Pulmonary changes after radiotherapy for conservative treatment of breast cancer: a prospective study

Pulmonary Function and Lung Fibrosis up to 12 Years After Breast Cancer Radiotherapy

PURPOSE

Breast cancer (BC) treatment may affect pulmonary function, but evidence of long-term pulmonary toxicity is scarce. This study aimed to evaluate pulmonary function, radiation fibrosis (RF), and patient-reported dyspnea up to 12 years after different BC treatment modalities.

METHODS AND MATERIALS

Two hundred fifty patients with BC referred to postoperative radiotherapy (RT) were included in this study. High-resolution computed tomography, pulmonary function tests (PFTs), clinical examinations, and patient-reported dyspnea were assessed before RT and at 3, 6, and 12 months and up to 12 years after RT.

RESULTS

Vital capacity (VC), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and diffusion capacity of the lungs for carbon monoxide (DLCO) declined at 3 months after RT and remained low at long-term follow-up except for DLCO, which increased up to 12 years after RT. VC, FEV1, and FVC changes differed between patients treated with and without chemotherapy, and FEV1 differed between patients treated with locoregional and local RT. An early decline in VC, FEV1, and FVC predicted a late decline in PFT values up to 12 years after RT (P = .020, P = .004, and P = .020, respectively). RF, mainly grade 1, was observed in 91% of patients at long-term follow-up. Few patients reported severe dyspnea at long-term follow-up, and there was no statistically significant association with concurrent RF or decline in PFT values from baseline.

CONCLUSIONS

Chemotherapy and locoregional RT affected performance in PFTs up to 12 years after RT. Reduction in VC, FVC, and FEV1 3 months after RT predicted a decline in PFT values at long-term follow-up. However, a late decline in PFT values was not associated with long-term RF or patient-reported dyspnea.

Understanding changes in pulmonary function and functional status in breast cancer patients after systemic chemotherapy and radiotherapy: a prospective study

BACKGROUND

Respiratory complications in breast cancer (BC) patients after chemotherapy (CT) and radiotherapy (RT) have been well acquainted and these complications should be investigated to prevent secondary problems and/or improve BC patients' clinical outcomes. Therefore, this study aimed to assess the potential acute effect of systemic chemotherapy and radiotherapy on respiratory function and functional status of patients with breast cancer.

METHODS

A total of 25 BC patients who were candidates for systemic chemotherapy and radiotherapy were recruited after oncological examination and included in this study. Respiratory function and functional status were assessed with the Pulmonary Function Test (PFT) and the Six-Minute Walk Test (6MWT), respectively. Patients were assessed before CT (c0), after CT (c1), and after RT (r1).

RESULTS

25 BC patients were assessed in c0 and c1 while only 15 out of 25 patients (60%) were assessed in r1. The actual values of Forced vital capacity (FVC) (t = 2.338, p =.028), Forced expiratory volume in 1s (FEV1 (t = 2.708, p =.012), and the forced expiratory flow of between 25% and 75% of vital capacity (FEF25-75%) (t = 2.200, p =.038) were found significantly different after systemic CT. Inspiratory (MIP) and expiratory (MEP) muscle strength also did not show a significant change from c0 to c1. A significant effect of the type of surgery was found (Wilks' lambda, F [1, 19] = 6.561, p =.019, ηp2 = 0.25) between c0 and c1 in actual FVC value. The main effect of time was found significant in FVC (F [2, 28] = 4.840, p =.016, ηp2 = 0.25) from c0 to r1. Pairwise comparisons with Bonferroni correction showed that there was a significant difference between c0 and r1 (p =.037).

DISCUSSION

The present study showed decreased FVC and FEV1 actual values and percent predicted rates from baseline to the completion of treatment. Since the interactional effect of the type of surgery was significant, we suggest that clinical and demographic factors such as age should be considered when interpreting the early changes in PFT. In addition, the significant linear trend of decreasing in some specific outcomes in respiratory function also highlighted the need for continuous monitoring of potential respiratory problems in patients with BC from baseline to the completion of chemotherapy and radiotherapy.

Impact of breath hold on regional nodal irradiation and heart volume in field in left breast cancer adjuvant irradiation

PURPOSE

Compared to the free-breathing technique, adjuvant left breast irradiation after breast-conserving surgery or mastectomy using the breath-hold method significantly reduces the heart mean dose, Left anterior descending artery, and ipsilateral lung doses. Movement with deep inspiration may also reduce heart volume in the field and regional node doses.

MATERIALS AND METHODS

Pre-radiotherapy planning CT was performed in the free-breathing, and breath-hold techniques using RPM, demographic information, clinicopathological data, heart volume in the field, heart mean dose, LAD mean dose, and regional nodal doses were calculated in both free breathing and DIBH. Fifty patients with left breast cancer receiving left breast adjuvant radiation were enrolled.

RESULTS

There was no significant difference in axillary LN coverage between the two techniques, except for SCL maximum dose, Axilla I node maximum dose, and Axilla II minimum dose in favor of the breath hold technique. The mean age was 47.54 years, 78% had GII IDC, 66% had positive LVSI results, and 74% of patients had T2. The breath hold strategy resulted in considerably decreased mean heart dose (p = 0.000), LAD dose (p = 0.000), ipsilateral lung mean dose (p = 0.012), and heart volume if the field (p = 0.013). The mean cardiac dosage and the dose of the LAD were significantly correlated (p = 0.000, R = 0.673). Heart volume in the field and heart mean dosage was not significantly correlated (p = 0.285, r = - 0.108).

CONCLUSION

When compared to free breathing scans, DIBH procedures result in considerably reduced dosage to the OAR and no appreciable changes in dose exposure to regional lymph node stations in patients with left-sided breast cancer.

Safety of hypofractionated volumetric modulated arc therapy for early breast cancer: A preliminary report

The present study attempts to evaluate the acute and subacute toxicities of hypofractionated volumetric modulated arc therapy (HFX-VMAT) in patients with early breast cancer (EBC). It is a retrospective analysis of 23 patients treated with HFX-VMAT after breast-conserving surgery between September 2021 and February 2022. A total dose of 50.05 to 52.55 Gy was delivered, consisting of 40.05 Gy to the ipsilateral whole breast in 15 fractions of 2.67 Gy and a tumor bed boost dose of 10-12.5 Gy in 4-5 fractions. The primary endpoint was acute/subacute radiation pneumonitis (RP). The secondary endpoint was poor cosmesis, indicating acute/subacute radiation dermatitis. Chest computed tomography (CT) and the Common Terminology Criteria for Adverse Events v.5.0 were used to assess acute and subacute RP and dermatitis, respectively, during radiotherapy (RT) and at 3- and 6-months post-RT. The median follow-up duration was 3.8 months (range, 2.3-4.2). A total of seven patients developed RP. None of these patients presented RP-related symptoms; the diagnosis was based on radiologic findings observed on follow-up chest CT. Among the seven patients with RP, five had right-sided, and two had left-sided breast tumors (71.4 vs. 28.6%; P=0.026). Grade 1 erythema was observed in 19 patients (82.6%) and grade 2 erythema in four (17.4%). The mean target dose, D_105% (the dose received by 105% of the target volume), homogeneity index, mean lung dose, ipsilateral lung V₂₀ (the percentage volume receiving 20 Gy), and V₃₀ (the percentage volume receiving 30 Gy) for ipsilateral whole breast RT were significantly associated with RP (P=0.039, 0.047, 0.018, 0.015, 0.018 and 0.003, respectively.). HFX-VMAT showed tolerable acute/subacute toxicities. Therefore, HFX-VMAT is an effective and safe treatment option for EBC.

Radiation-induced lung injury after breast cancer treatment: incidence in the CANTO-RT cohort and associated clinical and dosimetric risk factors

Purpose

Radiation-induced lung injury (RILI) is strongly associated with various clinical conditions and dosimetric parameters. Former studies have led to reducing radiotherapy (RT) doses to the lung and have favored the discontinuation of tamoxifen during RT. However, the monocentric design and variability of dosimetric parameters chosen have limited further improvement. The aim of our study was to assess the incidence of RILI in current practice and to determine clinical and dosimetric risk factors associated with RILI occurrence.

Material and methods

Data from 3 out of the 10 top recruiting centers in CANTO-RT, a subset of the CANTO prospective longitudinal cohort (NCT01993498), were retrospectively analyzed for RILI occurrence. This cohort, which recruited invasive cT0-3 cN0-3 M0 breast cancer patients from 2012 to 2018, prospectively recorded the occurrence of adverse events by questionnaires and medical visits at the end of, and up to 60 months after treatment. RILI adverse events were defined in all patients by the association of clinical symptoms and compatible medical imaging.

Results

RILI was found in 38/1565 (2.4%) patients. Grade II RILI represented 15/38 events (39%) and grade III or IV 2/38 events (6%). There were no grade V events. The most frequently used technique for treatment was 3D conformational RT (96%). In univariable analyses, we confirmed the association of RILI occurrence with pulmonary medical history, absence of cardiovascular disease medical history, high pT and pN, chemotherapy use, nodal RT. All dosimetric parameters were highly correlated and had close predictive value. In the multivariable analysis adjusted for chemotherapy use and nodal involvement, pulmonary medical history (OR=3.05, p<0.01) and high V30 Gy (OR=1.06, p=0.04) remained statistically significant risk factors for RILI occurrence. V30 Gy >15% was significantly associated with RILI occurrence in a multivariable analysis (OR=3.07, p=0.03).

Conclusion

Our study confirms the pulmonary safety of breast 3D RT in CANTO-RT. Further analyses with modern radiation therapy techniques such as IMRT are needed. Our results argue in favor of a dose constraint to the ipsilateral lung using V30 Gy not exceeding 15%, especially in patients presenting pulmonary medical history. Pulmonary disease records should be taken into account for RT planning.

Local and systemic therapy may be safely de-escalated in elderly breast cancer patients in China: A retrospective cohort study

Background

For elderly patients with breast cancer, the treatment strategy is still controversial. In China, preoperative axillary lymph node needle biopsy is not widely used, resulting in many patients receiving axillary lymph node dissection (ALND) directly. Our study aims to determine whether local and systemic therapy can be safely de-escalated in elderly breast cancer.

Methods

Patients aged ≥70 years were retrospectively enrolled from our institution’s medical records between May 2013 and July 2021. Groups were assigned according to local and systemic treatment regimens, and stratified analysis was performed by molecular subtypes. Univariate and multivariate survival analyses were used to compare the effects of different regimens on relapse-free survival (RFS).

Results

A total of 653 patients were enrolled for preliminary data analysis, and 563 patients were screened for survival analysis. The mean follow-up was 19 months (range, 1–82 months). Axillary lymph node metastases were pathologically confirmed in only 2.1% of cN0 cases and up to 97.1% of cN+ cases. In the aspect of breast surgery, RFS showed no significant difference between mastectomy and BCS group (p = 0.3078). As for axillary surgery, patients in the ALND group showed significantly better RFS than those in the sentinel lymph node biopsy (SLNB) group among pN0 patients (p = 0.0128). Among these cases, the proportion of cN+ in ALND was significantly higher than that in SLNB (6.4% vs. 0.4%, p = 0.002), which meant axillary lymph nodes (ALNs) of ALND patients were larger in imaging and more likely to be misdiagnosed as metastatic. With regard to adjuvant therapy, univariate and multivariate analyses showed that RFS in different comprehensive adjuvant regimens were similar especially among hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)− subgroup where patients who did not receive any adjuvant therapy accounted for 15.7% (p > 0.05).

Conclusions

It is feasible to reduce some unnecessary local or systemic treatments for elderly breast cancer patients, especially in HR+/HER2− subtype. Multiple patient-related factors should be considered when making treatment plans.

Respiratory Physiotherapy Intervention Strategies in the Sequelae of Breast Cancer Treatment: A Systematic Review

Breast cancer treatments can trigger respiratory sequelae. Respiratory physiotherapy helps to eliminate or mitigate the sequelae by optimizing respiratory function. This systematic review aims to synthesize the scientific evidence and assess its quality regarding the use of respiratory physiotherapy in the sequelae of breast cancer. The Cochrane Library, Physiotherapy Evidence Database, PubMed, Web of Science, Scientific Electronic Library Online, Cumulative Index of Nursing and Allied Literature Complete, and Scopus were searched. Study quality was determined using the PEDro scale, STROBE Statement, and Single-Case Experimental Design Scale. Ten studies, six clinical trials, one case study, and three observational studies were selected. The mean methodological quality of the clinical trials was 5.6, that of the case study was 7, and that of the observational studies was 56%. Respiratory physiotherapy has been observed to improve respiratory capacity, lung function, respiratory muscle strength, effort tolerance, dyspnea, fatigue, thoracic mobility, upper limb volume, sleep quality and quality of life, as well as sensitivity to adverse physiological reactions, nausea, vomiting, and anxiety. However, it is not effective for vasomotor symptoms. More clinical trials are needed. These studies should homogenize the techniques used, as well as improve their methodological quality.

Pneumonitis and fibrosis after breast cancer radiotherapy: occurrence and treatment-related predictors

BACKGROUND

Radiation pneumonitis (RP) and radiation fibrosis (RF) are common side effects after breast cancer (BC) radiotherapy (RT). However, there is a great variation in the frequency of RP and RF. This study presents the occurrence of- and the treatment-related predictors for RP and RF. Further, physician- and patient-reported pulmonary symptoms during the first year after postoperative RT for BC are demonstrated.

MATERIALS AND METHODS

From 2007 to 2008, 250 BC patients referred for postoperative RT were included in a prospective cohort study and followed during the first year after RT. High-resolution computed tomography of the lungs and symptom registration were performed before RT and 3, 6, and 12 months after RT. Patient-reported symptoms were registered by standard quality of life questionnaires. Logistic regression analyses were applied to estimate treatment-related predictors for radiological RP (rRP), clinical RP (cRP), radiological RF (rRF), and clinical RF (cRF).

RESULTS

The occurrence of rRP and cRP at three months was 78% and 19%, while 12 months after RT rRF and cRF was 89% and 16%, respectively; all reported as grade 1. In multivariable analyses, mastectomy predicted cRP at three months (OR = 2.48, p = .03) and cRF at six months, ipsilateral lung volume receiving 20 Gray or more (V20), V30, and mean lung dose (MLD) predicted rRP at six months (OR = 1.06, p = .0003; OR = 1.10, p = .001; and OR = 1.03, p = .01, respectively). Endocrine treatment predicted cRF at 12 months (OR = 2.48, p = .02). Physicians reported significant more dyspnea at 3 months (p = .003) and patients reported 'a little dyspnea' more at 3 and 12 months compared to baseline (p = .007).

CONCLUSION

RP and RF are prevalent in the first year after BC radiation. Mastectomy predicted cRP at three months. V20, V30, D25, and MLD predicted rRP at 6 months, and endocrine treatment predicted cRF at 12 months. Patients and physicians reported dyspnea differently.

Health-Related Quality of Life Issues Experienced by Thoracic and Breast Sarcoma Patients: A Rare and Understudied Group

Thoracic and breast sarcomas constitute a rare subgroup within the sarcoma population. There is limited knowledge about their health-related quality of life (HRQoL) and a valid disease-specific HRQoL instrument is lacking. This qualitative study aimed to investigate the HRQoL issues experienced by a small group of thoracic and breast sarcoma patients. Semi-structured interviews with 19 thoracic and four breast sarcoma patients were conducted and thematically analysed. Physical issues mentioned by both groups were fatigue, sleep disturbances, pain, wound infections, and symptoms related to chemotherapy and radiotherapy. Tightness in the back and restrictions in performing tasks above arm height were specific physical issues for breast sarcoma patients, whereas respiratory problems were only mentioned by thoracic sarcoma patients. Body image issues, changes in mood, fear of recurrence, and living with uncertainty were important mental health issues for both subgroups. Social issues in both groups included challenges in work and relationships, financial difficulties, loss of independence, and limitations in social activities. The identified physical, mental, and social health challenges can significantly impact thoracic and breast sarcoma patients’ HRQoL. Results of this qualitative study will guide personalised supportive care for breast and thoracic sarcoma patients and help in determining the best possible HRQoL measurement strategy for sarcoma patients with different primary sarcoma locations.

CT findings of acute radiation-induced pneumonitis in breast cancer

OBJECTIVES

To evaluate the CT findings of acute radiation pneumonitis (RP) in breast cancer patients undergoing post-operative radiotherapy, and to analyze clinicodosimetric factors associated with acute RP.

METHODS

Between 2015 and 2017, 61 patients with breast cancer who underwent follow-up chest CT at 3 months after radiotherapy were analyzed. The degree of acute RP on CT was evaluated by the change of extent and scoring system (grade 0, no RP; Grade 1, ground-glass opacities (GGOs); Grade 2, GGOs and/or consolidations; Grade 3, clear focal consolidation; Grade 4, dense consolidation). The dosimetric parameters were calculated from the dose-volume histogram of RT.

RESULTS

The acute RP on CT was scored as follows: Grade 0, in 37.7%, Grade 1 in 13.1%, Grade 2 in 44.3%, and Grade 3 in 4.9%. The median extent of RP in patients with Grades 1 to 3 was 6.2 ml (range, 0.2-95.9). There were no clinicodosimetric factors significantly associated with the presence of RP or its severity. One patient developed symptomatic RP.

CONCLUSION

This study showed no correlation between acute RP and clinicodosimetric factors, and acute RP based on CT findings were much more common than symptomatic RP.

ADVANCES IN KNOWLEDGE

CT findings of acute RP or extent of RP were not significantly related to clinicodosimetric factors in breast cancer patients.

Impact of Low-Dose Irradiation of the Lung and Heart on Toxicity and Pulmonary Function Parameters after Thoracic Radiotherapy

Simple Summary

To assess the impact of thoracic (low) dose irradiation on pulmonary function changes after thoracic radiotherapy (RT) data of 62 patients were analyzed. There were several significant correlations between pulmonary function and dose parameters of the lung and heart, most of which remained significant in the multivariate analysis.

Abstract

Objective: To assess the impact of (low) dose irradiation to the lungs and heart on the incidence of pneumonitis and pulmonary function changes after thoracic radiotherapy (RT). Methods/Material: Data of 62 patients treated with curative thoracic radiotherapy were analyzed. Toxicity data and pulmonary function tests (PFTs) were obtained before RT and at 6 weeks, at 12 weeks, and at 6 months after RT. PFTs included ventilation (e.g., vital capacity) and diffusion parameters (e.g., diffusion capacity for carbon monoxide (DL_CO)). Dosimetric data of the lung and heart were extracted to assess the impact of dose on PFT changes and radiation pneumonitis (RP). Results: No statistically significant correlations between dose parameters and changes in ventilation parameters were found. There were statistically significant correlations between DL_CO and low-dose parameters of the lungs (V_5Gy–V_30Gy (%)) and irradiation of the heart during the follow-up up to 6 months after RT, as well as a temporary correlation of the V_60Gy (%) on the blood gas parameters at 12 weeks after RT. On multivariate analysis, both heart and lung parameters had a significant impact on DL_CO. There was no statistically significant influence of any patient or treatment-related (including dose parameters) factors on the incidence of ≥G2 pneumonitis. Conclusion: There seems to be a lasting impact of low dose irradiation to the lung as well as irradiation to the heart on the DL_CO after thoracic radiotherapy. No influence on RP was found in this analysis.

Efectos del tratamiento con quimioterapia y radioterapia concomitante sobre los volúmenes pulmonares en mujeres con cáncer de mama en Talca, Chile

Introducción. El cáncer de mama (CM) es la enfermedad crónica no transmisible más frecuente y letal en mujeres. La información disponible sobre el impacto de sus diversos tratamientos en el sistema respiratorio es controversial.Objetivo. Determinar el efecto del tratamiento con quimioterapia y radioterapia concomitante en los volúmenes pulmonares de un grupo de mujeres con CM en Talca, Chile.Materiales y métodos. Estudio de casos y controles. La muestra (n=22) se dividió en dos grupos: control (n=11) y con CM (n=11). Para medir la capacidad vital forzada, los volúmenes pulmonares y la resistencia de las vías aéreas, se usó la prueba de pletismografía corporal. Para determinar la normalidad de los datos, se usó la prueba Shapiro-Wilks y, según sus resultados, se utilizó la prueba de t-Student o la de U de Mann-Whitney; se consideró un nivel de significancia de p<0.05.Resultados. Los flujos ventilatorios no presentaron diferencias significativas entre los dos grupos, mientras que los volúmenes pulmonares en el grupo con CM experimentaron una disminución significativa en las variables capacidad inspiratoria (CI) y volumen residual (VR) (p<0.05).Conclusión. Las mujeres con CM y que fueron tratadas con quimioterapia y radioterapia concomitante experimentaron una disminución en su CI y su VR en comparación con el grupo control, lo que podría impactar su calidad de vida.

Pulmonary function decreases moderately after accelerated high-dose irradiation for stage III non-small cell lung cancer

Background

Chemoradiotherapy (CRT) is the standard treatment for patients with inoperable stage III non‐small cell lung cancer (NSCLC) stage III. With a median OS beyond 30 months, adequate pulmonary function (PF) is essential to ensure acceptable quality of life after treatment. Forced expiratory volume in 1 second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) are the most widely used parameters to assess lung function. The aim of the current study was to evaluate dose‐volume effects of accelerated high‐dose radiation on PF.

Methods

A total of 72 patients were eligible for the current analysis. After induction chemotherapy, all patients received dose‐differentiated accelerated radiotherapy with intensity‐modulated radiotherapy (IMRT‐DART). PF tests were performed six weeks, three and six months after the end of radiotherapy.

Results

The median total dose to the tumor was 73.8 Gy (1.8 Gy bid) with a size dependent range between 61.2 and 90 Gy. In the whole cohort, 321 pulmonary function tests were performed. At six months, the median FEV1 relative to baseline was 0.95 (range: 0.56–1.36), and the relative median DLCO decreased to 0.98 (range: 0.64–1.50). The correlation between V20_{total lung} and FEV1 decline was statistically significant (P = 0.023). A total of 13 of 34 (38%) COPD patients had a 4%–21% FEV1 decrease.

Conclusion

Patients with a V20_{total lung} < 21% are at a low risk for PF decrease after high dose irradiation treatment. Although overall short term FEV1 and DLCO differ only moderately from baseline these changes may be clinically important, especially in patients with COPD.

Key points

Significant findings:

Pulmonary function after high dose irradiation decreases only moderately.

FEV1 and DLCO decrease depend on V20_{total lung}.

Small differences in lung function may be clinically important for COPD patients.

KPS predicts minimal clinically important differences (MCID).

What this study adds:

This study shows that high‐dose irradiation delivered with intensity‐modulated techniques does not impair short‐term lung function even in patients with compromised respiratory capacity before treatment. This is a pre‐requisite for adequate quality of life after thoraco‐oncological therapy.

Changes in lung volume parameters regarding the received dose in the lobes of the lungs after locoregional radiotherapy of breast cancer

Aim

The purpose of this study was to evaluate ΔLVP and correlate them with MLD and V20 in the lobes of the lung.

Background

Radiation-induced lung injury after breast irradiation is controversial. The incidence of such an injury could have negative consequences on breast cancer patients.

Materials and Methods

Twenty-three women treated with Breast-conserving surgery, chemotherapy, and locoregional RT underwent body plethysmography pre-RT and 3 and 6 months post-RT. Statistical analysis was used to evaluate ΔLVP over time and relate them with MLD, V20, age, and concurrent hormonal therapy.

Results

LVP decreased after 3 months and then showed a slight improvement by returning partially to their pre-RT values after 6 months. The mean ΔLVP was -0.64% for one Gy increase of MLD and -0.34% for one percent increase of V20 after 3 months. After 6 months, only ΔVC showed 0.45% reduction with MLD in the upper lobe. Finally, there was no significant correlation between ΔLVP with respect to age and concurrent hormonal therapy.

Conclusions

The results of this study showed that lung volume changes were not a cause for concern in breast cancer patients. There are three reasons to support this conclusion. Lung volume changes and percentage reductions in LVP for each Gy increase of MLD and each percentage increase of V20 in each lobe were small; patients were asymptomatic during the follow-up period; and LVP showed partial improvements after 6 months.

Deep inspiration breath-hold for left-sided breast irradiation: Analysis of dose-mass histograms and the impact of lung expansion

Background

The aim of this study was to compare dose-volume histogram (DVH) with dose-mass histogram (DMH) parameters for treatment of left-sided breast cancer in deep inspiration breath-hold (DIBH) and free breathing (FB). Additionally, lung expansion and anatomical factors were analyzed and correlated to dose differences.

Methods

For 31 patients 3D conformal radiation therapy plans were retrospectively calculated on FB and DIBH CTs in the treatment planning system. The calculated doses, structures and CT data were transferred into MATLAB and DVHs and DMHs were calculated. Mean doses (Dmean), volumes and masses receiving certain doses (Vx, Mx) were determined for the left lung and the heart. Additionally, expansion of the left lung was evaluated using deformable image registration. Differences in DVH and DMH dose parameters between FB and DIBH were statistically analyzed and correlated to lung expansion and anatomical factors.

Results

DIBH reduced Dmean (DVH) and relative V20 (V20 [%]) of the left lung in all patients, on average by − 19 ± 9% (mean ± standard deviation) and − 24 ± 10%. Dmean (DMH) and M20 [%] were also significantly reduced (− 12 ± 11%, − 16 ± 13%), however 4 patients had higher DMH values in DIBH than in FB. Linear regression showed good correlations between DVH and DMH parameters, e.g. a dosimetric benefit smaller than 8.4% for Dmean (DVH) in DIBH indicated more irradiated lung mass in DIBH than in FB. The mean expansion of the left lung between FB and DIBH was 1.5 ± 2.4 mm (left), 16.0 ± 4.0 mm (anterior) and 12.2 ± 4.6 mm (caudal). No significant correlations were found between expansions and differences in Dmean for the left lung. The heart dose in DIBH was reduced in all patients by 53% (Dmean) and this dosimetric benefit correlated to lung expansion in anterior.

Conclusions

Treatment of left-sided breast cancer in DIBH reduced dose to the heart and in most cases the lung dose, relative irradiated lung volume and lung mass. A mass related dosimetric benefit in DIBH can be achieved as long as the volume related benefit is about ≥8–9%. The lung expansion (breathing pattern) showed no impact on lung dose, but on heart dose. A stronger chest breathing (anterior expansion) for DIBH seems to be more beneficial than abdominal breathing.

Changes of lung parenchyma density following high dose radiation therapy for thoracic carcinomas - an automated analysis of follow up CT scans

Background

An objective way to qualify the effect of radiotherapy (RT) on lung tissue is the analysis of CT scans after RT. In this analysis we focused on the changes in Hounsfield units (ΔHU) and the correlation with the corresponding radiation dose after RT.

Methods

Pre- and post-RT CT scans were matched and ΔHU was calculated using customized research software. ΔHU was calculated in 5-Gy-intervals and the correlation between ΔHU and the corresponding dose was calculated as well as the regression coefficients. Additionally the mean ΔHU and ΔHU in 5-Gy-intervals were calculated for each tumor entity.

Results

The mean density changes at 12 weeks and 6 months post RT were 28,16 HU and 32,83 HU. The correlation coefficient between radiation dose and ΔHU at 12 weeks and 6 months were 0,166 (p = 0,000) and 0,158 (p = 0,000). The resulting regression coefficient were 1439 HU/Gy (p = 0,000) and 1612 HU/Gy (p = 0,000). The individual regression coefficients for each patient range from − 2,23 HU/Gy to 7,46 HU/Gy at 12 weeks and − 0,45 HU/Gy to 10,51 HU/Gy at 6 months. When looking at the three tumor entities individually the highest ΔHU at 12 weeks was seen in patients with SCLC (38,13 HU) and at 6 month in those with esophageal carcinomas (40,98 HU).

Conclusion

For most dose intervals there was an increase of ΔHU with an increased radiation dose. This is reflected by a statistically significant, although low correlation coefficient. The regression coefficients of all patients show large interindividual differences.

Impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer

Objective:

To evaluate the impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer.

Methods:

Breast cancer patients in whom thoracic radiotherapy was indicated after surgical treatment and chemotherapy were submitted to HRCT, respiratory evaluation, and exercise capacity evaluation before radiotherapy and at three months after treatment completion. Respiratory muscle strength testing, measurement of chest wall mobility, and complete pulmonary function testing were performed for respiratory evaluation; cardiopulmonary exercise testing was performed to evaluate exercise capacity. The total radiotherapy dose was 50.4 Gy (1.8 Gy/fraction) to the breast or chest wall, including supraclavicular lymph nodes (SCLN) or not. Dose-volume histograms were calculated for each patient with special attention to the ipsilateral lung volume receiving 25 Gy (V₂₅), in absolute and relative values, and mean lung dose.

Results:

The study comprised 37 patients. After radiotherapy, significant decreases were observed in respiratory muscle strength, chest wall mobility, exercise capacity, and pulmonary function test results (p < 0.05). DLCO was unchanged. HRCT showed changes related to radiotherapy in 87% of the patients, which was more evident in the patients submitted to SCLN irradiation. V₂₅% significantly correlated with radiation pneumonitis.

Conclusions:

In our sample of patients with breast cancer, thoracic radiotherapy seemed to have caused significant losses in respiratory and exercise capacity, probably due to chest wall restriction; SCLN irradiation represented an additional risk factor for the development of radiation pneumonitis.

Is pectus excavatum a risk factor for radiation-induced lung disease in patients undergoing radiation therapy following breast-conserving surgery?

Background

The relationship between radiation dose to the ipsilateral lung and subsequent radiation‐induced lung disease (RILD) in breast cancer patients with pectus excavatum (PE) undergoing radiation therapy (RT) to residual breast tissue after breast‐conserving surgery has not yet been established. The incidence of RILD in such patients with PE, meaning that a large volume of the lung is within the radiation field, has not been determined. Therefore, the aim of this study was to determine the relationship between these factors.

Methods

The study cohort comprised 133 women who underwent three‐dimensional conformal RT to residual breast tissue after breast‐conserving surgery for breast cancer. Diagnoses of PE were based on Haller's, frontosagittal, and Monden's depression indices. Radiation doses to the ipsilateral lung were established from dose‐volume histograms.

Results

Fifty of the 133 participants (37.6%) were diagnosed with RILD; all were asymptomatic. Multivariate analysis revealed a significant correlation between the incidence of RILD and the administration of > 30 Gy (V30). Surprisingly, although patients with PE received higher ipsilateral lung doses, they were less likely to develop RILD than those without PE.

Conclusions

Our data indicate that the incidence of RILD is correlated with the administration of > 30 Gy (V30) and that PE is not a risk factor for RILD after RT to residual breast tissue after breast‐conserving surgery for breast cancer. Surprisingly, individuals with PE may have a lower incidence of RILD than those without this condition.

Internal Mammary Chain Sentinel Nodes in Early-Stage Breast Cancer Patients: Toward Selective Removal

BACKGROUND

Removal of internal mammary chain sentinel nodes (IMCSNs) affects prognosis and treatment of breast cancer, and internal mammary chain radiotherapy (IMCRT) can improve survival for selected patients. This study aimed to determine the effect of IMCSN biopsy on recurrence-free survival (RFS) and overall survival (OS) and to identify predictive factors for IMCSN and distant metastasis.

METHODS

Patients with IMCSNs were selected from a prospective database for the period 1999-2007. Lymphoscintigraphy was performed after intratumoral technetium-99 m injection, and all sentinel nodes were removed. Both RFS and OS were calculated for subgroups with tumor-positive, tumor-negative, or non-removed IMCSNs. Predictive factors were identified for tumor-positive IMCSNs and distant metastasis by regression analysis.

RESULTS

For 287 (85%) of 336 patients, IMCSN biopsy was performed, and metastasis was detected in 38 patients (13%). The patients with tumor-positive IMCSNs had poorer OS than the patients with no IMCSN metastasis or non-removed IMCSNs (p = 0.002). These patients also had worse RFS due to distant metastasis (p = 0.002). Axillary metastasis was predictive for tumor-positive IMCSNs (positive predictive value, 38.5%). The predictive factors for distant metastasis were tumor-positive IMCSNs (hazard ratio [HR], 2.5), non-removed IMCSNs (HR, 2.3), tumor diameter greater than 1.5 cm (HR, 3.5), and age older than 65 years (HR, 3.1; reference, < 50 years).

CONCLUSIONS

Patients with IMCSNs have worse survival due to distant metastasis. The clinically relevant predictive factor for distant metastasis is tumor larger than 1.5 cm. According to the authors' current protocol, IMCSN biopsy is performed for patients younger than 70 years who have a tumor larger than 1.5 cm, with the cardiotoxicity of the adjuvant IMCRT weighed against the survival benefit.

Evaluation of tissue computed tomography number changes and dosimetric shifts after conventional whole-breast irradiation in patients undergoing breast-conserving surgery

The aim of this study was to assess tissue computed tomography (CT) number changes and corresponding dosimetric shifts in repeatedly performed simulation CT (re-sim CT) scans after conventionally fractionated irradiation in breast cancer patients. A total of 28 breast cancer patients who underwent breast-conserving surgery were enrolled in this study. All the patients had received 50.4 Gy of conventional whole-breast irradiation (WBI) and underwent re-sim CT scans for tumor bed boost. For evaluation of dosimetric shifts between initial and re-sim CT scans, electron boost plans in the same field size with the same monitor unit with source-to-skin distance of 100 cm were conducted. Dosimetric parameters (V_105%, V_103%, V_100%, V_98%, V_95%, V_90%: V_x% indicates volumes which receive X% of prescribed doses) between initial and re-sim CT scans were compared. The CT number data (CT_mean, CT_max, CT_min) of the original and irradiated CT (re-sim CT) scans from each representative structure (lung, rib bone, soft tissue, muscle, etc.) were examined and recruited. CT numbers showed highly variable changes. Soft tissue CT_mean and muscle CT_max/CT_min showed statistically and significantly increased values in the CT (re-sim CT) compared to the original CT scans. Rib bone CT_mean/CT_min showed statistically and significantly decreased values in the re-sim CT compared to the original CT scans. Other CT number values showed no statistically significant changes. Among the dosimetric parameters, only V_105% (p = 0.015, mean = 3.07 cc versus 1.63 cc) and V_103% (p = 0.017, mean = 13.8 cc versus 11.9 cc) exhibited statistically increased values in the re-sim CT compared to the original CT scans. CT number changes after conventional WBI were different according to tissue component. For electron boost plans, the implementation of a re-sim CT might be helpfully considered because significant dosimetric factor changes were observed especially in the high-dose areas (hot spots: V_105% and V_103%).

New Clinical Features and Dosimetric Predictor Identification for Symptomatic Radiation Pneumonitis after Tangential Irradiation in Breast Cancer Patients

Background: Tangential irradiation is the most popular postoperative radiotherapy technique for breast cancer. However, irradiation has been related to symptomatic radiation pneumonitis (SRP), which decreases the quality of life of patients. This study investigated the clinical features and dosimetric parameters related to SRP of the ipsilateral lung to identify risk factors for SRP in breast cancer patients after three-dimensional conformal radiation therapy (3D-CRT) with tangential fields. Material and Methods: A total of 515 breast cancer patients were evaluated and divided into two groups: the local-regional irradiation group (259 patients) and the simple local irradiation group (256 patients). Clinical symptoms were registered and patient data collected. The relationship between the incidence of SRP and dosimetric parameters for the ipsilateral lung was assessed within 6 months after 3D-CRT. Dosimetric parameters were compared using t tests. The dosimetric predictors for SRP were estimated using a logistic regression model and receiver operating characteristic curve analysis. Results: In total, 19 patients (3.7%) developed grade 2 SRP. In the local-regional irradiation group, the probability of SRP in the lung body was greater than that in the lung apex (3.9% vs. 1.5%). V20 and V30 were independent predictors for SRP in the local-regional irradiation group (odds ratio = 1.152 and 1.439, both p = 0.030), whereas only V20 was an independent predictor of SRP in the simple local irradiation group (odds ratio = 1.351, p = 0.001). With 39.8% as the optimal threshold for V20 and 25.7% for V30 for local-regional irradiation, SRP could be predicted with an accuracy of 80.3% and 79.9%, a sensitivity of 61.5% and 69.2%, and a specificity of 81.3% and 80.5%, respectively. With 20.2% as the optimal V20 threshold for simple local irradiation, SRP could be predicted with an accuracy of 88.7%, a sensitivity of 83.3% and a specificity of 89.6%. Conclusions: SRP has become a rare complication with mild symptoms and occurs mainly in the lung body. V20 and V30 may be useful dosimetric predictors to evaluate SRP risk of the ipsilateral lung in breast cancer.

Changes in pulmonary function tests in breast carcinoma patients treated with locoregional post-mastectomy radiotherapy: results of a pilot study

BACKGROUND

The aim of present pilot study was to evaluate the changes in pulmonary function tests (PFTs) after locoregional post-mastectomy radiotherapy (PMRT) in breast cancer patients.

MATERIALS AND METHODS

Twenty consecutive patients with histopathologically confirmed breast carcinoma stages T1-T4, N1-N2, who were treated with modified radical mastectomy with neoadjuvant or adjuvant chemotherapy underwent PFTs, including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), forced expiratory flow at 50%, and peak expiratory flow rate, maximum mid expiratory flow (MMEF_25-75), maximal oxygen consumption (VO₂max), and carbon monoxide diffusing capacity (DLCO) before, at 30 days, and at 90 days after locoregional PMRT. A two-tailed paired Student's t-test was used to compare mean values among the variables between the groups.

RESULTS

A significant drop in FVC, FEV₁, and DLCO was noticed at day 90 after the completion of locoregional PMRT with P-values 0.033, 0.042, and 0.031, respectively, while MMEF_25-75 and VO₂max were not significantly affected (P-values 0.075 and 0.062, respectively) favoring a restrictive lung injury pattern. However, no patient was found to be symptomatic.

CONCLUSION

A significant drop in reduction in PFTs occurred at day 90 after the completion of locoregional PMRT. PFTs shall be performed in all breast cancer patients receiving locoregional PMRT for early detection of radiation-induced lung toxicity as all patients in our cohort were found asymptomatic.

An effective deep-inspiration breath-hold radiotherapy technique for left-breast cancer: impact of post-mastectomy treatment, nodal coverage, and dose schedule on organs at risk

Background

We developed, applied, and prospectively evaluated a novel deep-inspiration breath-hold (DIBH) screening and delivery technique to optimize cardiac sparing in left-breast radiotherapy (RT) at our clinic. The impact of set-up and dose variables upon organs at risk (OAR) dose in DIBH RT was investigated.

Methods and materials

All patients with left-breast cancer referred between 2011 and 2014 – of all disease stages, set-up variations, and dose prescriptions – were included. Radiographers used simple screening criteria at CT simulation, to systematically assess patients for obvious DIBH benefit and capability. Selected patients received forward-planned intensity-modulated RT (IMRT) based on a DIBH CT scan. A 3D-surface monitoring system with visual feedback assured reproducible DIBH positioning during gated radiation delivery. Patient, target set-up, and OAR dose information were collected at treatment.

Results

Of 272 patients who were screened, 4 withdrew, 56 showed no obvious advantage, and 56 showed benefit but had suitability issues; 156 patients were selected and successfully completed DIBH treatment. The technique was compatible with complex set-up and optimal target coverage was maintained. Comparison of free-breathing (FB) and DIBH treatment plans in the first five patients enrolled confirmed DIBH reduced heart radiation by ~80% (p = 0.032). Low OAR doses were achieved overall: the mean (95% confidence interval [CI]) heart dose was 1.17 (1.12–1.22) Gy, and the mean ipsilateral lung dose was 5.26 (5.01–5.52) Gy. Patients who underwent a standard radiation schedule (40 Gy/15#) after breast-conserving surgery had the lowest OAR doses: post-mastectomy treatment, simultaneous supraclavicular (SCV) node coverage, and alternative dose schedule (50 Gy/25#) were interrelated variables associated with increased OAR risk and compromised ipsilateral lung dose constraints.

Conclusion

The DIBH technique was successfully implemented and resulted in optimally low heart radiation. All patients who demonstrate sufficient DIBH technique at planning CT are now offered DIBH RT at our clinic. Patients with more advanced disease, particularly those with additional pulmonary risk factors, warrant additional focus to improve lung sparing.

Pulmonary injury associated with radiation therapy - Assessment, complications and therapeutic targets

Pulmonary injury is more common in patients undergoing radiation therapy for lungs and other thoracic malignancies. Recently with the use of most-advanced technologies powerful doses of radiation can be delivered directly to tumor site with exquisite precision. The awareness of technical and clinical parameters that influence the chance of radiation induced lung injury is important to guide patient selection and toxicity minimization strategies. At the cellular level, radiation activates free radical production, leading to DNA damage, apoptosis, cell cycle changes, and reduced cell survival. Preclinical research shows the potential for therapies targeting transforming growth factor-β (TGF-B), Toll like receptor (TLRs), Tumour necrosis factor-alpha (TNF-alpha), Interferon gamma (IFN-γ) and so on that may restore lung function. At present Amifostine (WR-2721) is the only approved broad spectrum radioprotector in use for patients undergoing radiation therapy. Newer techniques also offer the opportunity to identify new biomarkers and new targets for interventions to prevent or ameliorate these late effects of lung damage.

Radiation-Induced Organizing Pneumonia: A Characteristic Disease that Requires Symptom-Oriented Management

Radiation-induced organizing pneumonia (RIOP) is an inflammatory lung disease that is occasionally observed after irradiation to the breast. It is a type of secondary organizing pneumonia that is characterized by infiltrates outside the irradiated volume that are sometimes migratory. Corticosteroids work acutely, but relapse of pneumonia is often experienced. Management of RIOP should simply be symptom-oriented, and the use of corticosteroids should be limited to severe symptoms from the perspective not only of cost-effectiveness but also of cancer treatment. Once steroid therapy is started, it takes a long time to stop it due to frequent relapses. We review RIOP from the perspective of its diagnosis, epidemiology, molecular pathogenesis, and patient management.

Changes in pulmonary function and influencing factors after high-dose intrathoracic radio(chemo)therapy

PURPOSE

Using prospectively collected patient-related, dose-related, and pulmonary function test (PFT) data before radiotherapy (RT) and at several follow-up visits after RT, the time course of PFT changes after high-dose radio(chemo)therapy and influencing factors were analyzed.

MATERIALS AND METHODS

From April 2012 to October 2015, 81 patients with non-small-cell lung carcinoma (NSCLC), small cell lung carcinoma (SCLC), or esophageal carcinoma where treated with high-dose radio(chemo)therapy. PFT data were collected before treatment and 6 weeks, 12 weeks, and 6 months after RT. The influence of patient- and treatment-related factors on PFT was analyzed.

RESULTS

Mean forced expiratory volume in 1 s (FEV1) constantly declined during follow-up (p = 0.001). In total, 68% of patients had a reduced FEV1 at 6 months. Mean vital capacity (VC) didn't change during follow-up (p > 0.05). Mean total lung capacity (TLC) showed a constant decline after RT (p = 0.026). At 6 months, 60% of patients showed a decline in VC and 73% in TLC. The mean diffusion capacity for carbon monoxide (DLCO) declined at 6 and 12 weeks, but recovered slightly at 6 months (p < 0.0005). At 6 months, 86% of patients had a reduced DLCO. After treatment, the partial pressure of CO₂ in the blood (pCO₂) was increased and pO₂ was decreased (p > 0.05). Only the pretreatment PFT classification had a significant influence on the post-RT FEV1.

CONCLUSION

DLCO seems to be the most reliable indicator for lung tissue damage after thoracic RT. Ventilation parameters appear to be less reliable. Concerning patient- or treatment-related factors, no reliable conclusion can be drawn regarding which factors may be relevant.

Radiation Pneumonitis in Association with Internal Mammary Node Irradiation in Breast Cancer Patients: An Ancillary Result from the KROG 08-06 Study

Purpose

The aim of this study is to present the incidence of radiation pneumonitis (RP) reported within 6 months after treatment for breast cancer with or without internal mammary node irradiation (IMNI).

Methods

In the Korean Radiation Oncology Group (KROG) 08-06 phase III randomized trial, patients who were node-positive after surgery were randomly assigned to receive radiotherapy either with or without IMNI. A total of 747 patients were enrolled, and three-dimensional treatment planning with computed tomography simulation was performed for all patients. Of the 747 patients, 722 underwent chest X-rays before and within 6 months after radiotherapy. These 722 patients underwent evaluation, and RP was diagnosed on the basis of chest radiography findings and clinical symptoms. The relationship between the incidence of RP and clinical/dosimetric parameters was analyzed.

Results

RP developed in 35 patients (4.8%), including grade 1 RP in 26 patients (3.6%), grade 2 RP in nine patients (1.2%); there was no incidence of grade 3 or higher RP. Grade 2 RP cases were observed in only the IMNI group. The risk of developing RP was influenced by IMNI treatment; pneumonitis occurred in 6.5% of patients (n=23/356) who underwent IMNI and in 3.3% of patients (n=12/366) who did not (p=0.047). The differences in lung dosimetric parameters (mean lung dose, V10–40) were statistically significant between the two groups.

Conclusion

IMNI treatment resulted in increased radiation exposure to the lung and a higher rate of RP, but the incidence and severity of RP was minimal and acceptable. This minor impact on morbidity should be balanced with the impact on survival outcome in future analyses.

A lot to a little or a little to a lot-which dose-volume relationship ensures the best clinical outcome in the high dose radiation therapy of thoracic tumors? A prospective approach

BACKGROUND

The purpose of this prospective randomized trial is to determine which constellation of dose and corresponding volume of the lung tissue-either a lot to a little or a little to a lot-should be preferred to ensure the best possible outcome for patients with thoracic carcinomas.

METHODS

From Apr 2012 to Oct 2015, 81 patients with NSCLC, SCLC or esophageal carcinoma were randomized and treated with either a 4-field-IMRT or a VMAT technique with or without additional chemotherapy. Data regarding clinical outcome, pulmonary function tests (PFT) and quality of life (QoL) was collected before RT, 6 weeks, 12 weeks and 6 months after treatment, QoL data additionally 1 year post RT. Follow up CTs were done 12 weeks and 6 months after RT.

RESULTS

There is no significant difference regarding the local (P=0.954) and distant (P=0.206) outcome, side effects (all P>0.05) or survival (P=0.633) at any follow-up appointment. The comparison of the PFT shows a statistically significant difference for the DLCO 6 weeks post RT (P=0.028). All other parameters do not differ significantly at any follow up appointment. Regarding the QoL there is no statistically significant difference at any follow up appointment (P>0.1). There is a statistically significant difference between the mean density of the lung parenchyma at 12 weeks (P<0.0005) and 6 months post RT (P<0.0005).

CONCLUSIONS

Since there is no significant and relevant difference between both treatment arms regarding PFT, clinical outcome and QoL it does not seem to relevant how the DVH is shaped exactly as long as established dose constraints for the organs at risk are respected. As to whether the difference between the CT density changes is clinically relevant further analysis is needed.

Respiratory Factors Contributing to Exercise Intolerance in Breast Cancer Survivors: A Case-Control Study

CONTEXT

Breast cancer survivors often experience activity-related dyspnea and exercise intolerance, but the underlying mechanisms remain unknown.

OBJECTIVES

We evaluated physiological contributors to reduced peak oxygen uptake (VO2), with particular attention to the role of respiratory impairment.

METHODS

We compared symptom assessments, respiratory and peripheral muscle strength, pulmonary function, and ventilatory responses to symptom-limited incremental treadmill exercise in 29 women who had survived breast cancer and 29 age-matched healthy controls.

RESULTS

Peak VO2 was reduced more than 20%, on average, in the cancer group compared with controls (P < 0.001). Slopes of dyspnea intensity ratings over ventilation or VO2 were >50% greater in the cancer group compared to controls (P < 0.05). Women with breast cancer had lower lung diffusing capacity for carbon monoxide (DLCO), respiratory and limb muscle strength, and ventilatory thresholds during exercise compared with controls (all P < 0.05). During exercise, indices of ventilatory efficiency were similar to controls, but inspiratory capacity (IC) was lower and breathing pattern was more rapid and shallow in the cancer group (P < 0.05). The lower peak VO2 in the cancer group was associated with greater dyspnea intensity, and lower DLCO, IC and ventilatory threshold (all P < 0.05).

CONCLUSION

Breast cancer survivors had greater peripheral and respiratory muscle weakness, greater reduction of IC, impaired lung diffusion, and evidence of deconditioning compared with controls. Exercise intolerance was multifactorial and correlated well with the combination of these factors as well as with exertional dyspnea. Individualized physiological testing in breast cancer survivors can identify important contributors to exercise intolerance which can be targeted for treatment.

Hypofractionated Radiation Therapy for Breast Cancer: Long-Term Results in a Series of 85 Patients

Purpose

Whole-breast irradiation after conservative surgery is the standard treatment for early breast cancer. The purpose of this study is to report the late toxicity, cosmetic result, and disease control in a group of patients treated with hypofractionated radiotherapy (RT) comparing results with retrospective data of a control group who underwent conventional RT.

Methods

From 2006 to 2008, 85 patients were treated with hypofractionated schedule to dose of 45 Gy, 2.25 Gy/fr, followed by a boost. We evaluated late toxicity, cosmetic result, and disease control. The data were compared to a control group of 70 patients who underwent conventional RT before 2006.

Results

At 8 years of follow-up, the cumulative incidence of late skin toxicity was 6.2 in the hypofractionated RT group and 7.5 in the standard RT group (p = 0.94). The cumulative incidence of late subcutaneous tissue toxicity was 11.6 in the hypofractionated RT group and 18.7 in the standard RT group (p = 0.23). Cosmetic outcome was rated as excellent or good in 84/85 patients of the hypofractionated RT group and in 68/70 patients of the conventional RT group (p = 0.7). No statistically significant differences were found in terms of local control (p = 0.05), disease-free survival (p = 0.06), or overall survival (p = 0.17) between the 2 groups.

Conclusions

The present analysis, focused on long-term effects, disease control, and survival, confirms, in a daily practice setting, the low incidence of skin atrophy and fibrosis, the satisfactory cosmetic outcome, and the high grade of local and distant disease control with hypofractionated schedule.

Should we include SPECT lung perfusion in radiotherapy treatment plans of thoracic targets? Evidences from the literature

PURPOSE

To report the available data about the potential impact of integrating lung perfusion SPECT/CT in treatment plans optimization for the irradiation of thoracic targets.

MATERIALS AND METHODS

We searched in the PubMed and Scopus databases, English-written articles published from 2000 to June 2015 dealing with the integration of perfusion SPECT/CT in radiotherapy.

RESULTS

We found and analyzed 16 research articles (10 dosimetric, 6 clinical) for a total of 578 patients. Available data suggest dosimetric and clinical improvements when perfusion SPEC/CT is integrated in the radiotherapy treatment planing of selected patients with thoracic targets. In particular, patients presenting emphysema and/or large areas of deficit of perfusion show the most important improvements. Moreover, some studies show different risk of radiation pneumonitis (RP) depending on the localization of the tumor in the lungs: patients with low-located tumors, present an increased risk of RP, and functional data could be a benefit in treatment plan optimization. Unfortunately, none of the available studies finally reports any dosimetric constraint, which could be used in the clinical practice, even if most of them used the cut-off of the 30% of the maximal perfusion value to define the well-functioning lung.

CONCLUSIONS

Published data support the integration of lung perfusion scintigraphy in some selected categories of patients. Prospective studies should be designed to define the best candidates, and to assess the clinical advantage of this kind of optimization.

Mild Lung Restriction in Breast Cancer Patients After Hypofractionated and Conventional Radiation Therapy: A 3-Year Follow-Up

PURPOSE

To assess the effect of radiation therapy on lung function over the course of 3 years.

METHODS AND MATERIALS

Evolution of restrictive and obstructive lung function parameters was investigated in 108 breast cancer participants in a randomized, controlled trial comparing conventional radiation therapy (CR) and hypofractionated tomotherapy (TT) (age at inclusion ranging 32-81 years). Spirometry, plethysmography, and hemoglobin-corrected diffusing capacity were assessed at baseline and after 3 months and 1, 2, and 3 years. Natural aging was accounted for by considering all lung function parameters in terms of percent predicted values using the most recent reference values for women aged up to 80 years.

RESULTS

In the patients with negligible history of respiratory disease or smoking (n=77), the greatest rate of functional decline was observed during the initial 3 months, this acute decrease being more marked in the CR versus the TT arm. During the remainder of the 3-year follow-up period, values (in terms of percent predicted) were maintained (diffusing capacity) or continued to decline at a slower rate (forced vital capacity). However, the average decline of the restrictive lung function parameters over a 3-year period did not exceed 9% predicted in either the TT or the CR arm. Obstructive lung function parameters remained unaffected throughout. Including also the 31 patients with a history of respiratory disease or more than 10 pack-years showed a very similar restrictive pattern.

CONCLUSIONS

In women with breast cancer, both conventional radiation therapy and hypofractionated tomotherapy induce small but consistent restrictive lung patterns over the course of a 3-year period, irrespective of baseline respiratory status or smoking history. The fastest rate of lung function decline generally occurred in the first 3 months.

Changes in pulmonary function after definitive radiotherapy for NSCLC

INTRODUCTION

The objective of this study was to identify factors associated with early and long-term pulmonary function (PF) changes after definitive radiotherapy for NSCLC patients. PF was measured by spirometry i.e. forced expiratory volume in 1s (FEV1), and forced vital capacity (FVC).

MATERIALS

Early (within the first year) PF change was analyzed in 211 patients with 986 pairs of PF-tests (PFTs). Long-term PF change was analyzed relative to the PF at 12months after radiotherapy in 106 patients (1286 PFTs). To investigate the impact of patient and treatment related factors on PF, they were tested as covariates in multivariable analysis.

RESULTS

Early PF change was quantified at six months after the start of radiotherapy. Smoking status and increasing V60 was associated with a significant decrease in PF, whereas smoking was protective. In addition, neoadjuvant chemotherapy had a negative impact on FVC. Long-term FEV1 and FVC were analyzed using linear regression. Treatment year and V60 had a significant impact on loss of FEV1. V60 had a significant impact on FVC changes.

CONCLUSION

In this study, early PF change reached a plateau at 6months after the start of radiotherapy for NSCLC. Large volume of lung receiving high dose was associated with long-term FEV1 change.

Internal Mammary and Medial Supraclavicular Irradiation in Breast Cancer

BACKGROUND

The effect of internal mammary and medial supraclavicular lymph-node irradiation (regional nodal irradiation) added to whole-breast or thoracic-wall irradiation after surgery on survival among women with early-stage breast cancer is unknown.

METHODS

We randomly assigned women who had a centrally or medially located primary tumor, irrespective of axillary involvement, or an externally located tumor with axillary involvement to undergo either whole-breast or thoracic-wall irradiation in addition to regional nodal irradiation (nodal-irradiation group) or whole-breast or thoracic-wall irradiation alone (control group). The primary end point was overall survival. Secondary end points were the rates of disease-free survival, survival free from distant disease, and death from breast cancer.

RESULTS

Between 1996 and 2004, a total of 4004 patients underwent randomization. The majority of patients (76.1%) underwent breast-conserving surgery. After mastectomy, 73.4% of the patients in both groups underwent chest-wall irradiation. Nearly all patients with node-positive disease (99.0%) and 66.3% of patients with node-negative disease received adjuvant systemic treatment. At a median follow-up of 10.9 years, 811 patients had died. At 10 years, overall survival was 82.3% in the nodal-irradiation group and 80.7% in the control group (hazard ratio for death with nodal irradiation, 0.87; 95% confidence interval [CI], 0.76 to 1.00; P=0.06). The rate of disease-free survival was 72.1% in the nodal-irradiation group and 69.1% in the control group (hazard ratio for disease progression or death, 0.89; 95% CI, 0.80 to 1.00; P=0.04), the rate of distant disease-free survival was 78.0% versus 75.0% (hazard ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02), and breast-cancer mortality was 12.5% versus 14.4% (hazard ratio, 0.82; 95% CI, 0.70 to 0.97; P=0.02). Acute side effects of regional nodal irradiation were modest.

CONCLUSIONS

In patients with early-stage breast cancer, irradiation of the regional nodes had a marginal effect on overall survival. Disease-free survival and distant disease-free survival were improved, and breast-cancer mortality was reduced. (Funded by Fonds Cancer; ClinicalTrials.gov number, NCT00002851.).

Radiation Pneumonitis After Conventional Radiotherapy For Breast Cancer: A Prospective Study

BACKGROUND

Loco-regional radiotherapy is an important treatment modality in breast cancer and radiation pneumonitis (RP) is one of the early toxicities.

AIM

To study the occurrence, correlation of RP with patient and radiotherapy related factors and the effects on pulmonary function following conventional radiotherapy in breast cancer.

SETTINGS AND DESIGN

Prospective study, from a tertiary hospital in a developing country.

MATERIALS AND METHODS

Prospective analysis of clinical symptoms, pulmonary function and radiologic changes was done prior to and 12 weeks after adjuvant radiotherapy (n=46). Statistical analysis was done using SPSS version 10 software.

RESULTS

Radiological and clinical RP was seen in 45.65% (n=21) and 19.56% (n=9) respectively. RP was significantly higher with age >50 years (OR 4.4), chest wall irradiation with electrons, (electrons 83.3% vs cobalt60 32.4%, p=0.02) and supraclavicular field treatment with 6 MV photons (p= 0.011). There was significant relationship between Inferior Lung Distance (ILD) and RP (p=0.013). The fall in Total Lung Capacity (TLC) was significantly more in those with RP (p=0.02).

CONCLUSION

Clinical RP occurs in almost one-fifth of breast cancer patients treated with conventional radiotherapy. Chest wall irradiation with electrons, supraclavicular field irradiation with 6 MV photons, higher ILD and age >50 years was associated with increased RP. The pulmonary function parameter most affected was TLC. The factors associated with increased RP should be considered when adjuvant radiotherapy is planned to minimize its likelihood and intervene appropriately.

Exercise preferences, levels and quality of life in lung cancer survivors

PURPOSE

Lung cancer poses multiple challenges to adopting an exercise (EX) program, and the ideal timing of an EX program to improve quality of life (QoL) is unknown. This study explored the EX counselling and programming preferences of lung cancer survivors and examined the association of EX before diagnosis, during treatment and after treatment on QoL.

METHODS

Cross-sectional, retrospective survey design in a sample of lung cancer survivors. EX preferences were compared between patients who had received radical chest radiation or lung surgery versus those who had not. EX was measured by self-report using the Godin Leisure Time Exercise Questionnaire (GLTEQ). Separate linear regression models, controlling for significant covariates, examined the association of EX at each time point with scores on QoL measures and subscales.

RESULTS

Participants (N = 66, M age 66.4 ± 9.1) were between 4 months and 11.5 years after lung cancer diagnosis (M = 31.7 ± 22.9 months). Patients who had lung surgery were more likely to prefer to start an EX program during adjuvant treatment than those who did not have surgery (t(33) = 2.43, p = .025). Compared to prediagnosis EX (M = 36.7 ± 56.0 MET h/week), EX levels declined significantly during (M = 12.4 ± 25.0 MET h/week) and after (M = 12.3 ± 17.4 MET h/week) treatment (p < .05). After controlling for disease stage and income, regression models were not significant, but EX after treatment was a significant individual predictor of fatigue (β = .049, p = .006) and QoL measured by the Chronic Respiratory Disease Questionnaire (β = .163, p = .025).

CONCLUSIONS

Lung cancer patient preferences indicate that EX program timing should take into account whether the patient has undergone surgery. Lung cancer survivors' EX levels declined after diagnosis and engaging in EX after treatment may improve fatigue and QoL.

Analysis of predictive factors for lung injury after forward-planned intensity-modulated radiotherapy in whole breast irradiation

Purpose

This study was performed to assess frequency, timings of occurrence, and predictors of radiologic lung damage (RLD) after forward-planned intensity-modulated radiotherapy (FIMRT) for whole breast irradiation.

Methods

We retrospectively reviewed medical records of 157 breast cancer patients and each of their serial chest computed tomography (CT) taken 4, 10, 16, and 22 months after completion of breast radiotherapy (RT). FIMRT was administered to whole breast only (n=152), or whole breast and supraclavicular regions (n=5). Dosimetric parameters, such as mean lung dose and lung volume receiving more than 10 to 50 Gy (V₁₀-V₅₀), and clinical parameters were analyzed in relation to radiologic lung damage.

Results

In total, 104 patients (66.2%) developed RLD after whole breast FIMRT. Among the cases of RLD, 84.7% were detected at 4 months, and 15.3% at 10 months after completion of RT. More patients of 47 or younger were found to have RLD at 10 months after RT than patients older than the age (11.7% vs. 2.9%, p=0.01). In univariate and multivariate analyses, age >47 and V₄₀ >7.2% were significant predictors for higher risk of RLD.

Conclusion

RLD were not infrequently detected in follow-up CT after whole breast FIMRT. More detected cases of RLD among younger patients are believed to have developed at later points after RT than those of older patients. Age and V₄₀ were significant predictors for RLD after whole breast intensity-modulated radiotherapy.

Meta-analysis of incidence of early lung toxicity in 3-dimensional conformal irradiation of breast carcinomas

Background

This meta-analysis aims to ascertain the significance of early lung toxicity with 3-Dimensional (3D) conformal irradiation for breast carcinomas and identify the sub-groups of patients with increased risk.

Methods

Electronic databases, reference sections of major oncological textbooks and identified studies were searched for synonyms of breast radiotherapy and radiation pneumonitis (RP). Major studies in thoracic irradiation were reviewed to identify factors frequently associated with RP. Meta-analysis for RP incidence estimation and odds ratio calculation were carried out.

Results

The overall incidence of Clinical and Radiological RP is 14% and 42% respectively. Ten studies were identified. Dose-volume Histogram (DVH) related dosimetric factors (Volume of lung receiving certain dose, V_dose and Mean lung Dose, MLD), supraclavicular fossa (SCF) irradiation and age are significantly associated with RP, but not sequential chemotherapy and concomitant use of Tamoxifen. A poorly powered study in IMN group contributed to the negative finding. Smoking has a trend towards protective effect against RP.

Conclusion

Use of other modalities may be considered when Ipsilateral lung V_20Gy > 30% or MLD > 15 Gy. Extra caution is needed in SCF and IMN irradiation as they are likely to influence these dosimetric parameters.

Breast cancer subtypes: response to radiotherapy and potential radiosensitisation

Radiotherapy (RT) is of critical importance in the locoregional management of early breast cancer. Over 50% of patients receive RT at some time during the treatment of their disease, equating to over 500 000 patients worldwide receiving RT each year. Unfortunately, not all patients derive therapeutic benefit and some breast cancers are resistant to treatment, as evidenced by distant metastatic spread and local recurrence. Prediction of individual responses to RT may allow a stratified approach to this treatment permitting those patients with radioresistant tumours to receive higher doses of RT (total and/or tumour cavity boost doses) and/or radiosensitising agents to optimise treatment. Also, for those patients unlikely to respond at all, it would prevent harmful side effects occurring for no therapeutic gain. More selective targeting would better direct National Health Service resources, ease the burden on heavily used treatment RT machines and reduce the economic cost of cancer treatment. Unfortunately, there are no robust and validated biomarkers for predicting RT outcome. We review the available literature to determine whether classification of breast cancers according to their molecular profile may be used to predict successful response to, or increased morbidity from, RT. Class-specific biomarkers for targeting by radiosensitising agents are also discussed.

Radiation pneumonitis in breast cancer patients who received radiotherapy using the partially wide tangent technique after breast conserving surgery

Purpose

We assessed the risk of radiation pneumonitis (RP) in terms of dosimetric parameters in breast cancer patients, who received radiotherapy using the partially wide tangent technique (PWT), following breast conservation surgery (BCS).

Methods

We analyzed the data from 100 breast cancer patients who underwent radiotherapy using PWT. The entire breast, supraclavicular lymph node, and internal mammary lymph node (IMN) were irradiated with 50.4 Gy in 28 fractions. RP was scored on a scale of 0 to 5, based on Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity criteria. The dosimetric parameters, used in analysis for the ipsilateral lung, were the mean lung dose (MLD), V₅ (percentage of lung volume that received a dose of 5 Gy or more)-V₅₀, and normal tissue complication probability (NTCP).

Results

Of the 100 patients, three suffered from symptomatic RP (symptom grade ≥2), but were relieved by supportive care. The risk of RP was not correlated with the treatment regimen. RP associated mostly with asymptomatic minimal pulmonary radiologic change or mild dry cough developed more frequently in the group with MLD ≥20.5 Gy or NTCP ≥23% than in the group with MLD <20.5 Gy and NTCP <23% (48.6% vs. 25.4%, p=0.018).

Conclusion

Dosimetric parameters of MLD and NTCP were correlated with the incidence of RP, but the clinical impact was minimal. We suggest that PWT is a safe technique for the treatment of IMN for BCS patients with low risk of symptomatic RP.

Delayed noninvasive reduction of large bullae following thoracic irradiation

Chest radiotherapy is a mainstay of management of thoracic oncology patients. Radiotherapy also injures nontarget tissues such as the lungs, coronary arteries, and esophagus, and safe limits to the doses that can be delivered to tumors have been determined empirically. Patients afflicted with lung cancer due to smoking often have concomitant chronic obstructive pulmonary disease which, on occasion, manifests as bullous emphysema. We describe a case and course of treatment of lung cancer found incidentally in a patient followed for severe pulmonary emphysema. Treatment consisted of radiochemotherapy after induction chemotherapy. Three years after the end of antineoplastic treatment, a follow-up computed tomography scan revealed complete retraction of a large emphysematous bulla that had been present prior to treatment.