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Joshi S, Kothari B, Jaiswal D, Wadasadawala T, Badwe RA. Approach Toward Oncoplastic Breast Surgery: Local (Flap) Solutions for Indian Problems. Indian J Surg Oncol 2024; 15:95-102. [PMID: 38511031 PMCID: PMC10948632 DOI: 10.1007/s13193-023-01830-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/28/2023] [Indexed: 03/22/2024] Open
Affiliation(s)
- Shalaka Joshi
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Bhavika Kothari
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Dushyant Jaiswal
- Department of Plastic and Reconstructive Surgery, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - Tabassum Wadasadawala
- Department of Radiation Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra India
| | - R. A. Badwe
- Department of Surgical Oncology, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra India
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2
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Dzhugashvili M, Veldeman L, Kirby AM. The role of the radiation therapy breast boost in the 2020s. Breast 2023; 69:299-305. [PMID: 36958070 PMCID: PMC10068257 DOI: 10.1016/j.breast.2023.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Given that most local relapses of breast cancer occur proximal to the original location of the primary, the delivery of additional radiation dose to breast tissue that contained the original primary cancer (known as a "boost") has been a standard of care for some decades. In the context of falling relapse rates, however, it is an appropriate time to re-evaluate the role of the boost. This article reviews the evolution of the radiotherapy boost in breast cancer, discussing who to boost and how to boost in the 2020s, and arguing that, in both cases, less is more.
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Affiliation(s)
| | - L Veldeman
- Ghent University/Ghent University Hospital, Ghent, Belgium.
| | - A M Kirby
- Royal Marsden Hospital NHS Foundation Trust & Institute of Cancer Research, UK.
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3
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Civil YA, Oei AL, Duvivier KM, Bijker N, Meijnen P, Donkers L, Verheijen S, van Kesteren Z, Palacios MA, Schijf LJ, Barbé E, Konings IRHM, -van der Houven van Oordt CWM, Westhoff PG, Meijer HJM, Diepenhorst GMP, Thijssen V, Mouliere F, Slotman BJ, van der Velde S, van den Bongard HJGD. Prediction of pathologic complete response after single-dose MR-guided partial breast irradiation in low-risk breast cancer patients: the ABLATIVE-2 trial-a study protocol. BMC Cancer 2023; 23:419. [PMID: 37161377 PMCID: PMC10169374 DOI: 10.1186/s12885-023-10910-6] [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: 01/23/2023] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Partial breast irradiation (PBI) is standard of care in low-risk breast cancer patients after breast-conserving surgery (BCS). Pre-operative PBI can result in tumor downstaging and more precise target definition possibly resulting in less treatment-related toxicity. This study aims to assess the pathologic complete response (pCR) rate one year after MR-guided single-dose pre-operative PBI in low-risk breast cancer patients. METHODS The ABLATIVE-2 trial is a multicenter prospective single-arm trial using single-dose ablative PBI in low-risk breast cancer patients. Patients ≥ 50 years with non-lobular invasive breast cancer ≤ 2 cm, grade 1 or 2, estrogen receptor-positive, HER2-negative, and tumor-negative sentinel node procedure are eligible. A total of 100 patients will be enrolled. PBI treatment planning will be performed using a radiotherapy planning CT and -MRI in treatment position. The treatment delivery will take place on a conventional or MR-guided linear accelerator. The prescribed radiotherapy dose is a single dose of 20 Gy to the tumor, and 15 Gy to the 2 cm of breast tissue surrounding the tumor. Follow-up MRIs, scheduled at baseline, 2 weeks, 3, 6, 9, and 12 months after PBI, are combined with liquid biopsies to identify biomarkers for pCR prediction. BCS will be performed 12 months after radiotherapy or after 6 months, if MRI does not show a radiologic complete response. The primary endpoint is the pCR rate after PBI. Secondary endpoints are radiologic response, toxicity, quality of life, cosmetic outcome, patient distress, oncological outcomes, and the evaluation of biomarkers in liquid biopsies and tumor tissue. Patients will be followed up to 10 years after radiation therapy. DISCUSSION This trial will investigate the pathological tumor response after pre-operative single-dose PBI after 12 months in patients with low-risk breast cancer. In comparison with previous trial outcomes, a longer interval between PBI and BCS of 12 months is expected to increase the pCR rate of 42% after 6-8 months. In addition, response monitoring using MRI and biomarkers will help to predict pCR. Accurate pCR prediction will allow omission of surgery in future patients. TRIAL REGISTRATION The trial was registered prospectively on April 28th 2022 at clinicaltrials.gov (NCT05350722).
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Affiliation(s)
- Yasmin A. Civil
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Arlene L. Oei
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC Location Universiteit van Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Katya M. Duvivier
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Nina Bijker
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Philip Meijnen
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Lorraine Donkers
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Sonja Verheijen
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Zdenko van Kesteren
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Miguel A. Palacios
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Laura J. Schijf
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Ellis Barbé
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Inge R. H. M. Konings
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - C. Willemien Menke -van der Houven van Oordt
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Paulien G. Westhoff
- Department of Radiation Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - Hanneke J. M. Meijer
- Department of Radiation Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - Gwen M. P. Diepenhorst
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Victor Thijssen
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Laboratory for Experimental Oncology and Radiobiology (LEXOR), Center for Experimental Molecular Medicine (CEMM), Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Florent Mouliere
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - Berend J. Slotman
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Susanne van der Velde
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
| | - H. J. G. Desirée van den Bongard
- Department of Radiation Oncology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Boelelaan 1117, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
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4
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Riberdy V, Ruiz E, Hoekstra N, Struik G, Pignol JP. Comparison of visibility of iodinated hydrogel and gadolinium-modified hyaluronic acid spacer gels on computed tomography and onboard imaging. Phys Imaging Radiat Oncol 2022; 21:48-53. [PMID: 35243031 PMCID: PMC8861832 DOI: 10.1016/j.phro.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 11/18/2022] Open
Abstract
Background and purpose In accelerated partial breast irradiation (APBI), accurate definition of the tumour bed is crucial to reduce the risk of local recurrence and the volume of healthy tissue irradiated. Recently, hydrogels have been proposed to improve visibility of the lumpectomy cavity for APBI. The aim of this study was to alter two commercially available hyaluronic acid (HA) gels, with gadopentenate dimeglumine (GD), a magnetic resonance imaging (MRI) contrast agent. We hypothesize that after injection in the surgical cavity, the mixtures will be visible with computed tomography (CT) for improved treatment planning, cone-beam CT (CBCT) for improved patient setup and planar kilovoltage (kV) x-ray for real-time tracking during treatment. Materials and methods In this ex vivo study, GD was mixed with the two HA gels, and 1 mL of each mixture was injected into fatty and muscular tissue of a pork phantom. Visibility with CT, CBCT and planar x-ray imaging was assessed. Contrast-to-noise ratios (CNR) were measured and compared to commercially available iodinated polyethylene glycol (PEG). Results The gel mixtures showed increased visibility over HA gels without GD. When comparing CNR of the gel mixtures to that of iodinated PEG on CT, there was a 4-fold increase in muscle for both mixtures and a 1.6-fold to 3.6-fold increase in fat, depending on the HA gel. Gel mixtures showed better visibility with planar kV imaging over iodinated PEG. Conclusion Addition of GD to HA gels increases visibility with CT, CBCT and planar x-ray imaging, indicating potential for improved delineation and positioning in APBI.
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Affiliation(s)
- Vlora Riberdy
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
- Corresponding author at: Department of Medical Physics, 5820 University Ave., Halifax, NS B3H 1V7, Canada.
| | - Ethan Ruiz
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
| | - Nienke Hoekstra
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Gerson Struik
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Jean-Philippe Pignol
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
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5
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Fiser C, Crystal JS, Tevis SE, Kesmodel S, Rojas KE. Treatment and Survivorship Interventions to Prevent Poor Body Image Outcomes in Breast Cancer Survivors. BREAST CANCER: TARGETS AND THERAPY 2021; 13:701-709. [PMID: 34938117 PMCID: PMC8687859 DOI: 10.2147/bctt.s321721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 12/01/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Caroline Fiser
- Dewitt Daughtry Department of Surgery, University of Miami/Miller School of Medicine, Miami, FL, USA
| | - Jessica S Crystal
- Dewitt Daughtry Department of Surgery, University of Miami/Miller School of Medicine, Miami, FL, USA
| | - Sarah E Tevis
- Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Susan Kesmodel
- Dewitt Daughtry Department of Surgery, University of Miami/Miller School of Medicine, Miami, FL, USA
| | - Kristin E Rojas
- Dewitt Daughtry Department of Surgery, University of Miami/Miller School of Medicine, Miami, FL, USA
- Correspondence: Kristin E Rojas Dewitt Daughtry Department of Surgery, University of Miami, 1295 NW 14th Street, Miami, FL, 33136, USATel +1 305 243-0783 Email
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6
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Hoekstra N, Habraken S, Swaak-Kragten A, Pignol JP, Hoogeman M. Fiducial marker motion relative to the tumor bed has a significant impact on PTV margins in partial breast irradiation. Radiother Oncol 2021; 163:1-6. [PMID: 34329655 DOI: 10.1016/j.radonc.2021.07.020] [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: 05/27/2021] [Revised: 06/28/2021] [Accepted: 07/19/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION With the introduction of accelerated partial breast irradiation (APBI) and the trend of reducing the number of fractions, the geometric accuracy of treatment delivery becomes critical. APBI patient setup is often based on fiducials, as the seroma is frequently not visible on pretreatment imaging. We assessed the motion of fiducials relative to the tumor bed between planning CT and treatment, and calculated margins to compensate for this motion. METHODS A cohort of seventy patients treated with APBI on a Cyberknife was included. Planning and in-room pretreatment CT scans were registered on the tumor bed. Residual motion of the centers of mass of surgical clips and interstitial gold markers was calculated. We calculated the margins required per desired percentage of patients with 100% CTV coverage, and the systematic and random errors for fiducial motion. RESULTS For a single fraction treatment, a margin of 1.8 mm would ensure 100% CTV coverage in 90% of patients when using surgical clips for patient set-up. When using interstitial markers, the margin should be 2.2 mm. The systematic and random errors were 0.46 mm for surgical clip motion and 0.60 mm for interstitial marker motion. No clinical factors were found predictive for fiducial motion. CONCLUSIONS Fiducial motion relative to the tumor bed between planning CT and APBI treatment is non-negligible and should be included in the PTV margin calculation to prevent geographical miss. Systematic and random errors of fiducial motion were combined with other geometric uncertainties to calculate comprehensive PTV margins for different treatment techniques.
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Affiliation(s)
- Nienke Hoekstra
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands.
| | - Steven Habraken
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands
| | | | | | - Mischa Hoogeman
- Erasmus MC Cancer Institute, Department of Radiation Oncology, Rotterdam, The Netherlands
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7
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Machiels M, Weytjens R, Erven K, Westerhoff JM, Amrouch S, Bosiers J, Verkinderen L, Hauspy J, van Dam P, Stevens P, Bernaerts A, Strijbos M, Meijnders P, Dirix P, Verellen D, Van Laere S, Vermeulen PB, Billiet C. Oncological outcome, postoperative complications, and mammographic changes after intraoperative radiotherapy with electrons (IOERT) as a boost in a large single-institution cohort of breast cancer patients. Breast J 2020; 26:1937-1945. [PMID: 32779870 DOI: 10.1111/tbj.13986] [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: 04/27/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022]
Abstract
Advantages of using intraoperative radiotherapy with electrons (IOERT) as a boosting modality in breast-conserving therapy include the direct visualization of the tumor bed, a reduced skin dose, and patient convenience. We report oncological outcome, postoperative complication rate, and mammographic changes on follow-up imaging in women treated at our institution with IOERT as a boost modality in breast-conserving therapy for early-stage breast carcinoma. Between January 2007 and June 2018, 763 consecutive patients were enrolled. During breast-conserving surgery, an IOERT boost of 9 Gy was applied, followed by whole breast irradiation (WBI). At a median follow-up of 62.2 months (range: 0.5-135), 13 in-breast recurrences were observed, yielding a local tumor control rate of 98.4% at 5 years. In multivariable analysis, high tumor grading was predictive for local recurrence (HR = 5.6; 95%CI: 1.19-26.2). A total of 27 (3.5%) patients developed any kind of postoperative complication. None of the tumor characteristics nor any of the IOERT technical parameters were predictive for development of a postoperative complication. On follow-up imaging, 145 patients with mammographic changes BIRADS score ≥3 were found of which 50.3% required a biopsy. Only 17 patients had positive biopsies; none of the IOERT parameters were predictive for false-positive imaging. A 9 Gy IOERT boost combined with postoperative WBI provided outstanding local control rates, was well-tolerated, with limited postoperative complications. However, radiologists must be aware of a presumable higher prevalence of mammographic changes after IORT as a boost.
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Affiliation(s)
- Melanie Machiels
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Reinhilde Weytjens
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Katrien Erven
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium
| | | | - Souad Amrouch
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium
| | - Jana Bosiers
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium
| | | | - Jan Hauspy
- Department of Gynaecology, GZA Hospitals, Antwerp, Belgium
| | - Peter van Dam
- Multidisciplinary Oncologic Centre Antwerp (MOCA), Antwerp Universitys Hospital, Edegem, Belgium.,Center for Oncological Research (CORE), University of Antwerp, Antwerp, Belgium
| | - Piet Stevens
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium
| | - Anja Bernaerts
- Department of Radiology, GZA Hospitals, Antwerp, Belgium
| | | | - Paul Meijnders
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Piet Dirix
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Dirk Verellen
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Steven Van Laere
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Radiology, GZA Hospitals, Antwerp, Belgium.,Department of Oncology, GZA Hospitals, Antwerp, Belgium
| | - Peter B Vermeulen
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Radiology, GZA Hospitals, Antwerp, Belgium.,Department of Oncology, GZA Hospitals, Antwerp, Belgium
| | - Charlotte Billiet
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Oncologisch Centrum GZA, Translational Cancer Research Unit, Antwerp, Belgium
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8
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Tan RZF, Yong B, Aloweni FAB, Lopez V. Factors associated with postsurgical wound infections among breast cancer patients: A retrospective case-control record review. Int Wound J 2020; 17:1444-1452. [PMID: 32530562 DOI: 10.1111/iwj.13421] [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: 04/19/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 01/15/2023] Open
Abstract
Women with non-metastatic breast cancer will be offered surgery as their first option. Unfortunately, studies have shown that the most common postoperative complication is surgical wound infection (SWI). We investigated the prevalence of SWI in breast cancer patients and identified the factors predictive of its development. The study was conducted at the breast cancer centre in Singapore. A retrospective case-control review of medical records was used. During the 2013 to 2016 study period, there were 657 postsurgical breast cancer patients with only 105 records eligible for the study. The sample consisted of one to four case:control (21:84), matched according to their age at the time of their surgery. Patients presenting with SWI were grouped into cases, while those without SWI were grouped into the controls. Chi-square test and Mann-Whitney U test were used to identify risk factors associated with SWI. Regression analysis of predictive variables from the univariate analyses was included. These variables were type of breast surgery, implants, comorbidities, previous surgery, previous chemotherapy, surgical drains, seroma, blood transfusion, surgeon department, and length of stay. The prevalence of SWI was 9%. Demographic, clinical, and comorbidities were not associated with SWI. However, multivariate analysis found that "surgeon department," "discharged with surgical drains," and "postoperative seroma" were predictive of SWI. Monitoring SWI is indispensable to minimise burdens on individuals and institutions. Health care professionals should identify high-risk patients based on the identified predictive variables. A cross-institutional record review of SWI in postoperative breast cancer patients should be conducted.
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Affiliation(s)
| | - Bernice Yong
- Nursing Division, Speciality Nursing, Singapore General Hospital, Singapore
| | - Fazila Abu Bakar Aloweni
- Nursing Division, Patient Care Services and Professional Affairs Admin, Singapore General Hospital, Singapore
| | - Violeta Lopez
- School of Nursing, Hubei University of Medicine, Shiyan, China.,Alice Lee Centre for Nursing Studies, School of Nursing, National University of Singapore, Singapore
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9
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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]
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10
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Bosma SCJ, Leij F, Vreeswijk S, Maaker MD, Wesseling J, Vijver MVD, Scholten A, Rivera S, Bourgier C, Auzac G, Foukakis T, Lekberg T, Bongard D, Loo C, Rutgers E, Bartelink H, Elkhuizen PHM. Five-Year Results of the Preoperative Accelerated Partial Breast Irradiation (PAPBI) Trial. Int J Radiat Oncol Biol Phys 2020; 106:958-967. [PMID: 31987957 DOI: 10.1016/j.ijrobp.2019.12.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE In this multicenter phase 2 feasibility study, we investigated the impact of preoperative accelerated partial breast irradiation (PAPBI) on local control, breast fibrosis, and cosmetic outcome. METHODS AND MATERIALS Women aged >60 years with an invasive, unifocal (mammography and magnetic resonance imaging), nonlobular adenocarcinoma of the breast were treated with PAPBI. Six weeks after radiation therapy, a wide local excision was performed. Radiation therapy consisted of 10 × 4 Gy (2010-2013) or 5 × 6 Gy (after 2013) to the tumor (gross target volume) with a 25 mm margin (20 mm from gross target volume to clinical target volume, 5 mm planning target volume). RESULTS One hundred thirty-three patients treated between 2010 and 2016 were analyzed with a median follow-up of 5.0 years (0.9-8.8 years). Seventy-eight (59%) patients were treated with 10 × 4 Gy in 2 weeks and 55 (41%) patients with 5 × 6 Gy in 1 week. Eighteen postoperative complications (14%) occurred in 15 patients (11%). The proportion of patients with no to mild fibrosis in the treated part of the breast at 2 years and later time points was around 90%. Cosmesis improved over time in several patients: excellent to good cosmetic score as rated by the physician was 68% at 6 months and 92% at 5 years. Seventy-seven percent (6 months) to 82% (5 years) of patients were "satisfied" or "very satisfied" with their cosmetic outcome. Three recurrences were detected in the biopsy track and 1 recurrence in the ipsilateral breast. CONCLUSIONS PAPBI is a feasible method with a low postoperative complication rate, limited fibrosis, and good to excellent cosmetic outcome. The local recurrence rate was 3% at 5 years; however, no local recurrences were observed since removal of the needle biopsy track.
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Affiliation(s)
- Sophie C J Bosma
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Femke Leij
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Michiel de Maaker
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Astrid Scholten
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Sofia Rivera
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Celine Bourgier
- Department of Radiation Oncology, Institut du Cancer de Montpellier Val d'Aurelle, Montpellier, France
| | - Guillaume Auzac
- Department of Radiation Oncology, Gustave Roussy, Villejuif, France
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Lekberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Desiree Bongard
- Department of Radiation Oncology, University Medical Center, Utrecht, The Netherlands
| | - Claudette Loo
- Department of Radiology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Emiel Rutgers
- Department of Surgical Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Harry Bartelink
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, The Netherlands.
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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.
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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
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Bhattacharya IS, Haviland JS, Perotti C, Eaton D, Gulliford S, Harris E, Coles CE, Kirwan CC, Bliss JM, Kirby AM. Is breast seroma after tumour resection associated with patient-reported breast appearance change following radiotherapy? Results from the IMPORT HIGH (CRUK/06/003) trial. Radiother Oncol 2019; 136:190-196. [PMID: 31015124 PMCID: PMC6598856 DOI: 10.1016/j.radonc.2019.03.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/15/2019] [Accepted: 03/24/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Seroma describes a collection of serous fluid within a cavity, occurring following surgery. Seroma is associated with normal tissue effects (NTE) following breast radiotherapy, as reported by clinicians and on photographs. This study investigates the association between seroma and the NTE breast appearance change collected using patient-reported outcome measures (PROMs) in IMPORT HIGH, as well as investigating the association between breast appearance change and patient/tumour/treatment factors. METHODS Case-control methodology was used for seroma analysis within IMPORT HIGH. Cases were patients reporting moderate/marked breast appearance change and controls reported none/mild changes at year-3. One control was selected at random for each case. Seromas were graded as not visible/subtle or visible/highly visible on CT radiotherapy planning scans. Logistic regression tested associations, adjusting for patient/tumour/treatment factors. RESULTS 1078/1149 patients consented to PROMs, of whom 836 (78%) reported whether they had 3-year breast appearance change; 231 cases and 231 controls were identified. 304/462 (66%) patients received chemotherapy. Seroma prevalence was 20% (41/202) in cases and 16% (32/205) in controls, and less frequent in patients receiving adjuvant chemotherapy [10% (24/246) compared with 29% (40/138) without]. Visible seroma was not significantly associated with breast appearance change [OR 1.38 (95%CI 0.83-2.29), p = 0.219]. Larger tumour size, haematoma, current smoking and body image concerns at baseline were independent risk factors. CONCLUSIONS Seroma was not associated with patient-reported breast appearance change, but haematoma and smoking were significant risk factors. Lack of association may be related to lower prevalence of seroma compared with previous reports, perhaps reflecting patients receiving adjuvant chemotherapy in whom seroma resolves prior to radiotherapy.
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Affiliation(s)
- Indrani S Bhattacharya
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), United Kingdom.
| | - Joanne S Haviland
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), United Kingdom.
| | | | - David Eaton
- Mount Vernon Hospital, National Radiotherapy Trials QA Group, United Kingdom.
| | - Sarah Gulliford
- The Institute of Cancer Research, Radiotherapy and Imaging, United Kingdom; University College London Hospital, London, UK.
| | - Emma Harris
- The Institute of Cancer Research, Radiotherapy and Imaging, United Kingdom.
| | | | - Cliona C Kirwan
- Institute of Cancer Sciences, University of Manchester, University Hospital of South Manchester, United Kingdom.
| | - Judith M Bliss
- The Institute of Cancer Research Clinical Trials and Statistics Unit (ICR-CTSU), United Kingdom.
| | - Anna M Kirby
- Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Radiotherapy and Imaging, United Kingdom.
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Agrawal A. Oncoplastic breast surgery and radiotherapy-Adverse aesthetic outcomes, proposed classification of aesthetic components, and causality attribution. Breast J 2019; 25:207-218. [DOI: 10.1111/tbj.13193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/18/2018] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Amit Agrawal
- Cambridge Breast Unit, Cambridge University Hospitals; Cambridge UK
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Wang K, Yee C, Tam S, Drost L, Chan S, Zaki P, Rico V, Ariello K, Dasios M, Lam H, DeAngelis C, Chow E. Prevalence of pain in patients with breast cancer post-treatment: A systematic review. Breast 2018; 42:113-127. [DOI: 10.1016/j.breast.2018.08.105] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/08/2018] [Accepted: 08/27/2018] [Indexed: 12/12/2022] Open
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15
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Oncoplastic approach to excisional breast biopsies: a randomized controlled, phase 2a trial. Breast Cancer 2018; 26:84-92. [PMID: 30019283 DOI: 10.1007/s12282-018-0892-2] [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: 05/21/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Oncoplastic surgery has been used in breast cancer patients for better cosmetic outcome over the last decades. The aim of this prospective randomized study is to show its place in excisional breast biopsy. METHODS An oncoplastic approach excision was compared with conventional excisional breast biopsies. The study included 80 patients, of whom half received oncoplastic intervention and half received the conventional. The primary endpoint was the cosmetic result. Patient, surgeon and independent observers rated the results on a four-point scale. Scores other than self-perceived were based on third-month medical photographs. RESULTS Between May 20, 2015 and April 27, 2016, 40 patients were randomly assigned to oncoplastic biopsy and 40 patients were assigned to conventional excisional biopsy. Median follow-up was 5.6 months (IQR 3.0-6.0). Self-perceived perfect scoring for general cosmetic outcome was found significantly higher after oncoplastic biopsy (73 0.5%) comparing with control group (32.4%) (p = 0.001). This impact did not change after adjusting patients for potential confounders. Margin clearance rates in malignant cases were comparable in both arms (p = 0.999); four patients in oncoplastic biopsy group (40%) and three patients in control group (33%) had positive margins. CONCLUSIONS The oncoplastic biopsy achieved better cosmetic results with similar surgical margin positivity rates when compared with conventional breast biopsy. It may be a better biopsy option used for patients requiring excisional breast biopsy.
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A randomized controlled trial on the effect of a silver carboxymethylcellulose dressing on surgical site infections after breast cancer surgery. PLoS One 2018; 13:e0195715. [PMID: 29791437 PMCID: PMC5965831 DOI: 10.1371/journal.pone.0195715] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 03/27/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The incidence of surgical site infections (SSIs) after breast cancer surgery is relatively high; ranging from 3 to 19%. The role of wound dressings in the prevention of SSI after breast cancer surgery is unclear. This study compares a silver carboxymethylcellulose dressing (AQUACEL Ag Surgical (Aquacel) with standard wound dressing in SSI rate after breast cancer surgery. PATIENTS AND METHODS A single-centre randomized controlled trial among women ≥18 years, diagnosed with breast cancer, undergoing breast conserving or ablative surgery, was conducted in a combined in and outpatient setting. The intervention was the use of Aquacel, compared with standard gauze dressing. Primary outcome measure was SSI following CDC criteria. RESULTS A total of 230 patients were analysed: 106 in the Aquacel group and 124 controls. Seven patients (6.6%) developed SSI in the Aquacel group and 16 patients (12.9%) in the control group (RR 0.51 [95% Confidence Interval (CI): 0.22-1.20]; p = 0.112; adjusted OR 0.49 [0.19-1.25] p = 0.135)). Unplanned exploratory subgroup analysis of breast conserving surgery patients showed that SSI rate was 1/56 (1.8%) in the Aquacel group vs. 7/65 (10.8%) in controls; adjusted OR 0.15 [0.02-1.31] p = 0.087. The Aquacel group showed better patient satisfaction (median 8 vs. 7 on a Numerical Rating Scale, p = 0.006), fewer dressing changes within 48 hours(adjusted OR 0.12 [0.05-0.27] p<0.001), fewer re-operations (0% vs. 3.2%, p = 0.062), and lower mean wound-related treatment costs, both in a high (€265.42 (SD = 908) vs. €470.65 (SD = 1223) [p<0.001]) and low (€59.12 (SD = 129) vs. €67.55 (SD = 172) [p<0.001]) attributable costs of SSI model. CONCLUSION In this randomized controlled trial in women undergoing surgery for breast cancer, the use of AQUACEL Ag Surgical wound dressing did not significantly reduce the occurrence of SSIs compared to standard gauze dressing. The use of Aquacel resulted in significantly improved patient satisfaction, reduced dressing changes and reduced wound-related costs. TRIAL REGISTRATION www.trialregister.nl: NTR5840.
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Honart JF, Reguesse AS, Struk S, Sarfati B, Rimareix F, Alkhashnam H, Kolb F, Rem K, Leymarie N. Indications and Controversies in Partial Mastectomy Defect Reconstruction. Clin Plast Surg 2017; 45:33-45. [PMID: 29080658 DOI: 10.1016/j.cps.2017.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Breast cancer surgical treatment nowadays includes oncoplastic surgery. It is a reliable oncologic surgical treatment, which also prevents functional and aesthetic sequelae, thus improving the patient's quality of life and satisfaction. Numerous techniques have been described, with different levels of complexity and technicality. Their indications differ depending on the global breast volume and the degree of ptosis, on the tumor volume compared with the breast volume, and on the tumor location. This article describes the authors' many years of experience of breast cancer treatment using oncoplastic surgery. They also established a decision-making guide, whose implementation enables treatment of every patient.
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Affiliation(s)
- Jean-François Honart
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France.
| | - Anne-Sophie Reguesse
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Samuel Struk
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Benjamin Sarfati
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Françoise Rimareix
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Heba Alkhashnam
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Frédéric Kolb
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Kessara Rem
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
| | - Nicolas Leymarie
- Plastic and Reconstructive Surgery Department, Gustave Roussy, 114, Rue Edouard Vaillant, Villejuif 94800, France
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Baima J, Reynolds SG, Edmiston K, Larkin A, Ward BM, O'Connor A. Teaching of Independent Exercises for Prehabilitation in Breast Cancer. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2017; 32:252-256. [PMID: 26541465 DOI: 10.1007/s13187-015-0940-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We attempted to determine the feasibility of studying prehabilitation exercises to improve shoulder pain and abduction range of motion (ROM) after breast cancer surgery. We evaluated methods of exercise teaching and assessed effect on postsurgical seroma formation. This was a feasibility study with two non-blinded groups of subjects randomized by timing of appointment. This single-site study was performed at an academic tertiary medical center. Sixty cancer patients were randomly assigned to either group 1, in-person teaching arm, n = 36, or group 2, video-only teaching arm, n = 24. Forty-five patients completed the study. Shoulder exercises were assigned to both groups 1 month prior to surgery during evaluation. Group 1 received in-person instruction on exercises, plus an information sheet with exercises and a link to an online video. Group 2 received only the information sheet with exercises and a link to the online video. The primary outcomes considered are as follows: exercise compliance, shoulder pain (via visual analog scale), shoulder abduction ROM (via goniometer), and presence or absence of seroma. Seventy-six percent of study patients chose to exercise. There was no difference in exercise compliance between in-person teaching versus video teaching (75 %, 24/32 vs. 77 %, 10/13, OR = 1.03). Sixty-six of patients (20/30) lost greater than 10° shoulder abduction ROM at 1 month post surgery. Twenty-nine of patients (9/31) had worse shoulder pain than baseline at 1 month post surgery (24 %, 6/25 exercisers, and 50 %, 3/6 non-exercisers). Fifteen percent of patients (4/27) had worse shoulder pain than baseline at 3 months post surgery (8 %, 2/23 exercisers, and 100 %, 2/2 non-exercisers). Prehabilitation exercise program inferred no additional risk of seroma formation (Exercisers 21 %, 7/33 vs. non-exercisers 22 %, 2/9, OR = 0.94). Our subjects were able to perform three exercises independently in the preoperative period. A high-quality randomized controlled trial is necessary to assess the appropriate timing and efficacy of this intervention.
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Affiliation(s)
- Jennifer Baima
- University of Massachusetts Medical School, Worcester, MA, USA.
| | | | | | - Anne Larkin
- University of Massachusetts Medical School, Worcester, MA, USA
| | - B Marie Ward
- University of Massachusetts Medical School, Worcester, MA, USA
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Buwenge M, Cammelli S, Ammendolia I, Tolento G, Zamagni A, Arcelli A, Macchia G, Deodato F, Cilla S, Morganti AG. Intensity modulated radiation therapy for breast cancer: current perspectives. BREAST CANCER-TARGETS AND THERAPY 2017; 9:121-126. [PMID: 28293119 PMCID: PMC5345691 DOI: 10.2147/bctt.s113025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Owing to highly conformed dose distribution, intensity modulated radiation therapy (IMRT) has the potential to improve treatment results of radiotherapy (RT). Postoperative RT is a standard adjuvant treatment in conservative treatment of breast cancer (BC). The aim of this review is to analyze available evidence from randomized controlled trials (RCTs) on IMRT in BC, particularly in terms of reduction of side effects. Methods A literature search of the bibliographic database PubMed, from January 1990 through November 2016, was performed. Only RCTs published in English were included. Results Ten articles reporting data from 5 RCTs fulfilled the selection criteria and were included in our review. Three out of 5 studies enrolled only selected patients in terms of increased risk of toxicity. Three studies compared IMRT with standard tangential RT. One study compared the results of IMRT in the supine versus the prone position, and one study compared standard treatment with accelerated partial breast IMRT. Three studies reported reduced acute and/or late toxicity using IMRT compared with standard RT. No study reported improved quality of life. Conclusion IMRT seems able to reduce toxicity in selected patients treated with postoperative RT for BC. Further analyses are needed to better define patients who are candidates for this treatment modality.
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Affiliation(s)
- Milly Buwenge
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Radiation Oncology Center, University of Bologna, S.Orsola-Malpighi Hospital
| | - Silvia Cammelli
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Radiation Oncology Center, University of Bologna, S.Orsola-Malpighi Hospital
| | - Ilario Ammendolia
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Radiation Oncology Center, University of Bologna, S.Orsola-Malpighi Hospital
| | - Giorgio Tolento
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Radiation Oncology Center, University of Bologna, S.Orsola-Malpighi Hospital
| | - Alice Zamagni
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Radiation Oncology Center, University of Bologna, S.Orsola-Malpighi Hospital
| | | | | | | | - Savino Cilla
- Medical Physics Unit, Research and Care Foundation 'Giovanni Paolo II,' Catholic University of Sacred Heart, Campobasso, Italy
| | - Alessio G Morganti
- Department of Experimental, Diagnostic and Specialty Medicine - DIMES, Radiation Oncology Center, University of Bologna, S.Orsola-Malpighi Hospital
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Ozoya OO, Siegel EM, Srikumar T, Bloomer AM, DeRenzis A, Shibata D. Quantitative Assessment of Visceral Obesity and Postoperative Colon Cancer Outcomes. J Gastrointest Surg 2017; 21:534-542. [PMID: 28101721 PMCID: PMC5560865 DOI: 10.1007/s11605-017-3362-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 01/04/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Quantitative computed tomography (CT) assessment of visceral adiposity may be superior to body mass index (BMI) as a predictor of surgical morbidity. We sought to examine the association of CT measures of obesity and BMI with short-term postoperative outcomes in colon cancer patients. METHODS In this retrospective study, 110 patients treated with colectomy for stage I-III colon cancer were classified as obese or non-obese by preoperative CT-based measures of adiposity or BMI [obese: BMI ≥ 30 kg/m2, visceral fat area (VFA) to subcutaneous fat area ratio (V/S) ≥0.4, and VFA > 100 cm2]. Postoperative morbidity and mortality rates were compared. RESULTS Obese patients, by V/S and VFA but not BMI, were more likely to be male and have preexisting hypertension and diabetes. The overall complication rate was 25.5%, and there were no mortalities. Obese patients by VFA (with a trend for V/S but not BMI) were more likely to develop postoperative complications as compared to patients classified as non-obese: VFA (30.5 vs.10.7%, p = 0.03), V/S (29.2 vs. 9.5%, p = 0.05), and BMI (32.4 vs. 21.9%, p = 0.23). CONCLUSIONS Elevated visceral obesity quantified by CT is associated with the presence of key metabolic comorbidities and increased postoperative morbidity and may be superior to BMI for risk stratification.
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Affiliation(s)
- Oluwatobi. O. Ozoya
- Cancer Epidemiology, Moffitt Cancer Center, Tampa FL,Department of Global Health, College of Public Health, University of
South Florida, Tampa, FL
| | - Erin M. Siegel
- Cancer Epidemiology, Moffitt Cancer Center, Tampa FL,Health Research Informatics, Moffitt Cancer Center, Tampa, FL
| | - Thejal Srikumar
- Cancer Epidemiology, Moffitt Cancer Center, Tampa FL,Morsani College of Medicine, University of South Florida, Tampa,
FL
| | | | | | - David Shibata
- Department of Surgery, UT West Cancer Center, University of
Tennessee Health Science Center, Memphis, TN
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Assessment and planning for oncoplastic and reconstructive breast surgery: a review and a proposed chart. EUROPEAN JOURNAL OF PLASTIC SURGERY 2016. [DOI: 10.1007/s00238-016-1221-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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O'Shea T, Bamber J, Fontanarosa D, van der Meer S, Verhaegen F, Harris E. Review of ultrasound image guidance in external beam radiotherapy part II: intra-fraction motion management and novel applications. Phys Med Biol 2016; 61:R90-137. [PMID: 27002558 DOI: 10.1088/0031-9155/61/8/r90] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Imaging has become an essential tool in modern radiotherapy (RT), being used to plan dose delivery prior to treatment and verify target position before and during treatment. Ultrasound (US) imaging is cost-effective in providing excellent contrast at high resolution for depicting soft tissue targets apart from those shielded by the lungs or cranium. As a result, it is increasingly used in RT setup verification for the measurement of inter-fraction motion, the subject of Part I of this review (Fontanarosa et al 2015 Phys. Med. Biol. 60 R77-114). The combination of rapid imaging and zero ionising radiation dose makes US highly suitable for estimating intra-fraction motion. The current paper (Part II of the review) covers this topic. The basic technology for US motion estimation, and its current clinical application to the prostate, is described here, along with recent developments in robust motion-estimation algorithms, and three dimensional (3D) imaging. Together, these are likely to drive an increase in the number of future clinical studies and the range of cancer sites in which US motion management is applied. Also reviewed are selections of existing and proposed novel applications of US imaging to RT. These are driven by exciting developments in structural, functional and molecular US imaging and analytical techniques such as backscatter tissue analysis, elastography, photoacoustography, contrast-specific imaging, dynamic contrast analysis, microvascular and super-resolution imaging, and targeted microbubbles. Such techniques show promise for predicting and measuring the outcome of RT, quantifying normal tissue toxicity, improving tumour definition and defining a biological target volume that describes radiation sensitive regions of the tumour. US offers easy, low cost and efficient integration of these techniques into the RT workflow. US contrast technology also has potential to be used actively to assist RT by manipulating the tumour cell environment and by improving the delivery of radiosensitising agents. Finally, US imaging offers various ways to measure dose in 3D. If technical problems can be overcome, these hold potential for wide-dissemination of cost-effective pre-treatment dose verification and in vivo dose monitoring methods. It is concluded that US imaging could eventually contribute to all aspects of the RT workflow.
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Affiliation(s)
- Tuathan O'Shea
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden NHS Foundation Trust, Sutton, London SM2 5NG, UK
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Juneja P, Bonora M, Haviland JS, Harris E, Evans P, Somaiah N. Does breast composition influence late adverse effects in breast radiotherapy? Breast 2016; 26:25-30. [PMID: 27017239 DOI: 10.1016/j.breast.2015.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 12/04/2015] [Accepted: 12/12/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Large breast size is associated with increased risk of late adverse effects after surgery and radiotherapy for early breast cancer. It is hypothesised that effects of radiotherapy on adipose tissue are responsible for some of the effects seen. In this study, the association of breast composition with late effects was investigated along with other breast features such as fibroglandular tissue distribution, seroma and scar. METHODS The patient dataset comprised of 18 cases with changes in breast appearance at 2 years follow-up post-radiotherapy and 36 controls with no changes, from patients entered into the FAST-Pilot and UK FAST trials at The Royal Marsden. Breast composition, fibroglandular tissue distribution, seroma and scar were assessed on planning CT scan images and compared using univariate analysis. The association of all features with late-adverse effect was tested using logistic regression (adjusting for confounding factors) and matched analysis was performed using conditional logistic regression. RESULTS In univariate analyses, no statistically significant differences were found between cases and controls in terms of breast features studied. A statistically significant association (p < 0.05) between amount of seroma and change in photographic breast appearance was found in unmatched and matched logistic regression analyses with odds ratio (95% CI) of 3.44 (1.28-9.21) and 2.57 (1.05-6.25), respectively. CONCLUSIONS A significant association was found between seroma and late-adverse effects after radiotherapy although no significant associations were noted with breast composition in this study. Therefore, the cause for large breast size as a risk factor for late effects after surgery and optimally planned radiotherapy remains unresolved.
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Affiliation(s)
- Prabhjot Juneja
- The Institute of Cancer Research, London SW7 3RP, UK; The Royal Marsden NHS Foundation Trust, Sutton SM2 5PT, UK; North Sydney Cancer Centre, Royal North Shore Hospital, Sydney 2065, Australia; Institute of Medical Physics, University of Sydney, Sydney 2006, Australia
| | - Maria Bonora
- Centro Nazionale Adroterapia Oncologica, 27100 Pavia, Italy
| | - Joanne S Haviland
- Faculty of Health Sciences, University of Southampton, Southampton SO17 1BJ, UK; ICR-Clinical Trials and Statistics Unit (ICR-CTSU), Division of Clinical Studies, The Institute of Cancer Research, London SM2 5NG, UK
| | - Emma Harris
- The Institute of Cancer Research, London SW7 3RP, UK; The Royal Marsden NHS Foundation Trust, Sutton SM2 5PT, UK
| | - Phil Evans
- The Institute of Cancer Research, London SW7 3RP, UK; The Royal Marsden NHS Foundation Trust, Sutton SM2 5PT, UK; Centre for Vision Speech and Signal Processing, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Navita Somaiah
- The Institute of Cancer Research, London SW7 3RP, UK; The Royal Marsden NHS Foundation Trust, Sutton SM2 5PT, UK.
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Harris EJ, Mukesh MB, Donovan EM, Kirby AM, Haviland JS, Jena R, Yarnold J, Baker A, Dean J, Eagle S, Mayles H, Griffin C, Perry R, Poynter A, Coles CE, Evans PM. A multicentre study of the evidence for customized margins in photon breast boost radiotherapy. Br J Radiol 2015; 89:20150603. [PMID: 26585543 PMCID: PMC4985208 DOI: 10.1259/bjr.20150603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/10/2015] [Accepted: 11/19/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine if subsets of patients may benefit from smaller or larger margins when using laser setup and bony anatomy verification of breast tumour bed (TB) boost radiotherapy (RT). METHODS Verification imaging data acquired using cone-beam CT, megavoltage CT or two-dimensional kilovoltage imaging on 218 patients were used (1574 images). TB setup errors for laser-only setup (dlaser) and for bony anatomy verification (dbone) were determined using clips implanted into the TB as a gold standard for the TB position. Cases were grouped by centre-, patient- and treatment-related factors, including breast volume, TB position, seroma visibility and surgical technique. Systematic (Σ) and random (σ) TB setup errors were compared between groups, and TB planning target volume margins (MTB) were calculated. RESULTS For the study population, Σlaser was between 2.8 and 3.4 mm, and Σbone was between 2.2 and 2.6 mm, respectively. Females with larger breasts (p = 0.03), easily visible seroma (p ≤ 0.02) and open surgical technique (p ≤ 0.04) had larger Σlaser. Σbone was larger for females with larger breasts (p = 0.02) and lateral tumours (p = 0.04). Females with medial tumours (p < 0.01) had smaller Σbone. CONCLUSION If clips are not used, margins should be 8 and 10 mm for bony anatomy verification and laser setup, respectively. Individualization of TB margins may be considered based on breast volume, TB and seroma visibility. ADVANCES IN KNOWLEDGE Setup accuracy using lasers and bony anatomy is influenced by patient and treatment factors. Some patients may benefit from clip-based image guidance more than others.
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Affiliation(s)
- Emma J Harris
- Radiotherapy and Imaging, Institute of Cancer Research Sutton, UK
| | - Mukesh B Mukesh
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Oncology Centre, Colchester Hospital University NHS Trust, Colchester, UK
| | - Ellen M Donovan
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Anna M Kirby
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Joanne S Haviland
- ICR-CTSU, Institute of Cancer Research, Sutton, UK
- Macmillan Survivorship Research Group, Faculty of Health Sciences, University of Southampton, UK
| | - Raj Jena
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - John Yarnold
- Radiotherapy and Imaging, Institute of Cancer Research Sutton, UK
| | - Angela Baker
- Department of Physics, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - June Dean
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Sally Eagle
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Helen Mayles
- Department of Physics, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | | | - Rosalind Perry
- Department of Radiotherapy, Ipswich Hospital NHS Trust, Ipswich, UK
| | | | - Charlotte E Coles
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | | | - On behalf of the IMPORT high trialists
- Radiotherapy and Imaging, Institute of Cancer Research Sutton, UK
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Oncology Centre, Colchester Hospital University NHS Trust, Colchester, UK
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
- ICR-CTSU, Institute of Cancer Research, Sutton, UK
- Macmillan Survivorship Research Group, Faculty of Health Sciences, University of Southampton, UK
- Department of Physics, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
- Department of Radiotherapy, Ipswich Hospital NHS Trust, Ipswich, UK
- Radiotherapy Department, Peterborough City Hospital, UK
- CVSSP, University of Surrey, Guildford, UK
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DEN Hartogh MD, Philippens MEP, VAN Dam IE, Kleynen CE, Tersteeg RJHA, Kotte ANTJ, VAN Vulpen M, VAN Asselen B, VAN DEN Bongard DHJG. Post-lumpectomy CT-guided tumor bed delineation for breast boost and partial breast irradiation: Can additional pre- and postoperative imaging reduce interobserver variability? Oncol Lett 2015; 10:2795-2801. [PMID: 26722244 PMCID: PMC4665376 DOI: 10.3892/ol.2015.3697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 04/20/2015] [Indexed: 12/20/2022] Open
Abstract
For breast boost radiotherapy or accelerated partial breast irradiation, the tumor bed (TB) is delineated by the radiation oncologist on a planning computed tomography (CT) scan. The aim of the present study was to investigate whether the interobserver variability (IOV) of the TB delineation is reduced by providing the radiation oncologist with additional magnetic resonance imaging (MRI) or CT scans. A total of 14 T1-T2 breast cancer patients underwent a standard planning CT in the supine treatment position following lumpectomy, as well as additional pre- and postoperative imaging in the same position. Post-lumpectomy TBs were independently delineated by four breast radiation oncologists on standard postoperative CT and on CT registered to an additional imaging modality. The additional imaging modalities used were postoperative MRI, preoperative contrast-enhanced (CE)-CT and preoperative CE-MRI. A cavity visualization score (CVS) was assigned to each standard postoperative CT by each observer. In addition, the conformity index (CI), volume and distance between centers of mass (dCOM) of the TB delineations were calculated. On CT, the median CI was 0.57, with a median volume of 22 cm3 and dCOM of 5.1 mm. The addition of postoperative MRI increased the median TB volume significantly to 28 cm3 (P<0.001), while the CI (P=0.176) and dCOM (P=0.110) were not affected. The addition of preoperative CT or MRI increased the TB volume to 26 and 25 cm3, respectively (both P<0.001), while the CI increased to 0.58 and 0.59 (both P<0.001) and the dCOM decreased to 4.7 mm (P=0.004) and 4.6 mm (P=0.001), respectively. In patients with CVS≤3, the median CI was 0.40 on CT, which was significantly increased by all additional imaging modalities, up to 0.52, and was accompanied by a median volume increase up to 6 cm3. In conclusion, the addition of postoperative MRI, preoperative CE-CT or preoperative CE-MRI did not result in a considerable reduction in the IOV in postoperative CT-guided TB delineation, while target volumes marginally increased. The value of additional imaging may be dependent on CVS.
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Affiliation(s)
- Mariska D DEN Hartogh
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marielle E P Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Iris E VAN Dam
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Catharina E Kleynen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robbert J H A Tersteeg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexis N T J Kotte
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco VAN Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bram VAN Asselen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Valeta-Magara A, Hatami R, Axelrod D, Roses DF, Guth A, Formenti SC, Schneider RJ. Pro-oncogenic cytokines and growth factors are differentially expressed in the post-surgical wound fluid from malignant compared to benign breast lesions. SPRINGERPLUS 2015; 4:483. [PMID: 26361584 PMCID: PMC4560730 DOI: 10.1186/s40064-015-1260-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 08/18/2015] [Indexed: 12/16/2022]
Abstract
Purpose The accumulation of wound fluid known as seroma in the chest cavity following breast surgery is a common occurrence that can persist for many weeks. While the pro-inflammatory composition of seroma is well established, there has been remarkably little research to determine whether seroma contains pro-oncogenic factors, and whether this is influenced by previous malignant disease. Methods We developed a clinical trial in which we obtained post-surgical seroma fluids from women with benign or malignant disease 1 or 2 weeks following lumpectomy or mastectomy. We conducted an analysis of more than 80 different cytokines, chemokines and growth factors. Results We found that surgical cavity seroma from breast cancer patients has a higher expression of key tumor-promoting cytokines and lower expression of important tumor-inhibiting factors when compared to benign lesions from non-cancer patients. Patients with high body mass index also had higher levels of leptin regardless of malignancy. Conclusions We conclude that the breast post-surgical tumor cavity contains factors that are pro-inflammatory regardless of malignant or benign disease, but in malignant disease there is significant enrichment of additional pro-oncogenic chemokines, cytokines and growth factors, and reduction in tumor-inhibiting factors. These results are consistent with tumor conditioning of surrounding normal stromal tissue and creation of a pro-oncogenic environment that persists long after surgical removal of the tumor. Electronic supplementary material The online version of this article (doi:10.1186/s40064-015-1260-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Raheleh Hatami
- Department of Microbiology, NYU School of Medicine, New York, NY 10016 USA
| | - Deborah Axelrod
- Department of Surgery, NYU School of Medicine, New York, NY 10016 USA ; NYU Perlmutter Cancer Institute, NYU School of Medicine, New York, NY 10016 USA
| | - Daniel F Roses
- Department of Surgery, NYU School of Medicine, New York, NY 10016 USA ; NYU Perlmutter Cancer Institute, NYU School of Medicine, New York, NY 10016 USA
| | - Amber Guth
- Department of Surgery, NYU School of Medicine, New York, NY 10016 USA ; NYU Perlmutter Cancer Institute, NYU School of Medicine, New York, NY 10016 USA
| | - Silvia C Formenti
- Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016 USA ; Weill Cornell Medical College, New York, NY USA
| | - Robert J Schneider
- Department of Microbiology, NYU School of Medicine, New York, NY 10016 USA ; Department of Surgery, NYU School of Medicine, New York, NY 10016 USA ; NYU Perlmutter Cancer Institute, NYU School of Medicine, New York, NY 10016 USA ; Department of Radiation Oncology, NYU School of Medicine, New York, NY 10016 USA
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Scaife JE, Barnett GC, Noble DJ, Jena R, Thomas SJ, West CML, Burnet NG. Exploiting biological and physical determinants of radiotherapy toxicity to individualize treatment. Br J Radiol 2015; 88:20150172. [PMID: 26084351 PMCID: PMC4628540 DOI: 10.1259/bjr.20150172] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/07/2015] [Accepted: 05/21/2015] [Indexed: 12/16/2022] Open
Abstract
The recent advances in radiation delivery can improve tumour control probability (TCP) and reduce treatment-related toxicity. The use of intensity-modulated radiotherapy (IMRT) in particular can reduce normal tissue toxicity, an objective in its own right, and can allow safe dose escalation in selected cases. Ideally, IMRT should be combined with image guidance to verify the position of the target, since patients, target and organs at risk can move day to day. Daily image guidance scans can be used to identify the position of normal tissue structures and potentially to compute the daily delivered dose. Fundamentally, it is still the tolerance of the normal tissues that limits radiotherapy (RT) dose and therefore tumour control. However, the dose-response relationships for both tumour and normal tissues are relatively steep, meaning that small dose differences can translate into clinically relevant improvements. Differences exist between individuals in the severity of toxicity experienced for a given dose of RT. Some of this difference may be the result of differences between the planned dose and the accumulated dose (DA). However, some may be owing to intrinsic differences in radiosensitivity of the normal tissues between individuals. This field has been developing rapidly, with the demonstration of definite associations between genetic polymorphisms and variation in toxicity recently described. It might be possible to identify more resistant patients who would be suitable for dose escalation, as well as more sensitive patients for whom toxicity could be reduced or avoided. Daily differences in delivered dose have been investigated within the VoxTox research programme, using the rectum as an example organ at risk. In patients with prostate cancer receiving curative RT, considerable daily variation in rectal position and dose can be demonstrated, although the median position matches the planning scan well. Overall, in 10 patients, the mean difference between planned and accumulated rectal equivalent uniform doses was -2.7 Gy (5%), and a dose reduction was seen in 7 of the 10 cases. If dose escalation was performed to take rectal dose back to the planned level, this should increase the mean TCP (as biochemical progression-free survival) by 5%. Combining radiogenomics with individual estimates of DA might identify almost half of patients undergoing radical RT who might benefit from either dose escalation, suggesting improved tumour cure or reduced toxicity or both.
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Affiliation(s)
- J E Scaife
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - G C Barnett
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D J Noble
- Oncology Centre, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - R Jena
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
| | - S J Thomas
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
- Medical Physics Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C M L West
- Institute of Cancer Sciences, University of Manchester, Manchester Academic Health Science Centre, Christie Hospital, Manchester, UK
| | - N G Burnet
- University of Cambridge Department of Oncology, Cambridge Biomedical Campus, Addenbrooke's Hospital, Cambridge, UK
- Cancer Research UK VoxTox Research Group, University of Cambridge Department of Oncology, Addenbrooke's Hospital, Cambridge, UK
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van der Leij F, Bosma SCJ, van de Vijver MJ, Wesseling J, Vreeswijk S, Rivera S, Bourgier C, Garbay JR, Foukakis T, Lekberg T, van den Bongard DHJGD, van Vliet-Vroegindeweij C, Bartelink H, Rutgers EJ, Elkhuizen PHM. First results of the preoperative accelerated partial breast irradiation (PAPBI) trial. Radiother Oncol 2015; 114:322-7. [PMID: 25701298 DOI: 10.1016/j.radonc.2015.02.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 01/26/2015] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study is to assess the toxicity and cosmetic outcome of preoperative accelerated partial breast irradiation (PAPBI) for breast cancer patients with low risk on local recurrence. MATERIAL AND METHODS Women aged ⩾60years with an invasive, unifocal ⩽3cm on MRI, (non-lobular) adenocarcinoma of the breast and a negative sentinel node received PAPBI (40Gray in 10 fractions over 2 weeks). Six weeks after radiotherapy a wide local excision was performed. RESULTS 70 patients with a median follow-up of 23 months (3-44 months) were evaluated. The overall postoperative infection rate was 11%. At 1, 2 and 3 years of follow-up respectively 89%, 98% and 100% of patients had no or mild induration-fibrosis. Fibrosis was only found in a small volume of the breast. The global cosmetic outcome was good to excellent in 77% at 6 months to 100% at 3 years. Two patients developed a local recurrence. CONCLUSION Our first results show limited fibrosis in a small volume and good to excellent cosmetic outcome. In selected patients, preoperative radiotherapy appears to be a good option for breast conserving therapy.
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Affiliation(s)
- Femke van der Leij
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Sophie C J Bosma
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Jelle Wesseling
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Sandra Vreeswijk
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | | | | | - Theodoros Foukakis
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Tobias Lekberg
- Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Harry Bartelink
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Emiel J Rutgers
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands.
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Radiotherapy in Prostate Cancer Patients With Pelvic Lymphocele After Surgery: Clinical and Dosimetric Data of 30 Patients. Clin Genitourin Cancer 2014; 13:e223-e228. [PMID: 25497586 DOI: 10.1016/j.clgc.2014.11.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Revised: 11/12/2014] [Accepted: 11/13/2014] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The purpose of the study was to evaluate the feasibility of irradiation after prostatectomy in the presence of asymptomatic pelvic lymphocele. PATIENTS AND METHODS The inclusion criteria for this study were: (1) patients referred for postoperative (adjuvant or salvage) intensity modulated radiotherapy (IMRT; 66-69 Gy in 30 fractions); (2) detection of postoperative pelvic lymphocele at the simulation computed tomography [CT] scan; (3) no clinical symptoms; and (4) written informed consent. Radiotherapy toxicity and occurrence of symptoms or complications of lymphocele were analyzed. Dosimetric data (IMRT plans) and the modification of lymphocele volume during radiotherapy (cone beam CT [CBCT] scan) were evaluated. RESULTS Between January 2011 and July 2013, in 30 of 308 patients (10%) treated with radiotherapy after prostatectomy, pelvic lymphocele was detected on the simulation CT. The median lymphocele volume was 47 cm(3) (range, 6-467.3 cm(3)). Lymphocele was not included in planning target volume (PTV) in 8 cases (27%). Maximum dose to lymphocele was 57 Gy (range, 5.7-73.3 Gy). Radiotherapy was well tolerated. In all but 2 patients, lymphoceles remained asymptomatic. Lymphocele drainage-because of symptom occurrence-had to be performed in 2 patients during IMRT and in one patient, 7 weeks after IMRT. CBCT at the end of IMRT showed reduction in lymphocele volume and position compared with the initial data (median reduction of 37%), more pronounced in lymphoceles included in PTV. CONCLUSION Radiotherapy after prostatectomy in the presence of pelvic asymptomatic lymphocele is feasible with acceptable acute and late toxicity. The volume of lymphoceles decreased during radiotherapy and this phenomenon might require intermediate radiotherapy plan evaluation.
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den Hartogh MD, van den Bongard HJGD, Davidson MTM, Kotte ANTJ, Verkooijen HM, Philippens MEP, van Vulpen M, van Asselen B, Pignol JP. Full-thickness closure in breast-conserving surgery: the impact on radiotherapy target definition for boost and partial breast irradiation. A multimodality image evaluation. Ann Surg Oncol 2014; 21:3774-9. [PMID: 24874499 DOI: 10.1245/s10434-014-3801-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND During breast-conserving surgery (BCS), surgeons increasingly perform full-thickness closure (FTC) to prevent seroma formation. This could potentially impair precision of target definition for boost and accelerated partial breast irradiation (APBI). The purpose of this study was to investigate the precision of target volume definition following BCS with FTC among radiation oncologists, using various imaging modalities. METHODS Twenty clinical T1-2N0 patients, scheduled for BCS involving clip placement and FTC, were included in the study. Seven experienced breast radiation oncologists contoured the tumor bed on computed tomography (CT), magnetic resonance imaging (MRI) and fused CT-MRI datasets. A total of 361 observer pairs per image modality were analyzed. A pairwise conformity among the generated contours of the observers and the distance between their centers of mass (dCOM) were calculated. RESULTS On CT, median conformity was 44 % [interquartile range (IQR) 28-58 %] and median dCOM was 6 mm (IQR 3-9 mm). None of the outcome measures improved when MRI or fused CT-MRI were used. In two patients, superficial closure was performed instead of FTC. In these 14 image sets and 42 observer pairs, median conformity increased to 70 %. CONCLUSIONS Localization of the radiotherapy target after FTC is imprecise, on both CT and MRI. This could potentially lead to a geographical miss in patients at increased risk of local recurrence receiving a radiation boost, or for those receiving APBI. These findings highlight the importance for breast surgeons to clearly demarcate the tumor bed when performing FTC.
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Affiliation(s)
- Mariska D den Hartogh
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands,
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Goble RN, Drukteinis JS, Lee MC, Khakpour N, Kiluk JV, Laronga C. Early experience with ultrasound features after intrabeam intraoperative radiation for early stage breast cancer. J Surg Oncol 2014; 109:751-5. [DOI: 10.1002/jso.23581] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 01/27/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Rachel N. Goble
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | | | - M. Catherine Lee
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | - Nazanin Khakpour
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | - John V. Kiluk
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
| | - Christine Laronga
- Department of Women's Oncology; Moffitt Cancer Center; Tampa Florida
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Normal tissue complication probability (NTCP) parameters for breast fibrosis: pooled results from two randomised trials. Radiother Oncol 2013; 108:293-8. [PMID: 23953408 DOI: 10.1016/j.radonc.2013.07.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 07/04/2013] [Accepted: 07/14/2013] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The dose-volume effect of radiation therapy on breast tissue is poorly understood. We estimate NTCP parameters for breast fibrosis after external beam radiotherapy. MATERIALS AND METHODS We pooled individual patient data of 5856 patients from 2 trials including whole breast irradiation followed with or without a boost. A two-compartment dose volume histogram model was used with boost volume as the first compartment and the remaining breast volume as second compartment. Results from START-pilot trial (n=1410) were used to test the predicted models. RESULTS 26.8% patients in the Cambridge trial (5 years) and 20.7% patients in the EORTC trial (10 years) developed moderate-severe breast fibrosis. The best fit NTCP parameters were BEUD3(50)=136.4 Gy, γ50=0.9 and n=0.011 for the Niemierko model and BEUD3(50)=132 Gy, m=0.35 and n=0.012 for the Lyman Kutcher Burman model. The observed rates of fibrosis in the START-pilot trial agreed well with the predicted rates. CONCLUSIONS This large multi-centre pooled study suggests that the effect of volume parameter is small and the maximum RT dose is the most important parameter to influence breast fibrosis. A small value of volume parameter 'n' does not fit with the hypothesis that breast tissue is a parallel organ. However, this may reflect limitations in our current scoring system of fibrosis.
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A new level 1 oncoplastic technique for breast conserving surgery: Rotation glandular flap. Breast 2013; 22:186-189. [DOI: 10.1016/j.breast.2013.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2012] [Revised: 12/11/2012] [Accepted: 01/06/2013] [Indexed: 11/22/2022] Open
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