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Zhou B, Wang J, Yang X, Henry S, Lin JY, Torres MA, Liu T. Ultrasound Histogram Assessment of Acute Breast Toxicity After Breast Cancer Radiation Therapy: A Prospective Longitudinal Study. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:309-317. [PMID: 36441032 DOI: 10.1016/j.ultrasmedbio.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/19/2022] [Accepted: 09/04/2022] [Indexed: 06/16/2023]
Abstract
Accurate assessment of radiation-induced breast toxicity is crucial for the management of breast radiation therapy (RT). Standard assessment of breast toxicity based on clinicians' visual inspection and palpation has considerable inter- and intra-observer variability. To overcome this challenge, we present an ultrasound histogram method that objectively evaluates radiation-induced breast toxicity longitudinally. In a prospective study, patients enrolled (n = 67) received ultrasound scans at four time points: prior to RT, last day of RT, 3-4 wk post-RT and 9-12-wk post-RT. Ultrasound scans were acquired at five locations (tumor bed and 3, 6, 9 and 12 o'clock) on both breasts. Two hundred sixty-four ultrasound scans and 2640 B-mode images were analyzed. The histogram differences between irradiated and contralateral breasts were calculated to evaluate radiation-induced breast changes. On the basis of the B-mode images, the severity of breast toxicity was graded as absent, mild, moderate or severe. The performance of the histogram method was assessed with the receiver operating characteristic (ROC) curve. The areas under the ROC curve ranged from 0.78 to 0.9 (sensitivity: 0.88-0.96, specificity: 0.53-0.83) at the lower quadrant for differentiating absent/mild from moderate/severe toxicity at various time points. This study provides preliminary evidence that ultrasound histogram differences can serve as an imaging biomarker to longitudinally assess radiation-induced acute toxicity.
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Affiliation(s)
- Boran Zhou
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Jing Wang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Simone Henry
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Jolinta Y Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Mylin A Torres
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
| | - Tian Liu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA.
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Choi JI, Prabhu K, Hartsell WF, DeWees T, Sinesi C, Vargas C, Benda RK, Cahlon O, Chang AL. Outcomes and toxicities after proton partial breast radiotherapy for early stage, hormone receptor positive breast cancer: 3-Year results of a phase II multi-center trial. Clin Transl Radiat Oncol 2022; 37:71-77. [PMID: 36093343 PMCID: PMC9450061 DOI: 10.1016/j.ctro.2022.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
Proton therapy is a good treatment option for partial breast irradiation. Proton PBI results in excellent local tumor control and OAR sparing. Cosmesis and quality of life with PBT are comparable to other PBI modalities.
Purpose Proton therapy (PT) for partial breast irradiation (PBI) in early-stage breast cancer can decrease morbidity versus photon PBI with superior organs-at-risk sparing. We report 3-year outcomes of the first prospective, multicenter, phase II trial of proton PBI. Methods and Materials This Proton Collaborative Group phase II trial (PCG BRE007-12) recruited women ≥ 50 years with node-negative, estrogen receptor (ER)-positive, ≤3cm, invasive ductal carcinoma (IDC) or ductal carcinoma in situ undergoing breast conserving surgery followed by proton PBI (40 Gy(RBE), 10 daily fractions). Primary endpoint was freedom from ipsilateral breast cancer recurrence. Adverse events were prospectively graded using CTCAEv4.0. Breast Cancer Treatment Outcome Scale (BCTOS) assessed patient-reported quality of life (PRQOL). Results Thirty-eight evaluable patients enrolled between 2/2013–11/2016. Median age was 67 years (range 50–79); 55 % had left-sided disease, and median tumor size was 0.9 cm. Treatment was delivered in ≥ 2 fields predominantly with uniform scanning PT (n = 37). At 35-month median follow-up (12–62), all patients were alive, and none had local, regional or distant disease progression. One patient developed an ER-negative contralateral IDC. Seven grade 2 adverse events occurred; no radiotherapy-related grade ≥ 3 toxicities occurred. Changes in BCTOS subdomain mean scores were maximum 0.36, indicating no meaningful change in PRQOL. Median heart volume receiving 5 Gy (V5Gy), lung V20Gy, and lung V10Gy were 0 %, 0 % and 0.19 %, respectively. Conclusion At 3 years, proton PBI provided 100 % cancer control for early-stage, ER-positive breast cancer. Toxicities are minimal, and PRQOL remains acceptable with continued follow-up. These findings support PT as a safe and effective PBI delivery option.
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Affiliation(s)
- J. Isabelle Choi
- New York Proton Center, 225 East 126th Street, New York, NY 10035, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
- Corresponding author at: 225 East 126 Street, New York, NY 10035, USA.
| | - Kiran Prabhu
- Integris Health, 5911 W. Memorial, Oklahoma City, OK 73142, USA
| | - William F. Hartsell
- Northwestern Medicine, Chicago Proton Center, 4455 Weaver Pkwy, Warrenville, IL 60555, USA
| | - Todd DeWees
- Department of Quantitative Health Sciences, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA
| | - Christopher Sinesi
- Hampton University Proton Therapy Institute, 40 Enterprise Pkwy, Hampton, VA 23666, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5777 E Mayo Blvd, Scottsdale, AZ 85054, USA
| | - Rashmi K. Benda
- Lynn Cancer Institute, Boca Raton Regional Hospital, 701 NW 13 St, Boca Raton, FL 33486, USA
| | - Oren Cahlon
- New York Proton Center, 225 East 126th Street, New York, NY 10035, USA
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA
| | - Andrew L. Chang
- California Protons Cancer Therapy Center, 9730 Summers Ridge Rd, San Diego, CA 92121, USA
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Choi JI, Fox J, Bakst R, Hasan S, Press RH, Chhabra AM, Yeh B, Simone CB, Cahlon O. Proton Therapy for Partial Breast Irradiation: Rationale and Considerations. J Pers Med 2021; 11:289. [PMID: 33918662 PMCID: PMC8069416 DOI: 10.3390/jpm11040289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
In an era of continued advancements in personalized medicine for the treatment of breast cancer, select patients with early stage breast cancer may be uniquely poised to benefit from partial breast irradiation (PBI) delivered with proton therapy. PBI presents an opportunity to improve quality of life during treatment with a significantly shorter treatment duration. By targeting less non-target breast tissue, excess radiation exposure and resulting toxicities are also reduced. Proton therapy represents a precision radiotherapy technology that builds on these advantages by further limiting the normal tissue exposure to unnecessary radiation dose not only to uninvolved breast tissue but also the underlying thoracic organs including the heart and lungs. Herein, we present a concise review of the rationale for the use of proton therapy for PBI, evidence available to date, and practical considerations in the implementation and use of proton therapy for this indication.
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Affiliation(s)
- J. Isabelle Choi
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Jana Fox
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Montefiore Medical Center, Department of Radiation Oncology, New York, NY 10467, USA
| | - Richard Bakst
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shaakir Hasan
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Montefiore Medical Center, Department of Radiation Oncology, New York, NY 10467, USA
| | - Robert H. Press
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Arpit M. Chhabra
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Brian Yeh
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Charles B. Simone
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Oren Cahlon
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
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Strnad V, Yashar C. Breast brachytherapy. Brachytherapy 2020; 20:976-983. [PMID: 33353845 DOI: 10.1016/j.brachy.2020.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 11/12/2022]
Abstract
Accelerated partial breast irradiation with brachytherapy is a treatment method with a very low risk profile. In fact, accelerated partial breast irradiation brachytherapy has been proven in randomized trials to have fewer late side effects than whole-breast irradiation. Notably, Grade 3 late side effects are extremely rare, and excellent to good cosmetic results are observed in well over 90% of patients. In this article, published side effects of breast brachytherapy are reviewed and appropriate management discussed.
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Affiliation(s)
- Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Germany.
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
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Galalae R, Hannoun-Lévi JM. Accelerated partial breast irradiation by brachytherapy: present evidence and future developments. Jpn J Clin Oncol 2020; 50:743-752. [PMID: 32444872 DOI: 10.1093/jjco/hyaa064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/16/2020] [Accepted: 04/20/2020] [Indexed: 11/14/2022] Open
Abstract
Accelerated partial breast irradiation (APBI) delivers a short course of adjuvant RT after breast conserving surgery to only a limited part of the breast where the tumor was located. This procedure requires expertise, good communication, and close collaboration between specialized surgeons and attending radiation oncologists with adequate intraoperative tumor bed clip marking. However, APBI offers several intrinsic benefits when compared with whole breast irradiation (WBIR) including reduced treatment time (1 versus 4-6 weeks) and better sparing of surrounding healthy tissues. The present publication reviews the APBI level 1-evidence provided with various radiation techniques supplemented by long-term experience obtained from large multi-institutional phase II studies. Additionally, it offers an outlook on recent research with ultra-short or single-fraction APBI courses and new brachytherapy sources. Mature data from three randomized controlled trials (RCTs) clearly prove the noninferiority of APBI with 'only two techniques-1/MIBT (multicatheter interstitial brachytherapy) (two trials) and 2/intensity modulated radiotherapy (one trial)'-in terms of equivalent local control/overall survival to the previous standard 'conventionally fractionated WBIR'. However, MIBT-APBI techniques were superior in both toxicity and patient-reported outcomes (PROs) versus WBIR at long-term follow-up. Currently, in RCT-setting, alternative APBI techniques such as intraoperative electrons, 50-kV x-rays and three-dimensional conformal external beam radiotherapy (3D-CRT) failed to demonstrate noninferiority to conventionally fractionated WBIR. However, 3D-CRT-APBI compared noninferior to hypo-fractionated WBIR in preventing ipsilateral breast tumor recurrence (randomized RAPID-trial) but was associated with a higher rate of late radiation toxicity. Ultimately, MIBT remains the only APBI modality with noninferior survival/superior toxicity/PROs at 10-years and therefore should be prioritized over alternative methods in patients with breast cancer considered at low-risk for local recurrence according to recent international guidelines.
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Affiliation(s)
- Razvan Galalae
- MedAustron, Center for Ion Therapy and Research, Wiener Neustadt, Austria
- Department of Radiation Oncology, Medical Faculty, Christian-Albrechts-University, Kiel, Germany
| | - Jean-Michel Hannoun-Lévi
- Department of Radiation Oncology, Centre Antoine Lacassagne, University of Cote d'Azur, Nice, France
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Kennedy WR, Thomas MA, Stanley JA, Luo J, Ochoa LL, Clifton KK, Cyr AE, Margenthaler JA, DeWees TA, Price A, Kashani R, Green O, Zoberi I. Single-Institution Phase 1/2 Prospective Clinical Trial of Single-Fraction, High-Gradient Adjuvant Partial-Breast Irradiation for Hormone Sensitive Stage 0-I Breast Cancer. Int J Radiat Oncol Biol Phys 2020; 107:344-352. [PMID: 32084524 DOI: 10.1016/j.ijrobp.2020.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/05/2020] [Accepted: 02/07/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE We sought to evaluate the feasibility and tolerability of a novel accelerated partial breast irradiation regimen delivered in a single fraction postoperatively. METHODS AND MATERIALS We enrolled 50 patients with low-risk, hormone-sensitive breast cancer from 2015 to 2018 on a prospective phase 1/2 trial to receive single-fraction, high-gradient partial-breast irradiation (SFHGPBI) 2 to 8 weeks after lumpectomy for node-negative, invasive, or in situ breast cancer. The high gradient was achieved by prescribing 20 Gy to the surgical bed and 5 Gy to the breast tissue within 1 cm of the surgical bed simultaneously in 1 fraction using external beam. RESULTS The median age was 65 (range, 52-84). Ten patients (20%) had small-volume ductal carcinoma in situ while the remainder had stage I disease. At a median follow-up of 25 months, we evaluated toxicity, patient- and physician-reported cosmesis, patient-reported quality of life (QOL), and initial tumor control. There was no Common Terminology Criteria for Adverse Events v4.0 grade 3+ toxicity. Only 34% of patients experienced grade 1 erythema. Good-to-excellent pretreatment cosmesis was present in 100% and 98% per physicians and patients, respectively, and did not change post-SFHGPBI. Quantitative cosmesis by percentage of breast retraction assessment significantly improved over time during the post-SFHGPBI period per mixed repeated measures modeling (P = .0026). QOL per European Organization for Research and Treatment of Cancer QOL Questionnaires C30 and BR-23 did not decline other than temporarily in the systemic therapy effects and hair loss domains, both of which returned to pretreatment values. There was 1 noninvasive in-breast recurrence in a separate untreated quadrant 18 months post-SFHGPBI and 1 isolated axillary recurrence 30 months post-SFHGPBI, both salvaged successfully. There were no distant recurrences or cancer-related deaths observed. CONCLUSIONS Accelerated partial-breast irradiation delivered in a single fraction postoperatively using external beam techniques is a novel, feasible, well-tolerated regimen. SFHGPBI does not adversely affect cosmesis or QOL as reported by both physicians and patients. Initial tumor control rates are excellent, with longer follow-up required to confirm efficacy.
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Affiliation(s)
- William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jennifer A Stanley
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Jingqin Luo
- Department of Surgery, Siteman Cancer Center Biostatistics Core, Washington University School of Medicine, St Louis, Missouri
| | - Laura L Ochoa
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Katherine K Clifton
- Division of Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Amy E Cyr
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Julie A Margenthaler
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Todd A DeWees
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - Alex Price
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Olga Green
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri
| | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri.
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Maranzano E, Arcidiacono F, Italiani M, Anselmo P, Casale M, Terenzi S, Di Marzo A, Fabiani S, Draghini L, Trippa F. Accelerated partial-breast irradiation with high-dose-rate brachytherapy: Mature results of a Phase II trial. Brachytherapy 2019; 18:627-634. [PMID: 31285131 DOI: 10.1016/j.brachy.2019.06.002] [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: 03/25/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to report mature clinical and cosmetic results of accelerated partial-breast irradiation with interstitial multicatheter high-dose-rate brachytherapy (HDR-BRT) in patients with early breast cancer. METHODS AND MATERIALS 133 patients were recruited in a Phase II trial of exclusive HDR-BRT. Inclusion criteria were age ≥40 years, PS 0-2, unifocal invasive ductal cancer, intraductal cancer component <25%, negative axillary nodes, and tumor size ≤2.5 cm. Treatment schedule was 4 Gy twice a day up to a total dose of 32 Gy in eight fractions. RESULTS Median age was 67 years (range, 42-85). There were 7 (5%) pT1a, 48 (36%) pT1b, 72 (54%) pT1c, and 6 (5%) pT2. Estrogen and progesterone receptors were positive in 119 (89%) and 93 (70%) patients, respectively. The median followup was 110 months (range, 12-163). After HDR-BRT, there were 3 (2%) in-field breast recurrences and 1 (1%) out-field breast recurrence. 5 (4%) patients developed contralateral breast cancer, another one (1%) isolated regional relapse in axillary node and 3 (2%) distant progression of disease. 19 (14%) patients reported a second primary cancer. 5-, 10-, and 13-year overall survival and cancer-specific survival were 95% and 100%, 84.5% and 100%, and 81.4% and 100%, respectively. Cosmetic outcome was excellent in 80% of cases. Late toxicity was significantly related to the skin administered doses (≤55% vs. > 55% of the prescribed dose, p < 0.05). CONCLUSIONS Accelerated partial-breast irradiation delivered with HDR-BRT in selected patients with breast cancer was associated to high local control and survival with excellent cosmetic outcomes overall when skin dose was ≤55%.
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Affiliation(s)
| | | | - Marco Italiani
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | - Sara Terenzi
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | | | - Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
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Analysis of Outcomes in Patients With BRCA1/2 Breast Cancer Mutations Treated With Accelerated Partial Breast Irradiation (APBI). Am J Clin Oncol 2019; 42:446-453. [PMID: 30973374 DOI: 10.1097/coc.0000000000000542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze outcomes and survival for BRCA1/2+ patients treated with accelerated partial breast irradiation (APBI). MATERIALS AND METHODS Retrospective review was performed on 341 women treated with intracavitary APBI (Mammosite or Contura) postlumpectomy from 2002 to 2013. Patients were treated to 34.0 Gy in 10 BID fractions. Of 341 treated patients, 11 (3.2%) had BRCA1/2 mutations, 5 of whom had an oophorectomy. Ipsilateral breast tumor recurrence (IBTR), contralateral breast tumor recurrence (CBTR), and breast tumor recurrence progression-free survival were analyzed using SPSS-17. BRCA1/2+ patient outcomes were compared with a general population treated cohort. RESULTS Median age at diagnosis was 66 years, for BRCA1/2+ women it was 61 years. Median follow-up was 8.4 years and for BRCA1/2+ patients it was 8.8 years. IBTR for the entire cohort was 3.5%, while CBTR was 1.2%. Both IBTR and CBTR for the BRCA1/2+ group were 0%. The 5-year IBTR-free survival was 97.3% (95% confidence interval [CI]=94.9%, 98.6%), and the CBTR-free survival was 99.4% (95% CI=97.6%, 99.9%). The 5-year breast tumor recurrence-free survival was 96.7% (95% CI=94.1%, 98.2%). As no patients with BRCA1/2+ mutation died of metastatic breast cancer or recurrence during follow-up and review, overall survival could not be evaluated. CONCLUSIONS To date, BRCA1/2+ patients treated with APBI sustained no recurrences, or second cancers. Most patients had an ER+ status and underwent oophorectomy, which may be a protective mechanism for recurrence. This is the first outcomes report in the literature of BRCA1/2 mutations treated with APBI technique.
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Advantages of intraoperative implant for interstitial brachytherapy for accelerated partial breast irradiation either frail patients with early-stage disease or in locally recurrent breast cancer. J Contemp Brachytherapy 2018; 10:97-104. [PMID: 29789758 PMCID: PMC5961524 DOI: 10.5114/jcb.2018.75594] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/13/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To describe the intraoperative multicatheter implantation technique for accelerated partial breast irradiation (APBI) delivered with high-dose-rate brachytherapy (HDR-BT). Secondarily, to evaluate outcomes and toxicity in a series of 83 patients treated with this technique at our institution. Material and methods Retrospective analysis of a series of patients treated with HDR-BT APBI after intraoperative multicatheter interstitial implant between November 2006 and June 2017 at our institution. We assessed cosmesis, toxicity, overall survival (OS), and disease-free survival (DFS). Results Eighty-three patients were included: 59 patients (71.1%) with primary early-stage breast cancer and 24 (28.9%) with locally recurrent breast cancer. Tumorectomy was performed in all cases, with intraoperative tumor margin assessment and sentinel node biopsy. Median age was 82 years (range, 44-92). The total prescribed dose was 32 Gy (8 treatment fractions) in 60 patients (72.3%), and 34 Gy (10 fractions) in 23 patients (27.7%). Median follow-up was 40 months (range, 1-136 months). Three-year OS and DFS in the recurrent and primary cancer groups were 87% vs. 89%, and 96 % vs. 97.8%, respectively. Five patients died from non-cancer related causes. No local relapses were observed. Rates of acute and late toxicity were low in both groups. The cosmesis was good or excellent in most of patients treated for primary disease; in patients who underwent salvage brachytherapy for local recurrence, cosmesis was good in 49 patients and fair in 6. Conclusions This technique, although time-consuming, achieves good local disease control with a satisfactory toxicity profile in both early-stage and local recurrent breast cancer patients. It may be especially suitable for frail patients.
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Accelerated partial breast irradiation in a single 18 Gy fraction with high-dose-rate brachytherapy: preliminary results. J Contemp Brachytherapy 2018; 10:58-63. [PMID: 29619057 PMCID: PMC5881592 DOI: 10.5114/jcb.2018.73994] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/22/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the feasibility of acute and chronic toxicity in patients suitable for accelerated partial breast irradiation (APBI) in a single 18 Gy fraction with multicatheter high-dose-rate (HDR) brachytherapy, as well as cosmetic and oncological outcomes. Material and methods Between September 2014 and March 2016, twenty consecutive patients with low-risk invasive and ductal carcinoma in situ were treated with interstitial multicatheter HDR brachytherapy in a single 18 Gy fraction. Results Median age was 63.5 years (range, 51-79). Acute toxicity was observed in seven patients, while the pain during following days and hematoma were seen in four patients. With a median follow-up of 24 months, late toxicity was found in one patient with fat necrosis g2 and fibrosis g2 in another patient. The overall survival (OS) and locoregional control (LC) was 100%. Disease-free survival (DFS) and distant control was 95%. Good to excellent cosmetic outcomes were noted in 80% of patients and fair in 4 patients (20%). Conclusions This is the first report in the medical literature that focuses on feasibility and acute and chronic toxicity, with a median follow-up of 24 months (range, 20-40). The protocol is viable and convenient. However, a longer follow-up is needed to know chronic toxicity and oncologic outcomes.
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Seven-Year Outcomes Following Accelerated Partial Breast Irradiation Stratified by ASTRO Consensus Groupings. Am J Clin Oncol 2017; 40:483-489. [PMID: 25844825 DOI: 10.1097/coc.0000000000000190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Limited long-term data exist regarding outcomes for patients treated with accelerated partial breast irradiation (APBI), particularly, when stratified by American Society for Radiation Oncology (ASTRO) Consensus Statement (CS) risk groups. The purpose of this analysis is to present 5- and 7-year outcomes following APBI based on CS groupings. MATERIALS AND METHODS A total of 690 patients with early-stage breast cancer underwent APBI from 1993 to 2012, receiving interstitial brachytherapy (n=195), balloon-based brachytherapy (n=290), or 3-dimensional conformal radiotherapy (n=205) at a single institution. Patients were stratified into suitable, cautionary, and unsuitable groups with 5-year outcomes analyzed. Seven-year outcomes were analyzed for a subset with follow-up of ≥2 years (n=625). RESULTS Median follow-up was 6.7 years (range, 0.1 to 20.1 y). Patients assigned to cautionary and unsuitable categories were more likely to have high-grade tumors (21% to 25% vs. 9%, P=0.001), receive chemotherapy (15% to 38% vs. 6%, P<0.001), and have close/positive margins (9% to 11% vs. 0%, P<0.001). There was no difference in ipsilateral breast tumor recurrence at 5 or 7 years: 2.2%, 1.2%, 2.8% at 5 years (P=0.57), and 2.2%, 1.9%, 4.6% at 7 years (P=0.58) in the suitable, cautionary, and unsuitable groups, respectively. As compared with the suitable group, increased rates of distant metastases were noted for the unsuitable and cautionary groups at 5 years (P=0.04). CONCLUSIONS No differences in rates of ipsilateral breast tumor recurrence were seen at 5 or 7 years when stratified by ASTRO CS groupings. Modest increases in distant recurrence were noted in the cautionary and unsuitable groups. These findings suggest that the ASTRO CS groupings stratify more for systemic recurrence and may not appropriately select patients for whole versus partial breast irradiation.
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Upreti RR, Budrukkar A, Upreti U, Misra S, Wadasadawala T, Kohle S, Deshpande DD. Change of target volume and its dosimetric impact during the course of accelerated partial breast irradiation using intraoperative multicatheter interstitial brachytherapy after open cavity surgery. Brachytherapy 2017; 16:1028-1034. [DOI: 10.1016/j.brachy.2017.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/21/2017] [Accepted: 05/05/2017] [Indexed: 11/29/2022]
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Yoden E, Nose T, Otani Y, Asahi S, Tsukiyama I, Dokiya T, Saeki T, Fukuda I, Sekine H, Shikama N, Kumazaki Y, Takahashi T, Yoshida K, Kotsuma T, Masuda N, Nakashima K, Matsumura T, Nakagawa S, Tachiiri S, Moriguchi Y, Itami J, Oguchi M. Uncertainty of cosmetic evaluation after accelerated partial breast irradiation: interim analysis of a Japanese prospective multi-institutional feasibility study. Jpn J Radiol 2017; 35:381-388. [PMID: 28474300 DOI: 10.1007/s11604-017-0640-0] [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] [Received: 11/18/2016] [Accepted: 04/10/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE We conducted a multi-institutional prospective study on accelerated partial breast irradiation (APBI) using interstitial brachytherapy. The clinical results over a minimum follow-up period of 30 months are presented here. MATERIALS AND METHODS Forty-six patients with breast cancer were treated with breast-conserving surgery and postoperative APBI. After confirmation of negative surgical margins and negative lymph nodes, a high-dose-rate brachytherapy protocol of 36 Gy/6 fractions was carried out. All clinical data were prospectively collected using the Common Terminology Criteria for Adverse Events ver. 3.0. RESULTS No recurrence was observed. Cumulative rates of grade 2 or higher late sequelae were 25% for fibrosis, 2% for fractures, 9% for pain, and 9% for soft tissue necrosis. Rates of excellent or good cosmetic results as assessed by the physician and patient were 93 and 89% at the 12-month follow-up and 76 and 74% at the 30-month follow-up, respectively. Large volumes of resected tissue in small breasts were associated with fibrosis of grade 2 or higher. CONCLUSION APBI in Japanese women provides satisfactory clinical results except for cosmetic outcomes. There is some difficulty with the assessment of fibrosis and cosmetic outcomes, especially in patients with small breasts. CLINICAL TRIAL REGISTRATION NUMBER UMIN000001677.
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Affiliation(s)
- Eisaku Yoden
- Department of Radiation Oncology, Kawasaki Medical School, 577 Matsushima, Kurashiki, Okayama, 701-0192, Japan.
| | - Takayuki Nose
- Department of Radiation Oncology, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | - Yuki Otani
- Department of Radiology, Kaizuka City Hospital, Kaizuka, Japan
| | - Shuuji Asahi
- Department of Surgery, Aidu Chuo Hospital, Aizuwakamatsu, Japan
| | - Iwao Tsukiyama
- Department of Radiology, Aidu Chuo Hospital, Aizuwakamatsu, Japan
| | | | - Toshiaki Saeki
- Department of Breast Oncology, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Ichirou Fukuda
- Department of Radiology, National Disaster Medical Center, Tokyo, Japan
| | - Hiroshi Sekine
- Department of Radiology, The Jikei University Daisan Hospital, Tokyo, Japan
| | - Naoto Shikama
- Department of Radiation Oncology, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Yu Kumazaki
- Department of Radiation Oncology, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Takao Takahashi
- Department of Breast Oncology, International Medical Center, Saitama Medical University, Hidaka, Japan
| | - Ken Yoshida
- Department of Radiation Oncology, Osaka Medical Collage, Takatsuki, Japan
| | - Tadayuki Kotsuma
- Department of Radiation Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Norikazu Masuda
- Department of Surgery, Breast Oncology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | | | - Taisei Matsumura
- Department of Radiology, National Hospital Organization National Kyushu Medical Center, Fukuoka, Japan
| | - Shino Nakagawa
- Department of Surgery, National Hospital Organization National Kyushu Medical Center, Fukuoka, Japan
| | - Seiji Tachiiri
- Department of Radiation Oncology, Kyoto City Hospital, Kyoto, Japan
| | | | - Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Masahiko Oguchi
- Department of Radiation Oncology, Cancer Institute Hospital, The Japanese Foundation for Cancer Research, Tokyo, Japan
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High-dose-rate interstitial brachytherapy for accelerated partial breast irradiation - trial results of Azerbaijan National Center of Oncology. J Contemp Brachytherapy 2017; 9:106-111. [PMID: 28533797 PMCID: PMC5437082 DOI: 10.5114/jcb.2017.67145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/11/2017] [Indexed: 01/30/2023] Open
Abstract
Purpose To describe early results of two cohorts of patients with low and intermediate risk of early breast cancer treated with accelerated partial breast irradiation (APBI) using different schedules of multicatheter brachytherapy. Material and methods Patients with early stage breast cancer after breast conserving surgery were enrolled for a prospective analysis. The APBI, using multicatheter brachytherapy, was delivered either eight times 4 Gy in five days with a planned total dose of 32 Gy, or seven times 5 Gy in four days with a planned total dose of 35 Gy. Primary endpoints were side effects. Results Forty-eight patients were enrolled between 2012 and 2014. Patients characteristics were as follow: median age of patients was 55 years, early breast cancer was defined according GEC-ESTRO recommendations. With a median follow-up period of 37 months, no significant differences regarding late side effects and cosmesis between two cohorts of patients were documented. In total, cosmesis was excellent in 13/48 (27.1%) patients, good in 34/48 (70.8%) patients, and moderate in 1/48 patient (2.1%). Conclusions Accelerated partial breast irradiation using multicatheter brachytherapy with 32 Gy/8 fractions and 35 Gy/7 fractions for early breast cancer seems to be similar in terms of late side effects. According to our findings, APBI was also feasible for intermediate-risk of early breast cancer patients.
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Interobserver variations of target volume delineation and its impact on irradiated volume in accelerated partial breast irradiation with intraoperative interstitial breast implant. J Contemp Brachytherapy 2017; 9:139-145. [PMID: 28533802 PMCID: PMC5437076 DOI: 10.5114/jcb.2017.66027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/09/2017] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the interobserver variations in delineation of lumpectomy cavity (LC) and clinical target volume (CTV), and its impact on irradiated volume in accelerated partial breast irradiation using intraoperative multicatheter brachytherapy. Material and methods Delineation of LC and CTV was done by five radiation oncologists on planning computed tomography (CT) scans of 20 patients with intraoperative interstitial breast implant. Cavity visualization index (CVI), four-point index ranging from (0 = poor) to (3 = excellent) was created and assigned by observers for each patient. In total, 200 contours for all observers and 100 treatment plans were evaluated. Spatial concordance (conformity index, CIcommon, and CIgen), average shift in the center of mass (COM), and ratio of maximum and minimum volumes (Vmax/Vmin) of LC and CTV were quantified among all observers and statistically analyzed. Variation in active dwell positions (0.5 cm step) for each catheter, total reference air kerma (TRAK), volume enclosed by prescription isodose (V100%) among observers and its spatial concordance were analyzed. Results The mean ± SD CIcommon of LC and CTV was 0.54 ± 0.09, and 0.58 ± 0.08, respectively. Conformity index tends to increase, shift in COM and Vmax/Vmin decrease significantly (p < 0.05), as CVI increased. Out of total 309 catheters, 29.8% catheters had no change, 29.8% and 17.5% catheters had variations of 1 and 2 dwell positions (0.5 cm and 1 cm), respectively. 9.3% catheters shown variations ≥ 10 dwell positions (5 cm). The mean ± SD CIcommon of V100% was 0.75 ± 0.11. The mean observed Vmax/Vmin of prescription isodose and TRAK was 1.18 (range, 1.03 to 1.56) and 1.11 (range, 1.03 to 1.35), respectively. Conclusions Interobserver variability in delineation of target volume was found to be significantly related to CVI. Smaller variability was observed with excellent visualization of LC. Interobserver variations showed dosimetric impact on irradiation of breast tissue volume with prescription dose.
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Soror T, Kovács G, Seibold N, Melchert C, Baumann K, Wenzel E, Stojanovic-Rundic S. Cosmetic changes following surgery and accelerated partial breast irradiation using HDR interstitial brachytherapy : Evaluation by a multidisciplinary/multigender committee. Strahlenther Onkol 2017; 193:367-374. [PMID: 28044202 DOI: 10.1007/s00066-016-1093-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/29/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients with early-stage breast cancer can benefit from adjuvant accelerated partial breast irradiation (APBI) following breast-conserving surgery (BCS). This work reports on cosmetic results following APBI using multicatheter high-dose-rate interstitial brachytherapy (HDR-IBT). PATIENTS AND METHODS Between 2006 and 2014, 114 patients received adjuvant APBI using multicatheter HDR-IBT. For each patient, two photographs were analyzed: the first was taken after surgery (baseline image) and the second at the last follow-up visit. Cosmesis was assessed by a multigender multidisciplinary team using the Harvard Breast Cosmesis Scale. Dose-volume histogram (DVH) parameters and the observed cosmetic results were investigated for potential correlations. RESULTS The median follow-up period was 3.5 years (range 0.6-8.5 years). The final cosmetic scores were 30% excellent, 52% good, 14.5% fair, and 3.5% poor. Comparing the baseline and follow-up photographs, 59.6% of patients had the same score, 36% had a better final score, and 4.4% had a worse final score. Only lower target dose nonuniformity ratio (DNR) values (0.3 vs. 0.26; p = 0.009) were significantly associated with improved cosmetic outcome vs. same/worse cosmesis. CONCLUSION APBI using multicatheter HDR-IBT adjuvant to BCS results in favorable final cosmesis. Deterioration in breast cosmesis occurs in less than 5% of patients. The final breast cosmetic outcome in patients treated with BCS and APBI using multicatheter HDR-IBT is influenced primarily by the cosmetic result of the surgery. A lower DNR value is significantly associated with a better cosmetic outcome.
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Affiliation(s)
- Tamer Soror
- Interdisciplinary Brachytherapy Unit, University of Luebeck/UKSH-CL, Ratzeburger Allee 160, 23538, Luebeck, Germany.
- National Cancer Institute (NCI), Radiation Oncology Department, Cairo University, Cairo, Egypt.
| | - György Kovács
- Interdisciplinary Brachytherapy Unit, University of Luebeck/UKSH-CL, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Nina Seibold
- Interdisciplinary Brachytherapy Unit, University of Luebeck/UKSH-CL, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Corinna Melchert
- Interdisciplinary Brachytherapy Unit, University of Luebeck/UKSH-CL, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - Kristin Baumann
- Clinic for Gynecology and Obstetrics, University of Luebeck/UKSH-CL, Luebeck, Germany
| | - Eike Wenzel
- Clinic for Plastic Surgery, University of Luebeck/UKSH-CL, Luebeck, Germany
| | - Suzana Stojanovic-Rundic
- Institute for Oncology and Radiology (IORS), Medical School University of Belgrade, Belgrade, Serbia
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Shaitelman SF, Amendola B, Khan A, Beriwal S, Rabinovitch R, Demanes DJ, Kim LH, Cuttino L. American Brachytherapy Society Task Group Report: Long-term control and toxicity with brachytherapy for localized breast cancer. Brachytherapy 2017; 16:13-21. [DOI: 10.1016/j.brachy.2016.04.392] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 01/22/2023]
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18
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Morton D, Batchelar D, Hilts M, Berrang T, Crook J. Incorporating three-dimensional ultrasound into permanent breast seed implant brachytherapy treatment planning. Brachytherapy 2017; 16:167-173. [DOI: 10.1016/j.brachy.2016.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/12/2016] [Accepted: 09/13/2016] [Indexed: 11/25/2022]
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Sanford NN, Taghian AG. Accelerated Partial Breast Irradiation. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Tann AW, Hatch SS, Joyner MM, Wiederhold LR, Swanson TA. Accelerated partial breast irradiation: Past, present, and future. World J Clin Oncol 2016; 7:370-379. [PMID: 27777879 PMCID: PMC5056328 DOI: 10.5306/wjco.v7.i5.370] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/01/2016] [Accepted: 08/18/2016] [Indexed: 02/06/2023] Open
Abstract
Accelerated partial breast irradiation (APBI) focuses higher doses of radiation during a shorter interval to the lumpectomy cavity, in the setting of breast conserving therapy for early stage breast cancer. The utilization of APBI has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI more accessible in the community. Results of early APBI trials served as the basis for the current consensus guidelines, and multiple prospective randomized clinical trials are currently ongoing. The pending long term results of these trials will help us identify optimal candidates that can benefit from ABPI. Here we provide an overview of the clinical and cosmetic outcomes of various APBI techniques and review the current guidelines for selecting suitable breast cancer patients. We also discuss the impact of APBI on the economics of cancer care and patient reported quality of life.
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Stish BJ, Pafundi DH, Hieken TJ, Whitaker TJ, Furutani KM, Jakub JW, Boughey JC, Degnim AC, McLemore LB, Mou B, Mutter RW, Park SS. Feasibility and full-course dosimetry of an intraoperatively placed multichannel brachytherapy catheter for accelerated partial breast irradiation. Brachytherapy 2016; 15:796-803. [PMID: 27614660 DOI: 10.1016/j.brachy.2016.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/03/2016] [Accepted: 08/04/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Determine feasibility and resultant dosimetry of an intraoperatively placed multichannel intracavitary brachytherapy catheter for accelerated partial breast irradiation (APBI). METHODS Patients with breast cancer underwent intraoperative brachytherapy catheter placement based on frozen section analysis with immediate postoperative APBI. The planning target volume evaluation (PTVEval) and organs at risk were contoured on daily pretreatment CT scans for each patient, and the original treatment plan was applied to assess full-course dosimetry. RESULTS Of the first 21 patients consented for intraoperative catheter placement, 20 (95%) were able to proceed with treatment as planned. The mean volume of PTVEval receiving 90% of prescription dose (V90%) and mean percentage of prescription dose to 90% of the PTVEval (D90%) on initial planning were 96.7 (±1.1%) and 100.2 (±2.1%), respectively. Full-course dose coverage remained excellent with a mean PTVEval V90% and D90% of 95.0 (±4.4%) and 100.2 (±9.6%), respectively. Mean full-course maximum dose constraints for chest wall and skin were met by 70% and 95% of patients, respectively. Air accumulation >1 cc during treatment increased the risk of a daily fraction with PTVEval coverage below goal (odds ratio, 9.8; p = 0.05), whereas those with applicators <0.5 cm from the chest wall at planning were at risk of exceeding that organ's maximum dose constraint on a daily fraction (odds ratio, 45; p = 0.02). CONCLUSIONS Intraoperative catheter placement and early initiation of APBI based on frozen section pathology is feasible, yields acceptable dosimetry, and is an option for completing breast conserving therapy in less than 10 days.
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Affiliation(s)
- Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN
| | - Luke B McLemore
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Benjamin Mou
- Department of Radiation Oncology, British Columbia Cancer Agency, Centre for the Southern Interior, Kelowna, BC, Canada
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN.
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Long-Term Cancer Outcomes From Study NRG Oncology/RTOG 9517: A Phase 2 Study of Accelerated Partial Breast Irradiation With Multicatheter Brachytherapy After Lumpectomy for Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 95:1460-1465. [PMID: 27479725 DOI: 10.1016/j.ijrobp.2016.03.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/10/2016] [Accepted: 03/25/2016] [Indexed: 11/21/2022]
Abstract
PURPOSE To examine 10-year rates of local, regional, and distant recurrences, patterns of recurrence, and survival rates for breast cancer patients enrolled on Study NRG Oncology/Radiation Therapy Oncology Group 9517, a multi-institutional prospective trial that studied one of the earliest methods of accelerated partial breast irradiation (APBI), multicatheter brachytherapy (MCT). METHODS AND MATERIALS Eligibility included stage I/II unifocal breast cancer <3 cm in size after lumpectomy with negative surgical margins and 0 to 3 positive axillary nodes without extracapsular extension. The APBI dose delivered was 34 Gy in 10 twice-daily fractions over 5 days for high-dose-rate (HDR); and 45 Gy in 3.5 to 5 days for low-dose-rate (LDR) brachytherapy. The primary endpoint was HDR and LDR MCT reproducibility. This analysis focuses on long-term ipsilateral breast recurrence (IBR), contralateral breast cancer events (CBE), regional recurrence (RR), and distant metastases (DM), disease-free, and overall survival. RESULTS The median follow-up was 12.1 years. One hundred patients were accrued from 1997 to 2000; 98 were evaluable; 65 underwent HDR and 33 LDR MCT. Median age was 62 years; 88% had T1 tumors; 81% were pN0. Seventy-seven percent were estrogen receptor and/or progesterone receptor positive; 33% received adjuvant chemotherapy and 64% antiendocrine therapy. There have been 4 isolated IBRs and 1 IBR with RR, for 5.2% 10-year IBR without DM. There was 1 isolated RR, 1 with IBR, and 1 with a CBE, for 3.1% 10-year RR without DM. The 10-year CBE rate was 4.2%, with 5 total events. Eleven patients have developed DM, 8 have died of breast cancer, and 22 have died from other causes. The 10-year DFS and OS rates are 69.8% and 78.0%, respectively. CONCLUSION This multi-institutional, phase 2 trial studying MCT-APBI continues to report durable in-breast cancer control rates with long-term follow-up.
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Schutzer ME, Arthur DW, Anscher MS. Time-Driven Activity-Based Costing: A Comparative Cost Analysis of Whole-Breast Radiotherapy Versus Balloon-Based Brachytherapy in the Management of Early-Stage Breast Cancer. J Oncol Pract 2016; 12:e584-93. [PMID: 27006360 DOI: 10.1200/jop.2015.008441] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Value in health care is defined as outcomes achieved per dollar spent, and understanding cost is critical to delivering high-value care. Traditional costing methods reflect charges rather than fundamental costs to provide a service. The more rigorous method of time-driven activity-based costing was used to compare cost between whole-breast radiotherapy (WBRT) and accelerated partial-breast irradiation (APBI) using balloon-based brachytherapy. MATERIALS AND METHODS For WBRT (25 fractions with five-fraction boost) and APBI (10 fractions twice daily), process maps were created outlining each activity from consultation to post-treatment follow up. Through staff interviews, time estimates were obtained for each activity. The capacity cost rates (CCR), defined as cost per minute, were calculated for personnel, equipment, and physical space. Total cost was calculated by multiplying the time required of each resource by its CCR. This was then summed and combined with cost of consumable materials. RESULTS The total cost for WBRT was $5,333 and comprised 56% personnel costs and 44% space/equipment costs. For APBI, the total cost was $6,941 (30% higher than WBRT) and comprised 51% personnel costs, 6% space/equipment costs, and 43% consumable materials costs. The attending physician had the highest CCR of all personnel ($4.28/min), and APBI required 24% more attending time than WBRT. The most expensive activity for APBI was balloon placement and for WBRT was computed tomography simulation. CONCLUSION APBI cost more than WBRT when using the dose/fractionation schemes analyzed. Future research should use time-driven activity-based costing to better understand cost with the aim of reducing expenditure and defining bundled payments.
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Affiliation(s)
- Matthew E Schutzer
- Hunter Holmes McGuire Veterans Affairs Medical Center; Virginia Commonwealth University Hospital, Richmond, VA
| | - Douglas W Arthur
- Hunter Holmes McGuire Veterans Affairs Medical Center; Virginia Commonwealth University Hospital, Richmond, VA
| | - Mitchell S Anscher
- Hunter Holmes McGuire Veterans Affairs Medical Center; Virginia Commonwealth University Hospital, Richmond, VA
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Breast Brachytherapy: Interstitial Breast Brachytherapy. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Huo J, Giordano SH, Smith BD, Shaitelman SF, Smith GL. Contemporary Toxicity Profile of Breast Brachytherapy Versus External Beam Radiation After Lumpectomy for Breast Cancer. Int J Radiat Oncol Biol Phys 2015; 94:709-18. [PMID: 26972643 DOI: 10.1016/j.ijrobp.2015.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We compared toxicities after brachytherapy versus external beam radiation therapy (EBRT) in contemporary breast cancer patients. METHODS AND MATERIALS Using MarketScan healthcare claims, we identified 64,112 women treated from 2003 to 2012 with lumpectomy followed by radiation (brachytherapy vs EBRT). Brachytherapy was further classified by multichannel versus single-channel applicator approach. We identified the risks and predictors of 1-year infectious and noninfectious postoperative adverse events using logistic regression and temporal trends using Cochran-Armitage tests. We estimated the 5-year Kaplan-Meier cumulative incidence of radiation-associated adverse events. RESULTS A total of 4522 (7.1%) patients received brachytherapy (50.2% multichannel vs 48.7% single-channel applicator). The overall risk of infectious adverse events was higher after brachytherapy than after EBRT (odds ratio [OR] = 1.21; 95% confidence interval [CI] 1.09-1.34, P<.001). However, over time, the frequency of infectious adverse events after brachytherapy decreased, from 17.3% in 2003 to 11.6% in 2012, and was stable after EBRT at 9.7%. Beyond 2007, there were no longer excess infections with brachytherapy (P=.97). The overall risk of noninfectious adverse events was higher after brachytherapy than after EBRT (OR=2.27; 95% CI 2.09-2.47, P<.0001). Over time, the frequency of noninfectious adverse events detected increased: after multichannel brachytherapy, from 9.1% in 2004 to 18.9% in 2012 (Ptrend = .64); single-channel brachytherapy, from 12.8% to 29.8% (Ptrend<.001); and EBRT, from 6.1% to 10.3% (Ptrend<.0001). The risk was significantly higher with single-channel than with multichannel brachytherapy (hazard ratio = 1.32; 95% CI 1.03-1.69, P=.03). Of noninfectious adverse events, 70.9% were seroma. Seroma significantly increased breast pain risk (P<.0001). Patients with underlying diabetes, cardiovascular disease, and treatment with chemotherapy had increased infectious and noninfectious adverse events. The 5-year incidences of fat necrosis, breast pain, and rib fracture were slightly higher after brachytherapy than after EBRT (13.7% vs 8.1%, 19.4% vs 16.0%, and 1.6% vs 1.3%, respectively), but the risks were not significantly different for multichannel versus single-channel applicators. CONCLUSION Toxicities after breast brachytherapy were distinct from those after EBRT. Temporal toxicity trends may reflect changing technology and evolving practitioner experience with brachytherapy.
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Affiliation(s)
- Jinhai Huo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Kuo HC, Mehta KJ, Montgomery L, Shankar V, Yaparpalvi R, Hong L, Fox J, Tomé WA, Kalnicki S. Tumor bed variation during multi-lumen balloon-based accelerated partial breast irradiation: implication of surgical clips. Acta Oncol 2015; 55:526-9. [PMID: 26450856 DOI: 10.3109/0284186x.2015.1088168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Hsiang-Chi Kuo
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Keyur J. Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Leslie Montgomery
- Department of Surgery, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Viswanathan Shankar
- Department of Epidemiology and Population Health
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Ravindra Yaparpalvi
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Linda Hong
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Wolfgang A. Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
| | - Shalom Kalnicki
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA., and
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Trifiletti DM, Romano KD, Showalter SL, Reardon KA, Libby B, Showalter TN. Accelerated partial breast irradiation with brachytherapy: patient selection and technique considerations. BREAST CANCER-TARGETS AND THERAPY 2015; 7:211-21. [PMID: 26251627 PMCID: PMC4524268 DOI: 10.2147/bctt.s55860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Accelerated partial breast irradiation (APBI) through breast brachytherapy is a relatively recent development in breast radiotherapy that has gained international favor because of its reduction in treatment duration and normal tissue irradiation while maintaining favorable cancer-specific and cosmetic outcomes. Despite the fact that several large national trials have not reported final results yet, many providers are currently offering APBI to select patients and APBI is listed as a treatment option for selecting patients in the National Comprehensive Cancer Network guidelines. Multiple consensus guidelines exist in selecting patients for APBI, some with conflicting recommendations. In this review, the existing patient selection guidelines are reported, compared, and critiqued, grouping them in helpful subcategories. Unique patient and technical selection factors for APBI with brachytherapy are explored.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Shayna L Showalter
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kelli A Reardon
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Bruce Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Budrukkar A, Gurram L, Upreti RR, Munshi A, Jalali R, Badwe R, Parmar V, Shet T, Gupta S, Wadasadawala T, Sarin R. Clinical outcomes of prospectively treated 140 women with early stage breast cancer using accelerated partial breast irradiation with 3 dimensional computerized tomography based brachytherapy. Radiother Oncol 2015; 115:349-54. [DOI: 10.1016/j.radonc.2015.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 03/02/2015] [Accepted: 03/02/2015] [Indexed: 11/16/2022]
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Trifiletti DM, Jones R, Showalter SL, Libby BB, Brenin DR, Schroen A, Morris MM, Reardon KA, Showalter TN. Techniques for intraoperative radiation therapy for early-stage breast carcinoma. Future Oncol 2015; 11:1047-58. [DOI: 10.2217/fon.15.26] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
ABSTRACT Intraoperative radiation therapy (IORT) is a method of accelerated partial breast irradiation developed to replace other longer courses of radiotherapy with a single radiation session administered at the time of breast-conserving surgery. The purpose of this review is to summarize the advantages and disadvantages of breast IORT techniques that are currently available, as well to consider potential alternative techniques for breast IORT or ultra-short course breast radiotherapy. Furthermore, we highlight the published outcomes for the IORT treatment approaches including: electron therapy, superficial photon therapy and other techniques. Potential future directions of IORT are explored including novel IORT techniques utilizing intraoperative brachytherapy with in-room imaging and rapid treatment planning.
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Affiliation(s)
- Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ryan Jones
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Shayna L Showalter
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Bruce B Libby
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - David R Brenin
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anneke Schroen
- Division of Surgical Oncology, Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Monica M Morris
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Kelli A Reardon
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Ozyigit G, Gultekin M. Current role of modern radiotherapy techniques in the management of breast cancer. World J Clin Oncol 2014; 5:425-439. [PMID: 25114857 PMCID: PMC4127613 DOI: 10.5306/wjco.v5.i3.425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/07/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is the most common type of malignancy in females. Advances in systemic therapies and radiotherapy (RT) provided long survival rates in breast cancer patients. RT has a major role in the management of breast cancer. During the past 15 years several developments took place in the field of imaging and irradiation techniques, intensity modulated RT, hypofractionation and partial-breast irradiation. Currently, improvements in the RT technology allow us a subsequent decrease in the treatment-related complications such as fibrosis and long-term cardiac toxicity while improving the loco-regional control rates and cosmetic results. Thus, it is crucial that modern radiotherapy techniques should be carried out with maximum care and efficiency. Several randomized trials provided evidence for the feasibility of modern radiotherapy techniques in the management of breast cancer. However, the role of modern radiotherapy techniques in the management of breast cancer will continue to be defined by the mature results of randomized trials. Current review will provide an up-to-date evidence based data on the role of modern radiotherapy techniques in the management of breast cancer.
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Vera R, Trombetta M, Mukhopadhyay ND, Packard M, Arthur D. Long-term cosmesis and toxicity following 3-dimensional conformal radiation therapy in the delivery of accelerated partial breast irradiation. Pract Radiat Oncol 2014; 4:147-152. [DOI: 10.1016/j.prro.2013.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 06/17/2013] [Accepted: 07/04/2013] [Indexed: 11/26/2022]
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Day to day treatment variations of accelerated partial breast brachytherapy using a multi-lumen balloon. J Contemp Brachytherapy 2014; 6:68-75. [PMID: 24790624 PMCID: PMC4003432 DOI: 10.5114/jcb.2014.42025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 03/08/2014] [Accepted: 03/28/2014] [Indexed: 11/17/2022] Open
Abstract
Purpose To evaluate the variations of multi-lumen balloon (MLB)-based brachytherapy from simulation day to treatment day and their dosimetric impacts during accelerated partial breast irradiation (APBI). Material and methods A total of 42 CT images scanned from seven patients were evaluated with regards to daily variation due to of: 1) internal uncertainty: size and shape of balloon, seroma volume; 2) geometrical uncertainty-random: length of each catheter was measured for each fraction (total 70); 3) geometrical uncertainty-systematic: virtual systematic errors were tested by offsetting dwell positions. The original plans (as group A) had a mean value of 96.8% on V95 of the PTV_Eval. Plans were rerun (as group B) such that the mean value of the V95 was relaxed to 90.4%. By applying the reference plan to each daily CT image, variations of target coverage under different sources of error were evaluated. Results Shape and size of the balloon had means of < 1 mm decreased in diameter and < 0.4 cm3 decreased in volume; the mean seroma volume increased by 0.2 cm3. This internal variation has a mean of < 1% difference for both V90 and V95. The geometrical uncertainty made a mean deviation of 2.7 mm per root of sum of square. It caused the degradations of V90 and V95 by mean values of 1.0% and 1.2%, respectively. A systematic error of 3 mm and 4 mm would degrade both of V90 and V95 by 4% and 6%, respectively. The degradations on target coverage of the plans in group A were statistically the same as those in group B. Conclusions Overall, APBI treatments with MLB based brachytherapy are precise from day to day. However, minor variation due to daily treatment uncertainties can still degrade tumor bed coverage to an unacceptable coverage when V95 of the original plan is close to 90%.
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Chen PY. Accelerated Partial Breast Irradiation: Keeping Guidelines in Step With Evolving Data. Int J Radiat Oncol Biol Phys 2014; 88:263-5. [DOI: 10.1016/j.ijrobp.2013.11.231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 11/11/2013] [Accepted: 11/16/2013] [Indexed: 10/25/2022]
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Macdonald SM, Taghian AG. Partial–breast irradiation: towards a replacement for whole–breast irradiation? Expert Rev Anticancer Ther 2014; 7:123-34. [PMID: 17288524 DOI: 10.1586/14737140.7.2.123] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Largely thanks to all of the investigators and patients who have participated in randomized breast-conservation trials, many women facing a diagnosis of breast cancer today can conserve their breast with the help of adjuvant radiation therapy. A standard course of radiation consists of 5-7 weeks of daily radiation treatments delivered to the whole breast. The success of this treatment has led investigators to attempt to determine whether the same control can be achieved while decreasing the volume of breast tissue irradiated, thus allowing treatment to be delivered in a shorter period of time. This approach could alleviate time and logistical problems faced by patients during their course of treatment as well as improving overall cost-effectiveness. It can also allow complete avoidance of the adjacent heart and lung tissue in the radiation treatment portal. Partial-breast irradiation (the delivery of radiation to the resection cavity, plus a safety margin) delivered in just hours or days, is currently under investigation. Although relatively new, its use is growing rapidly and many institutional and cooperative group trials are quickly enlisting patients, while physicians are gaining experience in a variety of partial-breast irradiation techniques.
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Affiliation(s)
- Shannon M Macdonald
- Harvard Medical School, Massachusetts General Hospital, Department of Radiation Oncology, Boston, MA 02114, USA.
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Hepel JT. Late toxicity and cosmetic outcomes related to interstitial multicatheter brachytherapy for partial breast irradiation. Brachytherapy 2014; 13:23-6. [DOI: 10.1016/j.brachy.2013.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 09/05/2013] [Indexed: 11/25/2022]
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Rabinovitch R, Winter K, Kuske R, Bolton J, Arthur D, Scroggins T, Vicini F, McCormick B, White J. RTOG 95-17, a Phase II trial to evaluate brachytherapy as the sole method of radiation therapy for Stage I and II breast carcinoma--year-5 toxicity and cosmesis. Brachytherapy 2013; 13:17-22. [PMID: 24041956 DOI: 10.1016/j.brachy.2013.08.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 01/19/2023]
Abstract
PURPOSE Radiation Therapy Oncology Group (RTOG) 95-17, a Phase II trial to evaluate multicatheter brachytherapy (mCathBrachy) as the sole method of radiation therapy for Stage I-II breast cancer (BrCa), was the first cooperative group trial in North America to evaluate accelerated partial breast irradiation (APBI) and include patient-reported outcomes (PROs). This report presents the year-5 toxicity and cosmesis data. METHODS AND MATERIALS After lumpectomy and axillary dissection for invasive BrCa (tumor size <3cm with zero to three positive lymph nodes), 100 patients (pts), 98 evaluable, were treated (txed) with mCathBrachy from 1997 to 2000 with 34Gy administered twice daily in 10 high-dose-rate fractions or 45Gy in 3.5-6 days as a low-dose-rate implant to 1-2cm beyond the lumpectomy bed. The PROs and physician-reported outcomes of toxicity, cosmesis, and tx satisfaction at year-5 are reported here, defined as data submitted 54-78 months after tx. RESULTS Grade (G) 1-2 skin toxicity developed in 78% of the pts and G3 in 13% (no G4). The tx effects included skin dimpling/indentation (37%), fibrosis (45%), telangiectasias (45%), skin catheter marks (54%), and symptomatic fat necrosis (15%). Breast asymmetry was reported in 73%. Rates of excellent-to-good cosmesis were similar between PROs (66%) and radiation oncologists (68%). The PROs of tx satisfaction at year-5 was 75%. CONCLUSIONS RTOG 95-17 documents the year-5 skin toxicity and tx effects of mCathBrachy APBI, which are associated with PROs of good-to-excellent cosmesis and high tx satisfaction. This emphasizes the importance of PROs when assessing BrCa tx. National Surgical Adjuvant Breast and Bowel Project B39/RTOG 0413 will allow for definitive comparisons between APBI and whole breast radiation therapy.
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Affiliation(s)
- Rachel Rabinovitch
- Department of Radiation Oncology, University of Colorado Hospital, Aurora, CO.
| | - Kathryn Winter
- Department of Statistics, Radiation Therapy Oncology Group, Philadelphia, PA
| | - Robert Kuske
- Department of Radiation Oncology, AZ Oncology Services, Scottsdale, AZ; Radiation Oncology, Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - John Bolton
- Department of Surgery, Ochsner Clinic, New Orleans, LA
| | - Doug Arthur
- Department of Radiation Oncology, Medical College of Virginia, Richmond, VA
| | - Troy Scroggins
- Department of Radiation Oncology, Ochsner Baptist Medical Center, New Orleans, LA
| | - Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI; Radiation Oncology, Michigan HealthCare Professionals/21st Century Oncology, Farmington Hills, MI
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Julia White
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, WI; Department of Radiation Oncology, Ohio State University Medical Center, Columbus, OH
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Bergom C, Prior P, Kainz K, Morrow NV, Ahunbay EE, Walker A, Allen Li X, White J. A phase I/II study piloting accelerated partial breast irradiation using CT-guided intensity modulated radiation therapy in the prone position. Radiother Oncol 2013; 108:215-9. [PMID: 23932158 DOI: 10.1016/j.radonc.2013.05.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 05/19/2013] [Accepted: 05/28/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE External beam accelerated partial breast irradiation (EB-aPBI) is noninvasive with broader potential applicability than aPBI using brachytherapy. However, it has inherent challenges in daily reproducibility. Image-guide radiotherapy (IGRT) can improve daily reproducibility, allowing smaller treatment margins. Our institution proposed IG-IMRT in the prone position to evaluate dose homogeneity, conformality, normal tissue avoidance, and reliable targeting for EB-aPBI. We report preliminary results and toxicity from a phase I/II study evaluating the feasibility of EB-aPBI in the prone position using IG-IMRT. MATERIALS AND METHODS Twenty post-menopausal women with node-negative breast cancer, excised tumors <3.0 cm, negative sentinel lymph node biopsy, and surgical clips demarcating the lumpectomy cavity underwent prone EB-aPBI using IG-IMRT on an IRB-approved phase I/II study. All patients underwent CT planning in the prone position. The lumpectomy cavity PTV represented a 2.0 cm expansion. 38.5 Gy was delivered in 10 fractions over 5 days, such that 95% of the prescribed dose covered >99% of the PTV. Dose constraints for the whole breast, lungs and heart were met. RESULTS The median patient age was 61.5. Mean tumor size was 1.0 cm. 35% of patients had DCIS. Median PTV was 243 cc (108-530) and median breast reference volume was 1698 cc (647-3627). Average daily shifts for IGRT were (0.6, -4.6, 1.7 mm) with standard deviations of (6.3, 6.5, 6.4mm). Acute toxicity was G1 erythema in 80%, and G2 erythema, G2 fatigue, and G2 breast pain each occurred in 1 patient. With a median follow-up of 18.9 months (12-35), 40% of patients have G1 fibrosis and 30% have G1 hyperpigmentation. 95% of patients have good to excellent cosmesis. There have been no recurrences. CONCLUSIONS These data demonstrate that EB-aPBI in the prone position using IG-IMRT is well tolerated, yields good dosimetric conformality, and results in promising early toxicity profiles.
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Affiliation(s)
- Carmen Bergom
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
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Rodríguez-Spiteri Sagredo N, Martínez Regueira F, Olartecoechea Linaje B, Arredondo Chaves J, Cambeiro Vázquez M, Pina Insausti LJ, Elizalde Pérez A, y García-Lallana A, Sola Gallego JJ. [Accelerated partial breast irradiation with multicatheters during breast conserving surgery for cancer]. Cir Esp 2013; 91:490-5. [PMID: 23827929 DOI: 10.1016/j.ciresp.2013.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Revised: 02/06/2013] [Accepted: 02/14/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Accelerated partial breast irradiation (APBI) with multicatheters after lumpectomy for breast cancer (BC) may be an alternative to whole breast irradiation in selected patients. The aim is to show our 5 year experience. METHOD Between June 2007 and June 2012, 87 BC patients have been evaluated for APBI. Inclusion criteria were: age over 40 years, unifocal tumour, infiltrating ductal or intraductal carcinoma, tumour size smaller than 3 cm and no lymph node involvement. Complications, cosmetic results and local and distant recurrences were evaluated. RESULTS Treatment was completed in 48 patients and contraindicated in 39. The average age of treated patients was 59 years. Operating time was 123 min with 9 implanted catheters in each patient. No complications were observed during surgery or radiotherapy. Patients were discharged from hospital after 4 days. Tumour size was 11 mm. Of these, 35 were infiltrating ductal and 13 intraductal carcinomas. A total of 44 patients received adjuvant treatment. Mean follow-up was 22 months with no evidence of local or distant recurrence. The cosmetic outcome was good or excellent in 66% of cases. CONCLUSIONS APBI with multicatheter placed after lumpectomy for BC is feasible and safe but requires a strict selection of patients.
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Cuttino LW, Khan A, Wazer DE, Arthur DW, Vicini FA. When Retrospective Comparative Effectiveness Research Hinders Science and Patient-Centered Care. J Clin Oncol 2013; 31:2226-7. [DOI: 10.1200/jco.2012.47.6911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Atif Khan
- Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - David E. Wazer
- Tufts Medical Center, Boston, MA; and Brown University, Providence, RI
| | | | - Frank A. Vicini
- Michigan Healthcare Professionals/21st Century Oncology, Royal Oak, MI
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Barry M, Ho A, Morrow M. The evolving role of partial breast irradiation in early-stage breast cancer. Ann Surg Oncol 2013; 20:2534-40. [PMID: 23463089 DOI: 10.1245/s10434-013-2923-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 01/24/2023]
Abstract
Whole breast irradiation (WBI) over 5-7 weeks has long been considered standard adjuvant treatment after breast-conserving surgery. Recently the concept of irradiating the whole breast has been challenged by accelerated partial breast irradiation (APBI), which exclusively targets the lumpectomy site plus margin. We review the evidence supporting APBI from modern clinical trials, the pros and cons of various APBI techniques, and the controversies regarding the applicability of APBI to specific patient groups.
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Affiliation(s)
- Mitchel Barry
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Brachytherapy in accelerated partial breast irradiation (APBI) - review of treatment methods. J Contemp Brachytherapy 2012; 4:152-64. [PMID: 23346145 PMCID: PMC3551377 DOI: 10.5114/jcb.2012.30682] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 09/03/2012] [Accepted: 09/06/2012] [Indexed: 11/17/2022] Open
Abstract
Breast conserving surgery (BCS) with following radiotherapy (EBRT) of the conserved breast became widely accepted in the last decades as the treatment of early invasive breast cancer. In an early stage of breast cancer, research has shown that the area requiring radiation treatment to prevent cancer from local recurrence is the breast tissue that surrounds the area where the initial cancer was removed. Accelerated partial breast irradiation (APBI) is an approach that treats only the lumpectomy bed with 1-2 cm margin, rather than the whole breast and as a result allows accelerated delivery of the radiation dose in four to five days. Published results of APBI are very promising. It is evident that APBI will play a role in the management of a selected group of early breast cancer. We discuss current status, indications, technical aspects and recently published results of APBI using different brachytherapy techniques.
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A dose verification tool for high-dose-rate interstitial brachytherapy treatment planning in accelerated partial breast irradiation. Brachytherapy 2012; 11:359-68. [DOI: 10.1016/j.brachy.2012.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 03/14/2012] [Accepted: 03/20/2012] [Indexed: 11/19/2022]
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Budrukkar A, Jagtap V, Kembhavi S, Munshi A, Jalali R, Seth T, Parmar V, Raj Upreti R, Badwe R, Sarin R. Fat necrosis in women with early-stage breast cancer treated with accelerated partial breast irradiation (APBI) using interstitial brachytherapy. Radiother Oncol 2012; 103:161-5. [DOI: 10.1016/j.radonc.2011.12.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 11/22/2011] [Accepted: 12/28/2011] [Indexed: 10/14/2022]
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Ferraro DJ, Garsa AA, DeWees TA, Margenthaler JA, Naughton M, Aft R, Gillanders WE, Eberlein T, Matesa MA, Zoberi I. Comparison of accelerated partial breast irradiation via multicatheter interstitial brachytherapy versus whole breast radiation. Radiat Oncol 2012; 7:53. [PMID: 22458887 PMCID: PMC3359280 DOI: 10.1186/1748-717x-7-53] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/29/2012] [Indexed: 11/10/2022] Open
Abstract
Background Brachytherapy as adjuvant treatment for early-stage breast cancer has become widely available and offers patients an expedited treatment schedule. Given this, many women are electing to undergo brachytherapy in lieu of standard fractionation radiotherapy. We compare outcomes between patients treated with accelerated partial breast irradiation (APBI) via multicatheter interstitial brachytherapy versus patients who were also eligible for and offered APBI but who chose whole breast radiation (WBI). Methods Patients treated from December 2002 through May 2007 were reviewed. Selection criteria included patients with pTis-T2N0 disease, ≤ 3 cm unifocal tumors, and negative margins who underwent breast conservation surgery. Local control (LC), cause-specific (CSS) and overall survival (OS) were analyzed. Results 202 patients were identified in the APBI cohort and 94 patients in the WBI cohort. Median follow-up for both groups exceeded 60 months. LC was 97.0% for the APBI cohort and 96.2% for the WBI cohort at 5 years (ns). Classification by 2010 ASTRO APBI consensus statement categories did not predict worse outcomes. Conclusion APBI via multicatheter interstitial brachytherapy provides similar local failure rates compared to WBI at 5 years for properly selected patients. Excellent results were seen despite the high fraction of younger patients (< 60 years old) and patients with DCIS.
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Affiliation(s)
- Daniel J Ferraro
- Department of Radiation Oncology and Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO 63110, USA
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Abstract
In the last four decades breast-conserving surgery followed by whole breast irradiation has become the standard of care for the treatment of early-stage (0-I-II) breast carcinoma. With the advent of breast-screening, incidence of breast carcinomas with more favorable prognostic characteristics has increased significantly. This change in the prognostic profile of newly diagnosed breast cancers opened a new horizon for clinical research seeking for individual risk-adapted protocols of breast cancer radiotherapy. Several groups have been tested the efficacy of accelerated (partial or whole) breast irradiation, which has become the new treatment paradigm in the radiotherapy of early-stage breast cancers. Furthermore, others have attempted to identify subgroups of patients for whom radiotherapy after breast-conserving surgery could be safely omitted. Recently molecular gene expression assays have emerged as promising prognostic and predictive markers for local recurrence. This article reviews the results of these studies focusing on individual risk-adapted radiotherapy after breast-conserving surgery for patients with early-stage breast carcinoma.
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Affiliation(s)
- Csaba Polgár
- Országos Onkológiai Intézet Budapest Ráth Gy. u. 7-9. 1122.
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Hattangadi JA, Taback N, Neville BA, Harris JR, Punglia RS. Accelerated Partial Breast Irradiation Using Brachytherapy for Breast Cancer: Patterns in Utilization and Guideline Concordance. J Natl Cancer Inst 2011; 104:29-41. [DOI: 10.1093/jnci/djr495] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Shah MM, Horton JK, Yoo S, Hubbs JL, Demirci S, Light KL, Temple K, Patrone M, Marks LB. A Comparison of Clinical and Dosimetric Outcomes in Patients Receiving Partial Breast Irradiation with Photon-Only versus Mixed Photon/Electron Treatment Plans. Med Dosim 2011; 36:423-8. [DOI: 10.1016/j.meddos.2010.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 08/28/2010] [Accepted: 10/25/2010] [Indexed: 11/30/2022]
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Hattangadi JA, Powell SN, MacDonald SM, Mauceri T, Ancukiewicz M, Freer P, Lawenda B, Alm El-Din MA, Gadd MA, Smith BL, Taghian AG. Accelerated partial breast irradiation with low-dose-rate interstitial implant brachytherapy after wide local excision: 12-year outcomes from a prospective trial. Int J Radiat Oncol Biol Phys 2011; 83:791-800. [PMID: 22099046 DOI: 10.1016/j.ijrobp.2011.09.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 08/01/2011] [Accepted: 09/02/2011] [Indexed: 12/14/2022]
Abstract
PURPOSE To evaluate the long-term toxicity, cosmesis, and local control of accelerated partial breast irradiation with implant brachytherapy after wide local excision for Stage T1N0 breast cancer (BCa). MATERIALS AND METHODS Between 1997 and 2001, 50 patients with Stage T1N0M0 BCa were treated in a Phase I-II protocol using low-dose-rate accelerated partial breast irradiation with implant brachytherapy after wide local excision and lymph node surgery. The total dose was escalated in three groups: 50 Gy (n = 20), 55 Gy (n = 17), and 60 Gy (n = 13). Patient- and physician-assessed breast cosmesis, patient satisfaction, toxicity, mammographic abnormalities, repeat biopsies, and disease status were prospectively evaluated at each visit. Kendall's tau (τ(β)) and logistic regression analyses were used to correlate outcomes with dose, implant volume, patient age, and systemic therapy. RESULTS The median follow-up period was 11.2 years (range, 4-14). The patient satisfaction rate was 67%, 67% reported good-excellent cosmesis, and 54% had moderate-severe fibrosis. Higher dose was correlated with worse cosmetic outcome (τ(β) 0.6, p < .0001), lower patient satisfaction (τ(β) 0.5, p < .001), and worse fibrosis (τ(β) 0.4, p = .0024). Of the 50 patients, 35% had fat necrosis and 34% developed telangiectasias ≥1 cm(2). Grade 3-4 late skin and subcutaneous toxicities were seen in 4 patients (9%) and 6 patients (13%), respectively, and both correlated with higher dose (τ(β) 0.3-0.5, p ≤ .01). One patient had Grade 4 skin ulceration and fat necrosis requiring surgery. Mammographic abnormalities were seen in 32% of the patients, and 30% underwent repeat biopsy, of which 73% were benign. Six patients had ipsilateral breast recurrence: five elsewhere in the breast, and one at the implant site. One patient died of metastatic BCa after recurrence. The 12-year actuarial local control, recurrence-free survival, and overall survival rate was 85% (95% confidence interval, 70-97%), 72% (95% confidence interval, 54-86%), and 87% (95% confidence interval, 73-99%), respectively. CONCLUSION Low-dose-rate accelerated partial breast irradiation with implant brachytherapy provides acceptable local control in select early-stage BCa patients. However, treatment-related toxicity and cosmetic complications were significant with longer follow-up and at higher doses.
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Pinnarò P, Arcangeli S, Giordano C, Arcangeli G, Impiombato FA, Pinzi V, Iaccarino G, Soriani A, Landoni V, Strigari L. Toxicity and cosmesis outcomes after single fraction partial breast irradiation in early stage breast cancer. Radiat Oncol 2011; 6:155. [PMID: 22079051 PMCID: PMC3229442 DOI: 10.1186/1748-717x-6-155] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 11/11/2011] [Indexed: 01/30/2023] Open
Abstract
Background To report the clinical outcome after a Single Shot 3D-CRT PBI (SSPBI) in breast cancer patients after conservative surgery (ClinicalTrials.gov Identifier: NCT01316328). Methods A dose of 18Gy (in the first 4 patients) and 21Gy (in the remaining 60 patients) was prescribed in a single session and delivered to the index area (i.e. the area of breast including the primary tumor bed and the surrounding tissue) using 3D-CRT with patients in prone position. Acute and late toxicity was assessed using the National Cancer Institute's CTC for Adverse Events. Cosmesis was defined based on modified Harvard criteria. Differences between dosimetric or clinical parameters of patients with/without G2 or more late toxicity or unsatisfactory (poor or fair) cosmetic outcome were evaluated with the Mann-Whitney test. Odds ratios and 95% confidence interval were calculated for cosmesis and fibrosis. Univariate and multivariate analyses(UVA/MVA) were used to determine covariates associated with an increase in fibrosis or fat necrosis rate. Results Sixty four patients were enrolled. With a median follow-up of 3 years, G2 and G3 subcutaneous fibrosis was detected in 20(31%) and in 8(13%) patients, and ≥G2 fat necrosis was observed in 2(3%) patients. Good to excellent, fair and poor cosmesis was observed in 38(59%), 23(36%) and 3(5%) patients, respectively. Based on UVA, the breast volume receiving more than 21Gy (V21Gy) was found to be a predictor of the ≥G1 or ≥G2 fibrosis/fat necrosis. Based on MVA, V21Gy was confirmed as a predictor for ≥G1 fibrosis/fat necrosis, the results correlated as a trend for ≥G2. Cosmesis was correlated with whole breast (WB) mean dose (p = 0.030). Conclusion Our choice of a single dose of 21Gy significantly increased the treatment related toxicity. However, this should not discourage novel SSPBI approaches with lower equivalent doses.
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Affiliation(s)
- Paola Pinnarò
- Department of Radiation Oncology, Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy
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