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Colciago RR, Cavallo A, Magri MC, Vitullo A, La Rocca E, Giandini C, Bonfantini F, Di Cosimo S, Baili P, Sant M, Pignoli E, Valdagni R, Lozza L, De Santis MC. Hypofractionated whole-breast radiotherapy in large breast size patients: is it really a resolved issue? MEDICAL ONCOLOGY (NORTHWOOD, LONDON, ENGLAND) 2021; 38:107. [PMID: 34342725 DOI: 10.1007/s12032-021-01550-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to evaluate the impact of breast size on acute and late side effects in breast cancer (BC) patients treated with hypofractionated radiotherapy (Hypo-RT). In this study we analyzed patients over 50 years with a diagnosis of early BC, candidate for Hypo-RT after conservative surgery. Acute and late skin toxicities were evaluated in accordance with the RTOG scale. Multivariable logistic analysis was performed using dosimetric/anatomical factors resulted associated with toxicity outcome in univariable analysis. Among patients treated between 2009 and 2015, 425 had at least 5 years of follow-up. At RT end, acute skin toxicity ≥ G2 and edema ≥ G2 occurred in 88 (20.7%) and 4 (0.9%) patients, respectively. The multivariable analysis showed association of skin toxicity with boost administration (p < 0.01), treated skin area (TSA) receiving more than 20 Gy (p = 0.027) and breast volume receiving 105% of the prescription dose (V105%) (p = 0.016), but not breast size. At 5 years after RT, fibrosis ≥ G1 occurred in 89 (20.9%) patients and edema ≥ G1 in 36 (8.5%) patients. Fibrosis resulted associated with breast volume ≥ 1000 cm3 (p = 0.04) and hypertension (p = 0.04). As for edema, multivariable logistic analysis showed a correlation with hypertension and logarithm of age, but not with boost administration. Breast volume had an unclear impact (p = 0.055). A recurrent association was found between acute and late toxicities and breast V105%, which is correlated with breast size. This may suggest that a more homogenous RT technique may be preferred for patients with larger breast size.
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Affiliation(s)
- Riccardo Ray Colciago
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Radiotherapy, Università Degli Studi di Milano Bicocca, Milan, Italy
| | - Anna Cavallo
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Chiara Magri
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Angelo Vitullo
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy
| | - Eliana La Rocca
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy. .,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy.
| | - Carlotta Giandini
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy
| | - Francesca Bonfantini
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Serena Di Cosimo
- Department of Applied Research and Technological Development (DRAST), Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paolo Baili
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy.,Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Lozza
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy
| | - Maria Carmen De Santis
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy
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Hypofractionated Whole Breast Irradiation and Simultaneous Integrated Boost in Large-breasted Patients: Long-term Toxicity and Cosmesis. Clin Breast Cancer 2020; 20:527-533. [PMID: 32665192 DOI: 10.1016/j.clbc.2020.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/03/2020] [Accepted: 06/12/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the impact of breast size on long-term toxicity and cosmesis in patients with breast cancer treated with hypofractionated simultaneous integrated boost (SIB) using volumetric modulated arc therapy (VMAT). PATIENTS AND METHODS Patients with early stage breast cancer were treated with 3-week hypofractionated SIB-VMAT to the whole breast (40.5 Gy) and tumor bed (48 Gy). Two cohorts were identified: small/medium- (< 1000 cm3) and large- (> 1000 cm3) breasted patients. Acute and late (at 2 and 5 years) skin toxicity and cosmetic data were analyzed. Univariate and multivariate analysis evaluated associations between toxicity and dosimetric/anatomical variables. RESULTS From August 2010 to March 2017, a total of 1160 patients were treated; 831 had at least 2 years of follow-up and were analyzed. Treated skin area (TSA) receiving at least 20 Gy > 400 cm2 and V105% of Boost > 5 cm3 were significant predictors for acute skin toxicity. Multivariate analysis at 2 years was significant for boost volume > 70 cm3, TSA > 400 cm2, and breast size > 1500 cm3. At 5 year analysis (352 patients), none of the analyzed variables was significant. For cosmetic outcome, only the breast size (> 1000 cm3) and the boost size > 70 cm3 at 2 and 5 years, respectively, confirmed significance. CONCLUSIONS The TSA > 400 cm2 resulted as a significant predictor of both acute and late skin toxicity at 2 years; however, at 5 years, no breast size or dosimetric parameter suggested indications for increased toxicity. A worse cosmetic outcome was recorded at the 2-year follow up for large breasts, but was not confirmed at the 5-year follow-up. These long-term data suggest that hypofractionated SIB-VMAT is a viable modality also in large-breasted patients.
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Gortman AM, Aherne NJ, Amalaseelan J, Last A, Westhuyzen J, Chamberlain L, Shakespeare TP. Long-term outcomes of patients with conserved breast cancer treated with adjuvant hypofractionated prone breast intensity-modulated radiation therapy. J Med Imaging Radiat Oncol 2020; 64:845-851. [PMID: 32543013 DOI: 10.1111/1754-9485.13072] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 05/20/2020] [Indexed: 01/13/2023]
Abstract
INTRODUCTION New techniques for adjuvant radiation therapy after breast conservation include prone positioning, hypofractionation and intensity-modulated radiation therapy (IMRT). Long-term evaluations of this combination are lacking, and we report our own experience. METHODS Patients with invasive breast cancer followed for a minimum 36 months post-IMRT were eligible. Dose used was 40 Gray in 15 fractions over 3 weeks to the whole breast via forward-planned prone, whole breast IMRT. A 10 Gy in 5 fraction supine boost was offered. RESULTS Between January 2012 and January 2020, 2199 patients had breast conservation and adjuvant radiation: 489 received hypofractionated prone breast IMRT, with 155 eligible for our evaluation. Median follow-up was 52 months. Median age was 62 (range 36-80), 78.7% were T1, 20.6% were T2, and 12.3% were node-positive. Grade was 1 in 26.5%, 2 in 43.9% and 3 in 29.7%; 87.1% were oestrogen receptor positive, 3.2% were HER2 positive, and 11.0% were triple negative. 58.6% received a boost, 74.8% endocrine therapy and 32.3% chemotherapy. No patient developed local recurrence. One regional recurrence was successfully salvaged. Six patients (3.9%) developed metastases, and 1.9% died. Five-year actuarial local recurrence-free, regional recurrence-free and breast cancer-specific survival rates were 100.0%, 98.2% and 94.8%. Late grade 1 and 2 breast pain occurred in 20.0% and 1.3% of patients. Only 11.0% had new pain compared to pre-radiation. No patient developed radiation-induced pneumonitis, pulmonary fibrosis, rib fracture or cardiac toxicity. All patients scored cosmesis as 'good' or better. CONCLUSION Adjuvant hypofractionated prone breast IMRT has excellent locoregional control and minimal toxicity.
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Affiliation(s)
- Aron M Gortman
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore, New South Wales, Australia
| | - Noel J Aherne
- Department Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia.,Rural Clinical School, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - Julan Amalaseelan
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore, New South Wales, Australia
| | - Andrew Last
- Department Radiation Oncology, Mid North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Justin Westhuyzen
- Department Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Lauren Chamberlain
- Department Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Thomas P Shakespeare
- Department of Radiation Oncology, North Coast Cancer Institute, Lismore, New South Wales, Australia.,Department Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia.,Rural Clinical School, University of New South Wales, Coffs Harbour, New South Wales, Australia.,Department Radiation Oncology, Mid North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
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De Rose F, Fogliata A, Franceschini D, Iftode C, Navarria P, Comito T, Franzese C, Fernandes B, Masci G, Torrisi R, Tinterri C, Testori A, Santoro A, Scorsetti M. Hypofractionation with simultaneous boost in breast cancer patients receiving adjuvant chemotherapy: A prospective evaluation of a case series and review of the literature. Breast 2018; 42:31-37. [PMID: 30149235 DOI: 10.1016/j.breast.2018.08.098] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/16/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION To evaluate acute toxicity and cosmetic outcomes of hypofractionated simultaneous integrated boost (SIB) as adjuvant treatment after breast-conserving surgery and adjuvant chemotherapy and to review the association of chemotherapy and short fractionation with boost. MATERIALS AND METHODS Patients presenting early-stage breast cancer were enrolled in a phase II trial. All patients received VMAT-SIB technique to the whole breast and tumor bed in 15 fractions, for a total dose of 40.5 and 48 Gy. Acute and late skin toxicities and breast pain were recorded. Cosmetic outcomes were also assessed as excellent/good or fair/poor. RESULTS Between August 2010 and December 2015, 787 consecutive patients were treated and had at least 2 year follow-up. A subset of 175 patients underwent adjuvant chemotherapy (median age of 55 years) and was analysed. The median follow up was 39 months (range 24-80). At the end of RT treatment, skin toxicity was G1 in 51.1% of patients, G2 in 9.7%. At 2 years of follow up, it was G1 in 13.5% of patients, no cases ≥ G2; cosmetic outcome was excellent in 63.5% and good in 36.5% of the patients. No significant difference compared to the patients without systemic therapy was observed. CONCLUSION Hypofractionated VMAT-SIB in patients who had undergone adjuvant systemic therapy was safe and well tolerated in terms of acute and early late settings and cosmesis. Our data confirmed the results of other studies published on the association of hypofractionation and chemotherapy or concomitant boost.
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Affiliation(s)
- Fiorenza De Rose
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy
| | - Antonella Fogliata
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy.
| | - Davide Franceschini
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy
| | - Cristina Iftode
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy
| | - Pierina Navarria
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy
| | - Tiziana Comito
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy
| | - Ciro Franzese
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy
| | - Bethania Fernandes
- Humanitas Research Hospital and Cancer Center, Pathology Dept, Milan, Rozzano, Italy
| | - Giovanna Masci
- Humanitas Research Hospital and Cancer Center, Medical Oncology Dept, Milan, Rozzano, Italy
| | - Rosalba Torrisi
- Humanitas Research Hospital and Cancer Center, Medical Oncology Dept, Milan, Rozzano, Italy
| | - Corrado Tinterri
- Humanitas Research Hospital and Cancer Center, Breast Surgery Dept, Milan, Rozzano, Italy
| | - Alberto Testori
- Humanitas Research Hospital and Cancer Center, Breast Surgery Dept, Milan, Rozzano, Italy
| | - Armando Santoro
- Humanitas Research Hospital and Cancer Center, Medical Oncology Dept, Milan, Rozzano, Italy
| | - Marta Scorsetti
- Humanitas Research Hospital and Cancer Center, Radiotherapy and Radiosurgery Dept, Milan, Rozzano, Italy; Humanitas University, Biomedical Science Faculty, Milan, Rozzano, Italy
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Utilization of hypofractionated whole-breast radiation therapy in patients receiving chemotherapy: a National Cancer Database analysis. Breast Cancer Res Treat 2017. [PMID: 28639030 DOI: 10.1007/s10549-017-4345-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Results from four major hypofractionated whole-breast radiotherapy (HF-WBRT) trials have demonstrated equivalence in select patients with early-stage breast cancer when compared with conventionally fractionated WBRT (CF-WBRT). Because relatively little data were available on patients receiving neoadjuvant or adjuvant chemotherapy, consensus guidelines published in 2011 did not endorse the use of HF-WBRT in this population. Our goal is to evaluate trends in utilization of HF-WBRT in patients receiving chemotherapy. METHODS AND MATERIALS We retrospectively analyzed data from 2004 to 2013 in the National Cancer DataBase on breast cancer patients treated with HF-WBRT who met the clinical criteria proposed by consensus guidelines (i.e., age >0 years, T1-2N0, and breast-conserving surgery), regardless of receipt of chemotherapy. We employed logistic regression to delineate and compare clinical and demographic factors associated with utilization of HF-WBRT and CF-WBRT. RESULTS A total of 56,836 women were treated with chemotherapy and WBRT (without regional nodal irradiation) from 2004 to 2013; 9.0% (n = 5093) were treated with HF-WBRT. Utilization of HF-WBRT increased from 4.6% in 2004 to 18.2% in 2013 (odds ratio [OR] 1.21/year; P < 0.001). Among patients receiving chemotherapy, factors most dramatically associated with increased odds of receiving HF-WBRT on multivariate analysis were academic facilities (OR 2.07; P < 0.001), age >80 (OR 2.58; P < 0.001), west region (OR 1.91; P < 0.001), and distance >50 miles from cancer reporting facility (OR 1.43; P < 0.001). Factors associated with decreased odds of receiving HF-WBRT included white race, income <$48,000, lack of private insurance, T2 versus T1, and higher grade (all P < 0.02). CONCLUSIONS Despite the absence of consensus guideline recommendations, the use of HF-WBRT in patients receiving chemotherapy has increased fourfold (absolute = 13.6%) over the last decade. Increased utilization of HF-WBRT should result in institutional reports verifying its safety and efficacy.
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Xu M, Li J, Liu S, Wang S, Wang W, Li F, Liu T, Yu J. Different methods for target volume delineation of glandular breast tissue following breast-conserving surgery in breast cancer: A comparative study. Oncol Lett 2015; 10:625-630. [PMID: 26622544 DOI: 10.3892/ol.2015.3358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 02/23/2015] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to investigate an optimal and feasible method for delineating the target volume of glandular breast tissue following breast-conserving surgery. A total of 15 patients who underwent radiotherapy following breast-conserving surgery were recruited into the study. Clinical target volume was delineated by the following three methods based on computed tomography (CT): Anatomical landmarks (CTVan), breast palpation (CTVpa) and CT scan images (CTVgl). The target volume, degree of inclusion (DI) and conformal index (CI) defined by these methods were compared. The difference was significant between CTVan and CTVgl, and CTVpa and CTVgl (P<0.0001). The CI between CTVan and CTVpa was 0.644±0.122, significantly higher than that between CTVan and CTVgl (0.264±0.108; P<0.0001) or between CTVpa and CTVgl (0.328±0.115; P<0.0001). The DI of CTVpa in CTVan was 0.890±0.08 and the opposite was 0.709±0.144, while that of DI of CTVgl in CTVan or CTVpa was 0.994±0.005 and 0.989±0.008, respectively. The boundary difference between CTVan and CTVpa was 3.35±7.23, 5.57±13.37, 1.75±11.62 and 11.25±4.07 mm for the medial, lateral, cephalic and caudal boundaries, respectively. A significant difference was observed in the target volume of the breast defined by the three methods. The target volume defined by CTVgl was significantly smaller than that identified by the other two methods. Overall, the combination of palpation marks and anatomical landmarks to define the contouring scope of the breast was indicated to be a relatively rational method for delineating the target volume of the breast.
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Affiliation(s)
- Min Xu
- Shandong University School of Medicine, Jinan, Shandong, P.R. China ; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Jianbin Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Shanshan Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Suzhen Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Wei Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Fengxiang Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Tonghai Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
| | - Jinming Yu
- Shandong University School of Medicine, Jinan, Shandong, P.R. China ; Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, P.R. China
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Probst H, Bragg C, Dodwell D, Green D, Hart J. A systematic review of methods to immobilise breast tissue during adjuvant breast irradiation. Radiography (Lond) 2014. [DOI: 10.1016/j.radi.2013.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Tortorelli G, Di Murro L, Barbarino R, Cicchetti S, di Cristino D, Falco MD, Fedele D, Ingrosso G, Janniello D, Morelli P, Murgia A, Ponti E, Terenzi S, Tolu B, Santoni R. Standard or hypofractionated radiotherapy in the postoperative treatment of breast cancer: a retrospective analysis of acute skin toxicity and dose inhomogeneities. BMC Cancer 2013; 13:230. [PMID: 23651532 PMCID: PMC3660202 DOI: 10.1186/1471-2407-13-230] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 04/10/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To identify predictive factors of radiation-induced skin toxicity in breast cancer patients by the analysis of dosimetric and clinical factors. METHODS 339 patients treated between January 2007 and December 2010 are included in the present analysis. Whole breast irradiation was delivered with Conventional Fractionation (CF) (50 Gy, 2.0/day, 25 fractions) and moderate Hypofractionated Schedule (HS) (44 Gy, 2.75 Gy/day, 16 fractions) followed by tumour bed boost. The impact of patient clinical features, systemic treatments and, in particular, dose inhomogeneities on the occurrence of different levels of skin reaction has been retrospectively evaluated. RESULTS G2 and G3 acute skin toxicity were 42% and 13% in CF patients and 30% and 7.5% in HS patients respectively. The retrieval and revaluation of 200 treatment plans showed a strong correlation between areas close to the skin surface, with inhomogeneities >107% of the prescribed dose, and the desquamation areas as described in the clinical records. CONCLUSIONS In our experience dose inhomogeneity underneath G2 - G3 skin reactions seems to be the most important predictor for acute skin damage and in these patients more complex treatment techniques should be considered to avoid skin damage. Genetic polymorphisms too have to be investigated as possible promising candidates for predicting acute skin reactions.
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Affiliation(s)
- Grazia Tortorelli
- Department of Diagnostic Imaging, Molecular Imaging, Interventional Radiology and Radiotherapy, Tor Vergata University General Hospital, Viale Oxford 81, Rome 00133, Italy
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Hannan R, Thompson RF, Chen Y, Bernstein K, Kabarriti R, Skinner W, Chen CC, Landau E, Miller E, Spierer M, Hong L, Kalnicki S. Hypofractionated Whole-Breast Radiation Therapy: Does Breast Size Matter? Int J Radiat Oncol Biol Phys 2012; 84:894-901. [DOI: 10.1016/j.ijrobp.2012.01.093] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 01/27/2012] [Accepted: 01/31/2012] [Indexed: 10/28/2022]
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Schoenfeld JD, Harris JR. Abbreviated course of radiotherapy (RT) for breast cancer. Breast 2012; 20 Suppl 3:S116-27. [PMID: 22015277 DOI: 10.1016/s0960-9776(11)70308-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The use of RT as a component of breast-conserving therapy or after mastectomy has been proven to reduce the risk of local-regional recurrence (LRR) and to improve long-term breast cancer-specific and overall survival. As has been the common practice in the United States and Continental Europe, the majority of studies that demonstrated these benefits utilized daily radiation doses ranging from 1.8-2 Gray (Gy). However, due to geographic limitations, patient preferences and financial considerations, there have been continued attempts to evaluate the efficacy and toxicity of abbreviated courses of breast RT. Two key factors in these attempts have been: (1) advances in radiobiology allowing for a more precise estimation of equivalent dosing; and (2) advances in the delivery of RT that have resulted in substantially improved dose homogeneity in the target volume. As an alternative to approximately five weeks of daily treatment at 1.8-2 Gy, delivering radiobiologically-equivalent total doses in hypofractionated, abbreviated schedules has been evaluated in five randomized controlled trials, as well as many prospective and retrospective experiences. These studies have generally demonstrated equivalent rates of LRR, disease-free survival and overall survival with the use of hypofractionated regimens. Despite theoretical and historic concerns that hypofractionated regimens could increase damage to normal tissue, the rates of acute and long-term toxicities have generally not been increased in most recent series. Some toxicities, however, may take years to decades to manifest. Questions still remain regarding which patients are appropriate for abbreviated treatment. The majority of patients included in the studies supporting hypofractionated treatment were of older age with early-stage invasive ER+ disease of predominantly lower histological grade. This favorable subset of patients is also the most eligible for other alternative treatment approaches, such as partial-breast irradiation or hormonal therapy alone. Additionally, few to none of the patients included in most studies were treated with mastectomy, lymph node irradiation, a lumpectomy cavity radiation boost, or adjuvant chemotherapy. The existing evidence prompted the American Society for Radiation Oncology (ASTRO) to convene a task force to issue an evidence-based guideline in 2010 delineating the patients for whom an abbreviated radiation course is most supported by the current evidence [Smith et al. 2010, Int J Radiat Oncol Biol Phys]. Ongoing and future studies will further clarify the suitability of a hypofractionated treatment approach for the patient subgroups underrepresented in available trials. Additionally, alternative abbreviated treatment regimens, including those in which treatment is given once weekly and treatments that include an integrated lumpectomy cavity boost, are actively being investigated. Finally, innovative radiation techniques, such as the use of higher energies, prone treatment, and breathing-adapted therapy have further increased the homogeneity of breast irradiation and minimized dose delivered to nearby critical normal structures. Consequently, increasing experience with these techniques may expand the population of patients amenable to hypofractionated therapy.
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Affiliation(s)
- Jonathan D Schoenfeld
- Harvard Radiation Oncology Program, Dana-Farher Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA
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Raza S, Lymberis SC, Ciervide R, Axelrod D, Fenton-Kerimian M, Magnolfi C, Rosenstein B, Dewyngaert JK, Formenti SC. Comparison of Acute and Late Toxicity of Two Regimens of 3- and 5-Week Concomitant Boost Prone IMRT to Standard 6-Week Breast Radiotherapy. Front Oncol 2012; 2:44. [PMID: 22649788 PMCID: PMC3355878 DOI: 10.3389/fonc.2012.00044] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 04/16/2012] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Limited information is available comparing toxicity of accelerated radiotherapy (RT) to that of standard fractionation RT for early stage breast cancer. We report early and late toxicities of two prone regimens of accelerated intensity-modulated radiation therapy (IMRT) with a concomitant boost (CB) to the tumor bed delivered over 3 or 5 weeks as compared to standard 6 week RT with a sequential electron boost. METHODS From 2/2003 to 12/2007, 169 consecutive patients with Stage I-II breast cancer were offered the choice to undergo prone RT with either: a 6-week standard RT regimen of 46 Gy/23 fractions (fx) to the whole breast (WB), followed by a14 Gy sequential boost (SB) to the tumor bed (6wSB), a 5-week regimen of 50 Gy to WB with an IMRT CB of 6.25 Gy in 25 fx (5wCB); or a 3-week protocol of 40.5 Gy to WB with an IMRT CB of 7.5 Gy in 15 fx (3wCB). These regimens were estimated as biologically equivalent, based on alpha/beta = 4 for tumor control. Toxicities were reported using RTOG and LENT/SOMA scoring. RESULTS 51/169 patients chose standard 6wSB, 28 selected 5wCB, and 90 enrolled in 3wCB protocol. Maximum acute toxicity was Grade 3 dermatitis in 4% of the patients in the 6wSB compared 1% in 3wCB. In general, acute complications (breast pain, fatigue, and dermatitis) were significantly less in the 3wCB than in the other schedules (P < 0.05). With a median follow-up of 61 months, the only Grade 3 late toxicity was telangiectasia in two patients: one in 3wCB and one in 5wCB group. Notably, fibrosis was comparable among the three groups (P = NS). CONCLUSION These preliminary data suggest that accelerated regimens of breast RT over 3 or 5 weeks in the prone position, with an IMRT tumor bed CB, result in comparable late toxicity to standard fractionation with a sequential tumor boost delivered over 6 weeks. As predicted by radiobiological modeling the shorter regimen was associated with less acute effects.
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Affiliation(s)
- Shahzad Raza
- Department of Radiation Oncology and Surgery, New York University School of Medicine, New York University Langone Medical Center New York, NY, USA
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Hardee ME, Raza S, Becker SJ, Jozsef G, Lymberis SC, Hochman T, Goldberg JD, DeWyngaert KJ, Formenti SC. Prone Hypofractionated Whole-Breast Radiotherapy Without a Boost to the Tumor Bed: Comparable Toxicity of IMRT Versus a 3D Conformal Technique. Int J Radiat Oncol Biol Phys 2012; 82:e415-23. [DOI: 10.1016/j.ijrobp.2011.06.1950] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 05/31/2011] [Accepted: 06/03/2011] [Indexed: 11/25/2022]
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Feasibility and acute toxicity of hypofractionated radiation in large-breasted patients. Int J Radiat Oncol Biol Phys 2011; 83:79-83. [PMID: 22035661 DOI: 10.1016/j.ijrobp.2011.05.074] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/11/2011] [Accepted: 05/20/2011] [Indexed: 02/03/2023]
Abstract
PURPOSE To determine the feasibility of and acute toxicity associated with hypofractionated whole breast radiation (HypoRT) after breast-conserving surgery in patients excluded from or underrepresented in randomized trials comparing HypoRT with conventional fractionation schedules. METHODS AND MATERIALS A review was conducted of all patients consecutively treated with HypoRT at the University of Chicago. All patients were treated to 42.56 Gy in 2.66 Gy daily fractions in either the prone or supine position. Planning was performed in most cases using wedges and large segments or a "field-in-field" technique. Breast volume was estimated using volumetric measurements of the planning target volume (PTV). Dosimetric parameters of heterogeneity (V105, V107, V110, and maximum dose) were recorded for each treatment plan. Acute toxicity was scored for each treated breast. RESULTS Between 2006 and 2010, 78 patients were treated to 80 breasts using HypoRT. Most women were overweight or obese (78.7%), with a median body mass index of 29.2 kg/m(2). Median breast volume was 1,351 mL. Of the 80 treated breasts, the maximum acute skin toxicity was mild erythema or hyperpigmentation in 70.0% (56/80), dry desquamation in 21.25% (17/80), and focal moist desquamation in 8.75% (7/80). Maximum acute toxicity occurred after the completion of radiation in 31.9% of patients. Separation >25 cm was not associated with increased toxicity. Breast volume was the only patient factor significantly associated with moist desquamation on multivariable analysis (p = 0.01). Patients with breast volume >2,500 mL experienced focal moist desquamation in 27.2% of cases compared with 6.34% in patients with breast volume <2,500 mL (p = 0.03). CONCLUSIONS HypoRT is feasible and safe in patients with separation >25 cm and in patients with large breast volume when employing modern planning and positioning techniques. We recommend counseling regarding expected increases in skin toxicity in women with a PTV volume >2,500 mL.
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Huppert N, Jozsef G, DeWyngaert K, Formenti SC. The role of a prone setup in breast radiation therapy. Front Oncol 2011; 1:31. [PMID: 22655240 PMCID: PMC3356107 DOI: 10.3389/fonc.2011.00031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 09/20/2011] [Indexed: 02/03/2023] Open
Abstract
Most patients undergoing breast conservation therapy receive radiotherapy in the supine position. Historically, prone breast irradiation has been advocated for women with large pendulous breasts in order to decrease acute and late toxicities. With the advent of CT planning, the prone technique has become both feasible and reproducible. It was shown to be advantageous not only for women with larger breasts but in most patients since it consistently reduces, if not eliminates, the inclusion of heart and lung within the field. The prone setup has been accepted as the best localizing position for both MRI and stereotactic biopsy, but its adoption has been delayed in radiotherapy. New technological advances including image-modulated radiation therapy and image-guided radiation therapy have made possible the exploration of accelerated fractionation schemes with a concomitant boost to the tumor bed in the prone position, along with better imaging and verification of reproducibility of patient setup. This review describes some of the available techniques for prone breast radiotherapy and the available experience in their application. The NYU prone breast radiotherapy approach is discussed, including a summary of the results from several prospective trials.
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Affiliation(s)
- Nelly Huppert
- Department of Radiation Oncology, New York University School of Medicine, New York University Langone Medical CenterNew York, NY, USA
| | - Gabor Jozsef
- Department of Radiation Oncology, New York University School of Medicine, New York University Langone Medical CenterNew York, NY, USA
| | - Keith DeWyngaert
- Department of Radiation Oncology, New York University School of Medicine, New York University Langone Medical CenterNew York, NY, USA
| | - Silvia Chiara Formenti
- Department of Radiation Oncology, New York University School of Medicine, New York University Langone Medical CenterNew York, NY, USA
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Edwards-Bennett SM, Correa CR, Harris EE. Optimization of Adjuvant Radiation in Breast Conservation Therapy: Can We Minimize without Compromise? Int J Breast Cancer 2011; 2011:321304. [PMID: 22295217 PMCID: PMC3262572 DOI: 10.4061/2011/321304] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 07/08/2011] [Accepted: 08/09/2011] [Indexed: 11/20/2022] Open
Abstract
Adjuvant breast radiation therapy after breast conservation surgery is recommended as it yields significant reduction in the risk of local recurrence, and confers a potential overall survival benefit. Although the standard breast radiation regimen has historically been delivered over 5-7 weeks; more novel, shorter courses of breast radiation are currently being employed, offering the advantage of more convenience and less time-commitment. Herein, we review the recent literature substantiating these abbreviated radiation treatment approaches and the methods of delivery thereof. In addition, we discuss imaged guided techniques currently being utilized to further refine the delivery of adjuvant breast radiation therapy.
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Affiliation(s)
- Sophia M Edwards-Bennett
- Department of Radiation Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, USA
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A Dosimetric Comparison Between the Supine and Prone Positions for Three-Field Intact Breast Radiotherapy. Am J Clin Oncol 2011; 34:223-30. [DOI: 10.1097/coc.0b013e3181dbb9c1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Morganti AG, Cilla S, de Gaetano A, Panunzi S, Digesù C, Macchia G, Massaccesi M, Deodato F, Ferrandina G, Cellini N, Scambia G, Piermattei A, Valentini V. Forward planned intensity modulated radiotherapy (IMRT) for whole breast postoperative radiotherapy. Is it useful? When? J Appl Clin Med Phys 2011; 12:3451. [PMID: 21587195 PMCID: PMC5718668 DOI: 10.1120/jacmp.v12i2.3451] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Revised: 12/10/2010] [Accepted: 01/10/2011] [Indexed: 11/23/2022] Open
Abstract
The purpose was to compare the dosimetric results observed in 201 breast cancer patients submitted to tangential forward intensity-modulated radiation therapy (IMRT) with those observed in 131 patients treated with a standard wedged 3D technique for postoperative treatment of whole breast, according to breast size and supraclavicular node irradiation. Following dosimetric parameters were used for the comparison: D(max), D(min), D(mean), V(95%) and V(107%) for the irradiated volume; D(max), D(mean), V(80%) and V(95%) for the ipsilateral lung; D(max), D(mean), V(80%) and V(95%) for the heart. Stratification was made according to breast size and supraclavicular (SCV) nodal irradiation. As respect to irradiated volume, a significant reduction of V(107%) (mean values: 7.0 ± 6.6 versus 2.4 ± 3.7, p < 0.001) and D(max) (mean % values: 111.2 ± 2.7 versus 107.7 ± 6.3, p < 0.001), and an increase of D(min) (mean % values: 65.0 ± 17.4 versus 74.9 ± 12.9, p < 0.001) were observed with forward IMRT. The homogeneity of dose distribution to target volume significantly improved with forward IMRT in all patient groups, irrespective of breast size or supraclavicular nodal irradiation. When patients treated with supraclavicular nodal irradiation were excluded from the analysis, forward IMRT slightly reduced V(80%) (mean values: 3.7 ± 2.6 versus 3.0 ± 2.4, p = 0.03) and V(95%) (mean values 1.9 ± 1.8 versus 1.2%± 1.5; p = 0.001) of the ipsilateral lung. The dose to the heart tended to be lower with IMRT but this difference was not statistically significant. Tangential forward IMRT in postoperative treatment of whole breast improved dosimetric parameters in terms of homogeneity of dose distribution to the target in a large sample of patients, independent of breast size or supraclavicular nodal irradiation. Lung irradiation was slightly reduced in patients not undergoing to supraclavicular irradiation.
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Affiliation(s)
- Alessio G. Morganti
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Savino Cilla
- Medical Physics UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Andrea de Gaetano
- CNR‐Institute of Systems Analysis and Computer Science (IASI)BioMathLabRome
| | - Simona Panunzi
- CNR‐Institute of Systems Analysis and Computer Science (IASI)BioMathLabRome
| | - Cinzia Digesù
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Gabriella Macchia
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Mariangela Massaccesi
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Francesco Deodato
- Radiotherapy UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Gabriella Ferrandina
- Gynaecology Oncology UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Numa Cellini
- Department of RadiotherapyPoliclinico Universitario “Agostino Gemelli”, Catholic UniversityRomeItaly
| | - Giovanni Scambia
- Gynecology Oncology DepartmentPoliclinico Universitario “Agostino Gemelli”, Catholic UniversityRomeItaly
| | - Angelo Piermattei
- Medical Physics UnitDepartment of Oncology“John Paul II” Center for High Technology Research and Education in Biomedical SciencesCampobasso
| | - Vincenzo Valentini
- Department of RadiotherapyPoliclinico Universitario “Agostino Gemelli”, Catholic UniversityRomeItaly
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MacDonald SM, Harisinghani MG, Katkar A, Napolitano B, Wolfgang J, Taghian AG. Nanoparticle-Enhanced MRI to Evaluate Radiation Delivery to the Regional Lymphatics for Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2010; 77:1098-104. [DOI: 10.1016/j.ijrobp.2009.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Revised: 06/01/2009] [Accepted: 06/02/2009] [Indexed: 02/06/2023]
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Sola A. Revisión de la literatura sobre radioterapia en el cáncer de mama temprano. Medwave 2010. [DOI: 10.5867/medwave.2010.01.4331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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