were between 38Gy and 49.7Gy, 11Gy and 47.1Gy and 5Gy 38.7Gy, 32.1Gy and 5Gy (result available for only one study) respectively. Finally, the average doses delivered to axilla levels I-III with intensity modulated radiation therapy were between 14.5Gy and 42.6Gy, 3.4Gy and 35Gy and between 1.2Gy and 25.5Gy respectively. CONCLUSIONS Incidental axillary dose seems insufficient to be therapeutic regardless of the irradiation technique. There are meaningful differences between intensity modulated radiation therapy and 3D-conformal radiotherapy.
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Bathily T, Borget I, Rivin Del Campo E, Rivera S, Bourgier C. Partial versus whole breast irradiation: Side effects, patient satisfaction and costs. Cancer Radiother 2019; 23:83-91. [PMID: 30929861 DOI: 10.1016/j.canrad.2018.06.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/16/2018] [Accepted: 06/08/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE Since accelerated partial breast irradiation has demonstrated non-inferiority to whole breast irradiation regarding recurrence rate in patients with early stage breast cancer, our objective was to compare its impact on short-term adverse events, patient satisfaction and costs. MATERIALS AND METHODS Patients with early stage breast cancer treated by breast-conserving surgery between 2007 and 2012 were included: 48 women who received three-dimensional conformal accelerated partial breast irradiation in a multicentre phase-II trial were paired with 48 patients prospectively treated with whole breast irradiation. Adverse events, and patients' opinions concerning cosmesis, satisfaction and pain, were gathered 1 month after treatment. Direct and indirect costs were collected from the French National Health Insurance System perspective until the end of radiotherapy. RESULTS When comparing its impact, skin reactions occurred in 37% of patients receiving three-dimensional conformal accelerated partial breast radiotherapy and 60% of patients receiving whole breast irradiation (P=0.07); 98% were very satisfied in the group three-dimensional conformal accelerated partial breast radiotherapy versus 46% in the group treated with whole breast irradiation (P<0.001); direct costs were significantly lower in the group treated with partial breast irradiation (mean cost: 2510€ versus 5479€/patient), due to less radiation sessions. CONCLUSION In patients with early-stage breast cancer, partial irradiation offered a good alternative to whole breast irradiation, as it was less expensive and satisfactory. These, and the clinical safety and tolerance results, need to be confirmed by long-term accelerated partial breast irradiation results in on-going phase III trials.
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Affiliation(s)
- T Bathily
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - I Borget
- Service de biostatistique et d'épidémiologie, Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Inserm U1018, CESP, 114, rue Édouard-Vaillant, 94805 Villejuif, France; Université Paris-Sud, université Paris-Saclay, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - E Rivin Del Campo
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France.
| | - S Rivera
- Department of Radiation Oncology, Gustave-Roussy Cancer Campus, 114, rue Édouard-Vaillant, 94805 Villejuif, France
| | - C Bourgier
- Department of Radiation Oncology, Institut du cancer de Montpellier, 208, avenue des Apothicaires, 34298 Montpellier, France
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Techniques d’irradiation du cancer du sein en 2016 : intérêt et indications de la radiothérapie conformationnelle avec modulation d’intensité. Cancer Radiother 2016; 20:572-5. [DOI: 10.1016/j.canrad.2016.07.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/11/2016] [Indexed: 11/23/2022]
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Cabanne A, Schick U, Pradier O, Rivera S. [Establishing margins from CTV to PTV in breast cancer treatment]. Cancer Radiother 2016; 20:640-4. [PMID: 27614520 DOI: 10.1016/j.canrad.2016.07.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/24/2016] [Accepted: 07/28/2016] [Indexed: 12/25/2022]
Abstract
The benefit of postoperative radiotherapy for breast cancer both in terms of local control and overall survival is widely acknowledged. Today, technological advances in simulation imaging and positioning control enable the definition of new margins from CTV to PTV. Improvements in mathematical modeling of random and systematic errors impact the treatment plans. However, there is no universal absolute value to consistently determine the margins from CTV to PTV. It is down to each centre to assess and correct as much as possible uncertainties due to positioning and internal movements depending on techniques and methods used for the implementation of treatment and monitoring. IMRT and respiratory gating techniques for breast radiotherapy will be considered more systematically in the years to come.
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Affiliation(s)
- A Cabanne
- Service de radiothérapie, CHRU Morvan, 2, avenue Foch, 29200 Brest, France.
| | - U Schick
- Service de radiothérapie, CHRU Morvan, 2, avenue Foch, 29200 Brest, France
| | - O Pradier
- Service de radiothérapie, CHRU Morvan, 2, avenue Foch, 29200 Brest, France
| | - S Rivera
- Service A de radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
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Budach W, Bölke E, Kammers K, Gerber PA, Nestle-Krämling C, Matuschek C. Adjuvant radiation therapy of regional lymph nodes in breast cancer - a meta-analysis of randomized trials- an update. Radiat Oncol 2015; 10:258. [PMID: 26691175 PMCID: PMC4687086 DOI: 10.1186/s13014-015-0568-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/10/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adjuvant radiotherapy (RT) of regional lymph nodes (LN) in early breast cancer is still a matter of debate. RT increases the Overall survival (OS) rate of breast cancer patients after breast conserving surgery and after mastectomy in patients with involved LN. The contribution of RT to regional LN to this improvement was poorly identified. Recently, the results of three large randomized trials addressing this question were published as full papers. MATERIAL AND METHODS Published data of the MA.20 (n = 1832), the EORTC22922-10925 (EORTC) (n = 4004) trial and the French trial (n = 1334) were the foundation of this meta-analysis. Major eligibility criteria were positive i) axillary LN (all trials), ii) LN negative disease with high risk for recurrence (MA.20), and iii) medial/central tumor location (French, EORTC). The MA.20 and the EORTC trial analyzed the effect of additional regional RT to the internal mammary (IM) LN and medial supraclavicular (MS) LN, whereas in the French trial all patients received RT to the MS-LN and solely RT to the IM-LN was randomized. Primary endpoint was OS. Secondary endpoints were disease-free survival (DFS) and distant metastasis free survival (DMFS). RESULTS Regional RT of MS-LN and IM-LN (MA.20 and EORTC) resulted in a significant improvement of OS [Hazard Ratio (HR) 0.88 (95 % CL 0.78 - 0.99)]. Adding results of the French trial and using a random effects model to respect the different design of the French trial, the effect on OS of regional RT remained significant [HR 0.90 (95 % CL 0.82 - 0.99)]. The absolute benefits in OS were 1 % in the MA.20 trial at 10 years, 1.6 % in the EORTC trial at 10 years, and 3.3 % in the French trial at 10 years (not significant in single trials). Regional RT of MS-LN and IM-LN (MA.20 and EORTC) yielded to a significant improvement of DFS [HR 0.86 (95 % CL 0.78 - 0.95)] and DMFS [HR 0.84 (95 % CL 0.75 - 0.94)]. CONCLUSION Additional regional RT to the internal mammary and medial supraclavicular LN statistically significantly improved DFS, DMFS, and OS in stage I-III breast cancer.
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Affiliation(s)
- Wilfried Budach
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany.
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany.
| | - Kai Kammers
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Peter Arne Gerber
- Department of Dermatology, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany.
| | | | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Dusseldorf, Germany.
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Jacob J, Heymann S, Borget I, Dumas I, Riahi E, Maroun P, Ezra P, Roberti E, Rivera S, Deutsch E, Bourgier C. Dosimetric Effects of the Interfraction Variations during Whole Breast Radiotherapy: A Prospective Study. Front Oncol 2015; 5:199. [PMID: 26442211 PMCID: PMC4584980 DOI: 10.3389/fonc.2015.00199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 08/31/2015] [Indexed: 11/27/2022] Open
Abstract
Introduction The aim of this work was to assess the dosimetric impact of the interfraction variations during breast radiotherapy. Materials and methods Daily portal imaging measurements were prospectively performed in 10 patients treated with adjuvant whole breast irradiation (50 Gy/25 fractions). Margins between the clinical target volume and the planning target volume (PTV) were 5 mm in the three dimensions. Parameters of interest were the central lung distance (CLD) and the inferior central margin (ICM). Daily movements were applied to the baseline treatment planning (TP1) to design a further TP (TP2). The PTV coverage and organ at risk exposure were measured on both TP1 and TP2, before being compared. Results A total of 241 portal images were analyzed. The random and systematic errors were 2.6 and 3.7 mm for the CLD, 4.3 and 6.9 mm for the ICM, respectively. No significant consequence on the PTV treatments was observed (mean variations: +0.1%, p = 0.56 and −1.8%, p = 0.08 for the breast and the tumor bed, respectively). The ipsilateral lung and heart exposure was not significantly modified. Conclusion In our series, the daily interfraction variations had no significant effect on the PTV coverage or healthy tissue exposure during breast radiotherapy.
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Affiliation(s)
- Julian Jacob
- Department of Radiotherapy, Gustave Roussy , Villejuif , France
| | - Steve Heymann
- Department of Radiotherapy, Gustave Roussy , Villejuif , France
| | - Isabelle Borget
- Department of Biostatistics and Epidemiology, Gustave Roussy , Villejuif , France ; University Paris-Sud , Kremlin-Bicêtre , France
| | - Isabelle Dumas
- Department of Physics, Gustave Roussy , Villejuif , France
| | - Elyes Riahi
- Department of Physics, Gustave Roussy , Villejuif , France
| | - Pierre Maroun
- Department of Radiotherapy, Gustave Roussy , Villejuif , France
| | - Patrick Ezra
- Department of Radiotherapy, Gustave Roussy , Villejuif , France
| | - Elena Roberti
- Department of Radiotherapy, Gustave Roussy , Villejuif , France
| | - Sofia Rivera
- Department of Radiotherapy, Gustave Roussy , Villejuif , France
| | - Eric Deutsch
- Department of Radiotherapy, Gustave Roussy , Villejuif , France ; University Paris-Sud , Kremlin-Bicêtre , France
| | - Céline Bourgier
- Department of Oncologic Radiotherapy, Institut du Cancer de Montpellier , Montpellier , France
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Falk AT, Fenoglietto P, Azria D, Bourgier C. [New external radiotherapy technologies for breast cancer]. Cancer Radiother 2014; 18:480-5. [PMID: 25182528 DOI: 10.1016/j.canrad.2014.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 06/24/2014] [Accepted: 06/26/2014] [Indexed: 10/24/2022]
Abstract
The purpose of new radiotherapy techniques is to better deliver dose conformation in the tumour volume while diminishing organs at risk exposition. Their development is soaring in the breast cancer field in the adjuvant setting with intensity-modulated radiation therapy but also in cerebral and extracerebral oligometastastic presentation. Their usage is still being debated for breast cancer care. The objective of this narrative review is to list and discuss clinical data at our disposal for these news technologies.
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Affiliation(s)
- A T Falk
- Département de radiothérapie, centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice cedex 2, France; Université de Nice Sophia-Antipolis, BP 2135, 06103 Nice cedex 2, France
| | - P Fenoglietto
- Département de radiothérapie oncologique, centre régional de lutte contre le cancer, 208, rue des Apothicaires, parc Euromédecine, 34298 Montpellier cedex 05, France
| | - D Azria
- Département de radiothérapie oncologique, centre régional de lutte contre le cancer, 208, rue des Apothicaires, parc Euromédecine, 34298 Montpellier cedex 05, France; Inserm U896, institut de recherche en cancérologie de Montpellier, 208, rue des Apothicaires, parc Euromédecine, 34298 Montpellier cedex 05, France; Université de Montpellier 1, CS 19044, 34967 Montpellier cedex 2, France
| | - C Bourgier
- Département de radiothérapie oncologique, centre régional de lutte contre le cancer, 208, rue des Apothicaires, parc Euromédecine, 34298 Montpellier cedex 05, France; Inserm U896, institut de recherche en cancérologie de Montpellier, 208, rue des Apothicaires, parc Euromédecine, 34298 Montpellier cedex 05, France; Université de Montpellier 1, CS 19044, 34967 Montpellier cedex 2, France.
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9
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[Partial breast irradiation]. Bull Cancer 2014; 101:52-5. [PMID: 24445657 DOI: 10.1684/bdc.2013.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Owing to breast cancer screening, breast cancer is more and more diagnosed at early stage. For those breast cancer women, breast conserving treatment (breast conserving surgery followed by whole breast irradiation) is commonly used since many years. New radiation modalities have been recently developed in early breast cancers particularly accelerated partial breast irradiation (APBI). Among all techniques of radiotherapy, 3D-conformal APBI and intraoperative radiotherapy (IORT) are the main modalities of radiotherapy used. The present review states on indications, treatment modalities and updated results of local control and side effects of partial breast irradiation.
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Bourgier C, Lemanski C, Riou O, Charissoux M, Fenoglietto P, Azria D. [Hypofractionated radiotherapy, a standard in breast cancer?]. Cancer Radiother 2013; 17:705-7. [PMID: 24176662 DOI: 10.1016/j.canrad.2013.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 09/12/2013] [Accepted: 09/20/2013] [Indexed: 01/08/2023]
Abstract
In the era of high-tech radiotherapy, hypofractionated schema is more and more widely used regardless of tumour sites. In this article, we expose the role, techniques and indications of hypofractionated radiotherapy in adjuvant breast radiotherapy.
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Affiliation(s)
- C Bourgier
- Département de radiothérapie oncologique, institut du cancer de Montpellier, 208, avenue des Apothicaires, parc Euromédecine, 34298 Montpellier cedex 5, France.
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