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He QS, Wang ZP, Li ZJ, Zhou P, Lian CL, Wu SG, Chen SF. Increased risk of cerebrovascular mortality in head and neck cancer survivors aged ≥ 65 years treated with definitive radiotherapy: a population-based cohort study. Radiat Oncol 2021; 16:185. [PMID: 34544466 PMCID: PMC8454064 DOI: 10.1186/s13014-021-01913-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/11/2021] [Indexed: 01/23/2023] Open
Abstract
Background To investigate the relationship between radiotherapy (RT) and the risk of cerebrovascular mortality (CVM) in head and neck cancer (HNC) survivors aged ≥ 65 years. Methods Patients with HNC survivors aged ≥ 65 years diagnosed between 2000 and 2012 were included from the Surveillance, Epidemiology, and End Results database. Kaplan–Meier analysis, Log-rank tests, and Cox proportional-hazards regression models were performed for statistical analyses. Results We included 16,923 patients in this study. Of these patients, 7110 (42.0%) patients received surgery alone, 5041 (29.8%) patients underwent RT alone, and 4772 (28.2%) patients were treated with surgery and RT. With a median follow-up time of 87 months, 1005 patients died with cerebrovascular disease. The 10-years CVM were 13.3%, 10.8%, and 11.2% in those treated with RT alone, surgery alone, and surgery plus RT, respectively (P < 0.001). The mean time for CVM was shorter in RT alone compared to surgery alone and surgery plus RT (52 months vs. 56–60 months). After adjusting for covariates, patients receiving RT alone had a significantly higher risk of developing CVM compared to those receiving surgery alone (hazard ratio [HR] 1.703, 95% confidence interval [CI] 1.398–2.075, P < 0.001), while a comparable risk of CVM was found between those treated with surgery alone and surgery plus RT (HR 1.106, 95% CI 0.923–1.325, P = 0.274). Similar trends were found after stratification age at diagnosis, gender, tumor location, and marital status. Conclusions Definitive RT but not postoperative RT can increase the risk of CVM among older HNC survivors. Long-term follow-up and regular screening for CVD are required for HNC patients who received definitive RT to decrease the risk of CVM.
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Affiliation(s)
- Qing-Song He
- Department of Neurology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China
| | - Zhen-Ping Wang
- Department of Radiology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, 570311, People's Republic of China
| | - Zhao-Jun Li
- Department of Radiation Oncology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, 570311, People's Republic of China
| | - Ping Zhou
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China
| | - Chen-Lu Lian
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China
| | - San-Gang Wu
- Department of Radiation Oncology, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China.
| | - Si-Fang Chen
- Department of Neurosurgery, the First Affiliated Hospital of Xiamen University, Xiamen, 361003, People's Republic of China.
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Is radiation-induced arteriopathy in long-term breast cancer survivors an underdiagnosed situation?: Critical and pragmatic review of available literature. Radiother Oncol 2021; 157:163-174. [PMID: 33515666 DOI: 10.1016/j.radonc.2021.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/01/2021] [Accepted: 01/10/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE Although considered exceptional, radiation-induced arteriopathy in long-term breast cancer survivors involves three main arterial domains in the irradiated volume, namely axillary-subclavian, coronary, and carotid. Stenosis of medium-large arteries is caused by "accelerated" atherosclerosis, particularly beyond 10 years after long-forgotten radiotherapy. The present review aims at summarizing what is known about arteriopathy, as well as the state of the art in terms of diagnosis and therapeutic management. DIAGNOSIS Pauci-symptomatic over years, the usual clinical presentation of arteriopathy involves arm pain with coldness due to subacute or critical ischemia (arterial occlusion), wrongly attributed to an exclusive neurological disorder, and more rarely transient ischemic accident or angina. Evaluation of the supra-aortic trunks by computed tomography and/or magnetic resonance angiography visualizes artery lesions, while Doppler ultrasonography in expert hands assesses diagnosis and downstream functional impact. In severe cases, more invasive angiography directly visualizes long irregular arterial stenosis (full-field radiotherapy), allowing accurate prognosis and treatment. MANAGEMENT Requires early diagnosis to enable initiation of medical treatment that increases blood flow (aspirin) as soon as moderate stenosis is detected, combined with correction of vascular risk factors. In intermediate cases, these therapeutic measures are completed by revascularization strategies using transluminal angioplasty-stenting (wall thickness). Antifibrotic treatment is useful in advanced cases with combined radiation injuries. CONCLUSION In follow-up of long-term breast cancer survivors with node irradiation, myocardial infarction is treated even if radiotherapy is forgotten, while recognition and diagnosis of chronic arm ischemia due to subclavian artery stenosis needs to be improved for appropriate therapeutic management.
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Lalani N, Voduc KD, Jimenez RB, Levasseur N, Gondara L, Speers C, Lohrisch C, Nichol A. Breast Cancer Molecular Subtype as a Predictor of Radiation Therapy Fractionation Sensitivity. Int J Radiat Oncol Biol Phys 2020; 109:281-287. [PMID: 32853707 DOI: 10.1016/j.ijrobp.2020.08.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE The predictive benefit of breast cancer molecular subtypes for systemic therapy approaches has been well established; yet, there is a paucity of data regarding their use as a predictor of radiation therapy fractionation sensitivity. The purpose of this study was to determine whether rates of local recurrence (LR) for patients treated with hypofractionated (HF) radiation therapy, in comparison to conventional fractionation, differ across breast cancer molecular subtypes in a large, prospectively collected cohort treated with modern systemic therapy. METHODS AND MATERIALS Patients who received a diagnosis of stage I-III breast cancer between 2005 and 2009 were identified. Molecular subtype was determined using the American Joint Committee on Cancer classification system (luminal-A, luminal-B, HER2+, triple negative [TN]). Multivariable Cox regression modeling was used to identify predictors of LR. LR-free-survival (LRFS) was determined using the Kaplan-Meier method and compared using the log-rank test. RESULTS A total of 5868 cases were identified with a median follow-up of 10.8 years. Patients with luminal-A subtype composed 45% of the cohort (n = 2628), compared with 30% luminal-B (n = 1734), 15% HER2+ (n = 903), and 10% TN (n = 603). A total of 76% (n = 4429) of patients were treated with HF. The 10-year LRFS was 97.1% (95% confidence interval [CI], 96.6-97.6) for the whole cohort. The 10-year LRFS based on molecular subtypes was 98.3% (95% CI, 97.6-98.7) luminal-A, 96.6% (95% CI, 95.5-97.4) luminal-B, 97.0% (95% CI, 95.5-98.0) HER2+, and 93.5% (95% CI, 91.1-95.3) TN (P < .001). There was no difference in the 10-year LRFS between patients treated with HF versus conventional fractionation among those with luminal-A (98.2% vs 98.4%; P = .42), luminal-B (96.6% vs 96.8%; P = .90), HER2+ (97.5% vs 95.8%; P = .12), or TN (93.9% vs 92.2%; P = .47). There was no significant interaction between subtype and fractionation regimen. CONCLUSIONS These data support the routine use of hypofractionated radiation therapy regimens across all breast cancer subtypes.
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Affiliation(s)
- Nafisha Lalani
- Department of Radiation Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada.
| | - K David Voduc
- Department of Radiation Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nathalie Levasseur
- Department of Medical Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Lovedeep Gondara
- Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Caroline Speers
- Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Caroline Lohrisch
- Department of Medical Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
| | - Alan Nichol
- Department of Radiation Oncology, BC Cancer - Vancouver Cancer Centre, Vancouver, BC, Canada
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Batumalai V, Delaney GP, Descallar J, Gabriel G, Wong K, Shafiq J, Barton M. Variation in the use of radiotherapy fractionation for breast cancer: Survival outcome and cost implications. Radiother Oncol 2020; 152:70-77. [PMID: 32721419 PMCID: PMC7382346 DOI: 10.1016/j.radonc.2020.07.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 11/30/2022]
Abstract
We evaluated the use of hypofractionation in breast radiotherapy in an Australian population-based cohort. Hypofractionation appears underused for breast radiotherapy in Australia over time. Variation in practice were observed by patient, tumour, sociodemographic and geographical factors. This study highlights that evidence-based practice will translate to reduced health care treatment costs.
Background and purpose Substantial variation in the adoption of hypofractionation for breast radiation therapy has been observed, despite the availability of consensus guidelines. This study aimed to investigate the variation in radiation therapy fractionation in breast cancer patients in New South Wales (NSW), Australia, and to estimate survival outcome and cost implications. Materials and methods This is a population-based cohort of patients who received radiation therapy for breast cancer (2009–2013), as captured in the NSW Central Cancer Registry. A logistic regression model was used to identify factors associated with fractionation type. Survival outcome was estimated using multivariable Cox proportional hazards model. Cost per treatment and potential cost saving associated with evidence-based fractionation was estimated. Results A total of 10,482 patients were available for analysis, divided into 3 cohorts (breast alone: N = 7000; breast + nodes: N = 1119; all chestwall: N = 2363). In multivariable analysis, increasing age, laterality (right), year of treatment (2013), early stage, lower socioeconomic status, and regional area of residence were independent predictors of hypofractionation for breast alone radiation therapy. For the breast + nodes and chest wall cohorts, common factors that predicted the use of hypofractionation were increasing age. In multivariable survival analysis, there was no difference between the fractionation regimens at 5 years. Estimated radiation therapy cost of this cohort approximated $52.1 million, compared with $38.5 million had these patients been treated with evidence-based fractionation. This demonstrated a potential saving of $13.6 million. Conclusion Hypofractionation appears underused for breast radiation therapy in NSW over time. This study highlights that evidence-based practice will translate to reduced health care treatment costs.
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Affiliation(s)
- Vikneswary Batumalai
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia.
| | - Geoff P Delaney
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
| | - Joseph Descallar
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Gabriel Gabriel
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Karen Wong
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Jesmin Shafiq
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia
| | - Michael Barton
- Ingham Institute for Applied Medical Research, South Western Clinical School, University of New South Wales, Australia; Department of Radiation Oncology, South Western Sydney Local Health District, New South Wales, Australia
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Killander F, Wieslander E, Karlsson P, Holmberg E, Lundstedt D, Holmberg L, Werner L, Koul S, Haghanegi M, Kjellen E, Nilsson P, Malmström P. No Increased Cardiac Mortality or Morbidity of Radiation Therapy in Breast Cancer Patients After Breast-Conserving Surgery: 20-Year Follow-up of the Randomized SweBCGRT Trial. Int J Radiat Oncol Biol Phys 2020; 107:701-709. [PMID: 32302682 DOI: 10.1016/j.ijrobp.2020.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Radiation therapy (RT) after breast-conserving surgery reduces locoregional recurrences and improves survival but may cause late side effects. The main purpose of this paper was to investigate long-term side effects after whole breast RT in a randomized clinical trial initiated in 1991 and to report dose-volume data based on individual 3-dimensional treatment plans for organs at risk. METHODS AND MATERIALS The trial included 1187 patients with T1-2 N0 breast cancer randomized to postoperative tangential whole breast RT or no further treatment. The prescription dose to the clinical target volume was 48 to 54 Gy. We present 20-year follow-up on survival, cause of death, morbidity, and later malignancies. For a cohort of patients (n = 157) with accessible computed tomography-based 3-dimensional treatment plans in Dicom-RT format, dose-volume descriptors for organs at risk were derived. In addition, these were compared with dose-volume data for a cohort of patients treated with contemporary RT techniques. RESULTS The cumulative incidence of cardiac mortality was 12.4% in the control group and 13.0% in the RT group (P = .8). There was an increase in stroke mortality: 3.4% in the control group versus 6.7% in the RT group (P = .018). Incidences of contralateral breast cancer and lung cancer were similar between groups. The median Dmean (range) heart dose for left-sided treatments was 3.0 Gy (1.1-8.1), and the corresponding value for patients treated in 2017 was 1.5 Gy (0.4-6.0). CONCLUSIONS In this trial, serious late side effects of whole breast RT were limited and less than previously reported in large meta-analyses. We observed no increase in cardiac mortality in irradiated patients. Doses to the heart were a median Dmean of 3.0 Gy for left-sided RT. The observed increase in stroke mortality may partly be secondary to cardiac side effects, complications to anticoagulant treatment, or to chance, rather than a direct side effect of tangential whole breast irradiation.
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Affiliation(s)
- Fredrika Killander
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden.
| | - Elinore Wieslander
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Karlsson
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Holmberg
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Regional Oncologic Centre West, Gothenburg, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lars Holmberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Translational Oncology & Urology Research (TOUR), School of Cancer and Pharmaceutical Sciences, Kingś College London, London, United Kingdom
| | - Linda Werner
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden
| | - Sasha Koul
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mahnaz Haghanegi
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Elisabeth Kjellen
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Per Nilsson
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden; Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Per Malmström
- Department of Clinical Sciences, Faculty of Medicine, Lund, Lund University, Sweden; Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
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Liu L, Yang Y, Guo Q, Ren B, Peng Q, Zou L, Zhu Y, Tian Y. Comparing hypofractionated to conventional fractionated radiotherapy in postmastectomy breast cancer: a meta-analysis and systematic review. Radiat Oncol 2020; 15:17. [PMID: 31952507 PMCID: PMC6969477 DOI: 10.1186/s13014-020-1463-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/07/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose To compare the efficacy and toxicity of hypofractionated radiotherapy versus conventional fractionated radiotherapy in postmastectomy breast cancer using meta-analysis. Methods The PubMed, EMbase, Cochrane Library, Google Scholar, Wan Fang and CNKI databases were searched to identify controlled clinical trials comparing hypofractionated radiotherapy versus conventional fractionated radiotherapy in postmastectomy breast cancer. Overall survival (OS) was the primary endpoint, and disease-free survival (DFS), locoregional recurrence (LRR), distant metastasis (DM), acute skin toxicity, acute lung toxicity, late skin toxicity, lymphedema,, shoulder restriction, and late cardiac related toxicity were the secondary endpoints. Results Twenty-five controlled clinical trials involving 3871 postmastectomy breast cancer patients were included in this meta-analysis according to the selection criteria. The meta-analysis revealed that there were no significant differences in OS (OR = 1.08, 95% CI = 0.87~1.33, P = 0.49), DFS (OR = 1.13, 95% CI = 0.91~1.40, P = 0.28), LRR (OR = 1.01, 95% CI = 0.76~1.33, P = 0.96), DM (OR = 1.16, 95% CI = 0.85~1.58, P = 0.34), acute skin toxicity (OR = 0.94, 95% CI = 0.67~1.32, P = 0.72), acute lung toxicity (OR = 0.94, 95% CI = 0.74~1.20, P = 0.62), late skin toxicity (OR = 0.98, 95% CI = 0.75~1.27, P = 0.88), lymphedema (OR = 0.99, 95% CI = 0.77~1.28, P = 0.94), shoulder restriction (OR = 0.75, 95% CI = 0.43~1.31, P = 0.31), or late cardiac related toxicity (OR = 1.17, 95% CI = 0.82~1.65, P = 0.39) between the two groups. Conclusions The results of this study show that compared to conventional fractionated radiotherapy, hypofractionated radiotherapy is not significantly different with respect to efficacy or toxicity in postmastectomy breast cancer. Additional large randomized clinical trials are needed to further confirm this conclusion.
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Affiliation(s)
- Lei Liu
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Yongqiang Yang
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Qi Guo
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Bixin Ren
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Qiliang Peng
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Li Zou
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Yaqun Zhu
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China
| | - Ye Tian
- Department of Radiotherapy and Oncology, The Second Affiliated Hospital of Soochow University, Institute of Radiotherapy and Oncology of Soochow University, San Xiang Road No. 1055, Suzhou, 215004, Jiangsu, China.
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Haussmann J, Budach W, Tamaskovics B, Bölke E, Corradini S, Djiepmo-Njanang FJ, Kammers K, Matuschek C. Which target volume should be considered when irradiating the regional nodes in breast cancer? Results of a network-meta-analysis. Radiat Oncol 2019; 14:102. [PMID: 31186015 PMCID: PMC6558843 DOI: 10.1186/s13014-019-1280-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 04/22/2019] [Indexed: 01/11/2023] Open
Abstract
Purpose/objective(s) Radiation treatment to the regional nodes results in an improvement in survival in breast cancer according to a meta-analysis of randomized trials. However, different volumes were targeted in these studies: breast or chestwall only (WBI/CWI), inclusion of the medial supraclavicular region and axillary apex (MS + WBI/CWI) or additional inclusion of the internal mammary chain (IM + MS + WBI/CWI). The benefit of treating the medial supraclavicular region and axillary apex compared to tangential breast or chestwall irradiation only remains unclear. Materials/methods A literature search was conducted identifying trials for adjuvant radiation volumes in nodal irradiation after breast surgery and axillary treatment. Events and effect sizes were extracted from the publications for the endpoints of overall survival (OS), breast cancer-specific survival (BCSS), disease-free survival (DFS), distant metastasis-free survival (DMFS) and loco-regional control (LRC). A network meta-analysis was performed using MetaXL V5.3 with the inverse variance heterogeneity model. Results We found two randomized studies (n = 5836) comparing comprehensive nodal irradiation to sole breast treatment as well as one randomized (n = 1407) and one prospective cohort study (n = 3377) analysing the additional treatment of the internal mammary chain against sole local and supraclavicular and axillary apex radiation. Compared to WBI/CWI alone the treatment of IM + MS + WBI/CWI (HR = 0.88; CI:0.78-0.99; p = 0.036) results in improved OS unlike MS + WBI/CWI (HR = 0.99; CI:0.86-1.14; p = 0,89). These results are confirmed in BCSS: IM + MS + WBI/CWI (HR = 0.82; CI:0.72-0.92; p = 0.002) and MS + WBI/CWI (HR = 0.96; CI:0.79-1.18; p = 0.69). PFS is significantly improved with the treatment of MS + WBI/CWI (OR = 0.83; CI:0.71-0.97; p = 0.019). Both nodal treatment volumes improve LRC (MS + WBI/CWI OR = 0.74; CI:0.62-0.87; p = 0.004 and IM + MS + WBI/CWI OR = 0.60; CI:0.43-0.86; p < 0,001). Yet only the internal mammary nodes provide a benefit in DMFS (MS + WBI/CWI HR = 0.97; CI:0.81-1.16; p = 0.74 and IM + MS + WBI/CWI HR = 0.84; CI:0.75-0.94; p = 0.002). Conclusion Expanding the radiation field to the axillary apex and supraclavicular nodes after axillary node dissection reduced loco-regional recurrences without improvement in overall and cancer-specific survival. A prolongation in survival due to regional nodal irradiation is achieved when the internal mammary chain is included. This derives from a reduction in distant metastasis.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany.
| | - Stefanie Corradini
- Department of Radiation Oncology, LMU University of Munich, Munich, Germany
| | | | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
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Local Relapse After Breast-Conserving Therapy Versus Mastectomy for Extensive Pure Ductal Carcinoma In Situ ≥4 cm. Int J Radiat Oncol Biol Phys 2019; 103:381-388. [DOI: 10.1016/j.ijrobp.2018.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/06/2018] [Accepted: 09/17/2018] [Indexed: 12/12/2022]
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Lin CY, Lin CL, Lo YC, Kao CH. Association between radioiodine treatment for thyroid cancer and risk of stroke. Head Neck 2017; 39:2311-2318. [PMID: 28815788 DOI: 10.1002/hed.24903] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 05/05/2017] [Accepted: 06/28/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the association between radioiodine (I-131) therapy for thyroid cancer and the risk of stroke in Taiwan. METHODS A total of 10 104 of the patients aged 20 years or older, who were newly diagnosed with thyroid cancer during 2000-2010, were recruited and classified into 2 cohorts according to whether they received I-131 therapy through 1:1 propensity score matching. The cumulative Kaplan-Meier curves for the incidence of stroke in the 2 cohorts were compared using the log-rank test. RESULTS After adjustment for age, sex, and comorbidities, the I-131 therapy group showed no significantly higher risk of ischemic stroke (adjusted HR [aHR] = 1.05; 95% confidence interval [CI] = 0.82-1.34) or hemorrhagic stroke (aHR = 1.06; 95% CI = 0.58-1.93) than did the non-I-131 therapy group. CONCLUSION The I-131 treatment for thyroid cancer did not increase the risk of stroke during 10-year follow-up.
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Affiliation(s)
- Chun-Yi Lin
- Department of Nuclear Medicine, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan.,College of Medicine, China Medical University, Taichung, Taiwan
| | - Yi-Chen Lo
- Department of Neurosurgery, Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan.,Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan.,Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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Hypofractionated Nodal Radiation Therapy for Breast Cancer Was Not Associated With Increased Patient-Reported Arm or Brachial Plexopathy Symptoms. Int J Radiat Oncol Biol Phys 2017; 99:1166-1172. [PMID: 29165285 DOI: 10.1016/j.ijrobp.2017.07.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/15/2017] [Accepted: 07/28/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine whether nodal radiation therapy (RT) for breast cancer using modest hypofractionation (HF) with 2.25 to 2.5 Gy per fraction (fx) was associated with increased patient-reported arm symptoms, compared with conventional fractionation (CF) ≤2 Gy/fx. METHODS AND MATERIALS Two cancer registries were used to identify subjects who received computed tomography-planned nodal RT for pT1-3, pN0-2, M0 breast cancer, from 2007 to 2010 at 2 cancer institutions. After ethics approval, patients were mailed an explanatory letter and the Self-reported Arm Symptom Scale, a validated instrument with 8 questions about arm symptoms and 5 related to activities of daily living. Clinicopathologic characteristics and Self-reported Arm Symptom Scale scores were compared between HF/CF cohorts using nonparametric analysis, χ2 analysis, and multivariate ordinal regression. RESULTS Of 1759 patients, 800 (45.5%) returned a completed survey. A total of 708 eligible cases formed the study cohort. Of these, 406 (57%) received HFRT (40 Gy/16 fx, 45 Gy/20 fx), and 302 (43%) received CFRT (45-50 Gy/25 fx, 50.4 Gy/28 fx). Median time interval after RT was 5.7 years. Forty-three percent and 75% of patients received breast-conserving surgery and chemotherapy, respectively. Twenty-two percent received breast boost RT, independent of fractionation. Median age at diagnosis was 59 years (HF) and 53 years (CF) (P<.001). The mean numbers of excised (n=12) and involved (n=3) nodes were similar between fractionation cohorts (P=.44), as were the mean sums of responses in arm symptoms (P=.17) and activities of daily living (P=.85). Patients receiving HF reported lower rates of shoulder stiffness (P=.04), trouble moving the arm (P=.02), and difficulty reaching overhead (P<.01) compared with the CF cohort. There was no difference in self-reported arm swelling or symptoms related to brachial plexopathy. CONCLUSIONS Nodal RT with hypofractionation was not associated with increased patient-reported arm symptoms or functional deficits compared with CF. Subjects treated with CF reported more disability in certain aspects of arm/shoulder function. These data support shorter fractionation utilization when regional nodes are within the therapeutic target.
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Cheng YJ, Nie XY, Ji CC, Lin XX, Liu LJ, Chen XM, Yao H, Wu SH. Long-Term Cardiovascular Risk After Radiotherapy in Women With Breast Cancer. J Am Heart Assoc 2017; 6:JAHA.117.005633. [PMID: 28529208 PMCID: PMC5524103 DOI: 10.1161/jaha.117.005633] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Radiotherapy for breast cancer often involves some incidental exposure of the heart to ionizing radiation. The effect of this exposure on the subsequent risk of heart disease is uncertain. We performed a meta‐analysis to investigate the link between radiotherapy and long‐term cardiovascular morbidity and mortality in patients with breast cancer. Methods and Results We performed a literature search using MEDLINE (January 1966 to January 2015) and EMBASE (January 1980 to January 2015) with no restrictions. Studies that reported relative risk (RR) estimates with 95%CIs for the associations of interest were included. Pooled effect estimates were obtained by using random‐effects meta‐analysis. Thirty‐nine studies involving 1 191 371 participants were identified. Patients who received left‐sided radiotherapy, as compared with those receiving right‐sided radiotherapy, experienced increased risks of developing coronary heart disease (RR 1.29, 95%CI 1.13‐1.48), cardiac death (RR 1.22, 95%CI 1.08‐1.37) and death from any cause (RR 1.05, 95%CI 1.01‐1.10). In a comparison of patients with radiotherapy and without radiotherapy, the RRs were 1.30 (95%CI 1.13‐1.49) for coronary heart disease and 1.38 (95%CI 1.18‐1.62) for cardiac mortality. Radiotherapy for breast cancer was associated with an absolute risk increase of 76.4 (95%CI 36.8‐130.5) cases of coronary heart disease and 125.5 (95%CI 98.8‐157.9) cases of cardiac death per 100 000 person‐years. The risk started to increase within the first decade for coronary heart disease and from the second decade for cardiac mortality. Conclusions Exposure of the heart to ionizing radiation during radiotherapy for breast cancer increases the subsequent risk of coronary heart disease and cardiac mortality.
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Affiliation(s)
- Yun-Jiu Cheng
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Ying Nie
- Outpatient Department, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Cheng-Cheng Ji
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xiao-Xiong Lin
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Li-Juan Liu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xu-Miao Chen
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hao Yao
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Su-Hua Wu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
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Bellefqih S, Elmajjaoui S, Aarab J, Khalil J, Afif M, Lachgar A, El Kacemi H, Kebdani T, Benjaafar N. Hypofractionated Regional Nodal Irradiation for Women With Node-Positive Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 97:563-570. [PMID: 28126305 DOI: 10.1016/j.ijrobp.2016.11.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 10/03/2016] [Accepted: 11/08/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the effect of hypofractionated radiation therapy (HFRT) of the breast/chest wall and regional nodes on overall survival (OS), disease-free survival (DFS), locoregional control and on treatment-related toxicity in patients with breast cancer and nodal involvement. METHODS AND MATERIALS Two hundred fifty-seven patients treated between October 2009 and June 2011 with hypofractionated locoregional radiation therapy (42 Gy in 15 fractions) were retrospectively reviewed, 51 (19.8%) after breast-conserving surgery and 206 (80.2%) after radical surgery. Patients treated with breast-conserving surgery received a boost dose to the tumor bed (delivered by photons, electrons, or interstitial high-dose-rate brachytherapy). Two hundred fifty-six (99.6%) patients underwent chemotherapy, 209 (81.3%) had hormonal treatment, and 65 (25.3%) had anti-HER2 targeted therapy. RESULTS The median follow-up time was 64 months (range, 11-88 months). The rates of 5-year OS, DFS, locoregional recurrence (LRR)-free survival, and distant metastasis (DM)-free survival were 86.6%, 84.4%, 93.9%, and 83.1%, respectively. In multivariate analysis (MVA), lymph node ratio >65%, lymphovascular invasion, and negative hormone receptor status predicted for OS, DSF, and DM. T3 to 4 stage was also associated with worse DFS and DM. Finally, for LRR the independent prognostic factors on MVA were N2 to 3 stage and grade 3. Hyperpigmentation was observed in 19.2% of patients, telangiectasia in 12.3%, and fibrosis in 30.7%. Grade ≥2 lymphedema was recorded in 5.8% of cases. During the study follow-up, no cardiac or symptomatic pneumonitis was observed, nor were plexopathy or rib fractures. CONCLUSION According to the findings from this retrospective study, HFRT seems to be an acceptable alternative for patients with breast cancer who need regional nodal irradiation. However, prospective randomized trials are necessary to confirm these preliminary results.
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Affiliation(s)
- Sara Bellefqih
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco.
| | - Sanaa Elmajjaoui
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Jihan Aarab
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Jihane Khalil
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Mohamed Afif
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Amine Lachgar
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Hanan El Kacemi
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Tayeb Kebdani
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Noureddine Benjaafar
- Department of Radiotherapy, National Institute of Oncology, Mohammed V University, Rabat, Morocco
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Berrington de González A, Ntowe E, Kitahara CM, Gilbert E, Miller DL, Kleinerman RA, Linet MS. Long-term Mortality in 43 763 U.S. Radiologists Compared with 64 990 U.S. Psychiatrists. Radiology 2016; 281:847-857. [PMID: 27440487 DOI: 10.1148/radiol.2016152472] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To compare mortality rates from all causes, specific causes, total cancers, and specific cancers to assess whether differences between radiologists and psychiatrists are consistent with known risks of radiation exposure and the changes in radiation exposure to radiologists over time. Materials and Methods The authors used the American Medical Association Physician Masterfile to construct a cohort of 43 763 radiologists (20% women) and 64 990 psychiatrists (27% women) (comparison group) who graduated from medical school in 1916-2006. Vital status was obtained from record linkages with the Social Security Administration and commercial databases, and cause of death was obtained from the National Death Index. Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for all causes and specific causes of death. Results During the follow-up period (1979-2008), 4260 male radiologists and 7815 male psychiatrists died. The male radiologists had lower death rates (all causes) compared with the psychiatrists (RR = 0.94; 95% CI: 0.90, 0.97), similar cancer death rates overall (RR = 1.00; 95% CI: 0.93, 1.07), but increased acute myeloid leukemia and/or myelodysplastic syndrome death rates (RR = 1.62; 95% CI: 1.05, 2.50); these rates were driven by those who graduated before 1940 (RR = 4.68; 95% CI: 0.91, 24.18). In these earliest workers (before 1940) there were also increased death rates from melanoma (RR = 8.75; 95% CI: 1.89, 40.53), non-Hodgkin lymphoma (NHL) (RR = 2.69; 95% CI: 1.33, 5.45), and cerebrovascular disease (RR = 1.49; 95% CI: 1.11, 2.01). The 208 deaths in female radiologists precluded detailed investigation, and the number of female radiologists who graduated before 1940 was very small (n = 47). Conclusion The excess risk of acute myeloid leukemia and/or myelodysplastic syndrome mortality in radiologists who graduated before 1940 is likely due to occupational radiation exposure. The melanoma, NHL, and cerebrovascular disease mortality risks are possibly due to radiation. The authors found no evidence of excess mortality in radiologists who graduated more recently, possibly because of increased radiation protection and/or lifestyle changes. © RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Amy Berrington de González
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
| | - Estelle Ntowe
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
| | - Cari M Kitahara
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
| | - Ethel Gilbert
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
| | - Donald L Miller
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
| | - Ruth A Kleinerman
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
| | - Martha S Linet
- From the Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, 9609 Medical Center Dr, Bethesda, MD 20892 (A.B.d.G., E.N., C.M.K., E.G., R.A.K., M.S.L.); and FDA Office of In Vitro Diagnostics and Radiological Health, White Oak Campus, Silver Spring, Md (D.L.M.)
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Deshmukh S, Sharan K, Fernandes DJ, Srinivasa VM, Yathiraj PH, Singh A, Reddy A. A Study on Dosimetric Outcomes and Acute Toxicity of Post Mastectomy Adjuvant Hypofractionated Radiotherapy for Breast Cancer. J Clin Diagn Res 2016; 10:XC05-XC08. [PMID: 27630936 DOI: 10.7860/jcdr/2016/20477.8146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 05/24/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Hypofractionated External Beam Radiotherapy (HFRT) is a relatively new adjuvant Radiotherapy (RT) schedule for breast cancers following breast conservation surgery and less commonly, following mastectomy. Here we report our experience on normal tissue exposure and acute toxicity of HFRT after mastectomy. AIM To assess the dosimetric outcomes and acute toxicity profile of adjuvant HFRT following mastectomy for breast cancer. MATERIALS AND MATERIALS This prospective observational study considered consecutive patients planned for adjuvant HFRT (42.5 Gy in 16 sessions delivered over 3 weeks) to the chest wall with/without regional nodes between October 2014 and June 2015. The dosimetric parameters including dose homogeneity to the target volume and exposure to heart and lung were analyzed. Acute haematological and dermatological toxicity was recorded until upto three months after completion of RT. RESULTS Among the 56 patients treated with HFRT, the mean age was 49 years (range: 28-69 years). Pathologically positive nodes and ≥pT3 primary was observed in 44 (78.6%) and 12 (21.4%) patients, respectively. Majority (87.5%) received prior adjunct chemotherapy. RT to the supraclavicular fossa was delivered for 39 (69.6%) patients. The mean V90 and V95 to the Planning Target Volume (PTV) were 95% (± 3.3%) and 93% (± 4%), respectively. The maximum dose received was on average 47.7 Gy (112%; range: 46.2-48.5 Gy). The mean lung dose was 10.2 Gy (± 3.5 Gy) and V20 was 20.9% (± 6%). The mean V25 to heart was 6.6% (± 4.8%) for left sided and 0% for right sided tumours (p=0.001). Acute skin toxicity peaked at completion of RT and was tolerable (grade 0, I, II and III reactions were 75%, 16% and 1.8%, respectively). No patient had ≥ grade III haematological toxicity, and treatment was not interrupted for any patient. CONCLUSION Adjuvant HFRT could be planned while meeting the dose constraints to normal tissues in all patients and was well tolerated, with mild to moderate acute adverse effects that did not warrant any therapeutic intervention or treatment interruption.
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Affiliation(s)
- Shivaprasad Deshmukh
- Resident, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | - Krishna Sharan
- Associate Professor, Departmentof Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | - Donald Jerard Fernandes
- Professor and Head, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | | | | | - Anshul Singh
- Assistant Professor, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
| | - Anusha Reddy
- Senior Resident, Department of Radiotherapy, Kasturba Medical College , Manipal, Karnataka, India
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Koulis TA, Phan T, Olivotto IA. Hypofractionated whole breast radiotherapy: current perspectives. BREAST CANCER-TARGETS AND THERAPY 2015; 7:363-70. [PMID: 26604820 PMCID: PMC4629948 DOI: 10.2147/bctt.s81710] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Adjuvant radiotherapy (RT) is an important part of breast cancer management but the dose and fractionation schedules used are variable. A total of 50 Gy in 25 daily fractions delivered over 5 weeks is often considered the “standard” adjuvant RT prescription. Hypofractionated regimes such as 42.5 Gy in 16 daily fractions or 40 Gy in 15 daily fractions following breast-conserving surgery have proven to be equally effective and achieve similar or better cosmetic and normal tissue outcomes for both invasive and in situ diseases and when treating the regional nodes. Hypofractionation is more convenient for patients and less costly. However, certain patients at higher risk of RT late effects may benefit from a less intense, even more extended fractionation schedule. This review describes the indications for whole breast hypofractionated adjuvant RT for patients with breast cancer following breast-conserving surgery and proposes that hypofractionation should be the new “standard” for adjuvant breast cancer RT.
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Affiliation(s)
- Theodora A Koulis
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Tien Phan
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Ivo A Olivotto
- Department of Oncology, University of Calgary, Tom Baker Cancer Centre, Calgary, AB, Canada
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Doré M, Cutuli B, Cellier P, Campion L, Le Blanc M. Hypofractionated irradiation in elderly patients with breast cancer after breast conserving surgery and mastectomy : Analysis of 205 cases. Radiat Oncol 2015; 10:161. [PMID: 26238442 PMCID: PMC4554320 DOI: 10.1186/s13014-015-0448-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 06/26/2015] [Indexed: 01/05/2023] Open
Abstract
Background Several randomized trials and meta-analyses confirmed a wide benefit of radiotherapy (RT), both after breast conserving surgery (BCS) and mastectomy. However, many elderly women don't receive RT. Hypofractionated (HF) RT allows « simplified » and more accessible treatments with equivalent results to classic RT in three large randomized trials. However, there are few available data on HF-RT for nodal irradiation, as well as for the boost. Methods We evaluated patients treated for IBC by HF-RT between 2004 and 2012 in two regional cancer centres. We used an original scheme delivering 45 Gy in 15 fractions three times a week, both after BCS or mastectomy, with or without nodal irradiation. After BCS, a 9 Gy boost in 3 fractions was delivered. Local, regional and distant recurrences were assessed, as well as acute and late cutaneous, cardiac or pulmonary toxicities. Results 205 patients were analysed, 116 after BCS (57 %) and 89 after mastectomy (43 %). Median age was 81 years (range: 52-91); 44 % had axillary nodal involvement (pN+). The Nottingham Prognostic Index (NPI) scored 0, 1, 2 and 3 in 10 %, 27 %, 44 % and 19 % of the cases. A nodal HF-RT was delivered in 65 patients (32 %) and boost in 98 patients (84 % of BCS) by 9 Gy/3 fr scheme. Fifty (24 %) patients underwent chemotherapy and 156 (75 %) hormonal treatment. With a 49-month median follow-up, 3/116 (2.6 %) patients and 4/89 (4.5 %) had local recurrence (LR) after BCS and mastectomy, respectively. The overall 5-year LR rate was 4.4 %. In univariate and multivariate analysis, LR risk factors were: high NPI (HR 5.46; p = 0.028), and triple negative tumour (HR 9.78; p = 0.006). Only 8 (4.5 %) patients had grade III skin toxicity; 29 (14 %) late fibrosis and 16 (8 %) telangiectasia. No pulmonary or cardiac toxicity was observed. Conclusion Our HF-RT scheme (with or without nodal irradiation) confirms in elderly patients the data from randomized trials, both after BCS or mastectomy. Toxicity seems very acceptable but requires a longer follow-up. A larger evaluation is still ongoing in several other centres in France.
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Affiliation(s)
- Mélanie Doré
- Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes, France.
| | - Bruno Cutuli
- Radiation Oncology Department, Institut de Cancérologie de Courlancy, Reims, France.
| | - Patrice Cellier
- Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Angers, France.
| | - Loïc Campion
- Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes, France.
| | - Magali Le Blanc
- Radiation Oncology Department, Institut de Cancérologie de l'Ouest, Nantes, France.
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Caudrelier JM, Truong P. Role of hypofractionated radiotherapy in breast locoregional radiation. Cancer Radiother 2015; 19:241-7. [DOI: 10.1016/j.canrad.2015.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/26/2015] [Indexed: 12/25/2022]
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Second Malignancies After Adjuvant Radiation Therapy for Early Stage Breast Cancer: Is There Increased Risk With Addition of Regional Radiation to Local Radiation? Int J Radiat Oncol Biol Phys 2015; 91:977-85. [DOI: 10.1016/j.ijrobp.2014.12.051] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/20/2014] [Accepted: 12/26/2014] [Indexed: 11/17/2022]
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Chan EK, Woods R, Virani S, Speers C, Wai ES, Nichol A, McBride ML, Tyldesley S. Long-term mortality from cardiac causes after adjuvant hypofractionated vs. conventional radiotherapy for localized left-sided breast cancer. Radiother Oncol 2015; 114:73-8. [DOI: 10.1016/j.radonc.2014.08.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Revised: 07/02/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
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Davis M, Witteles RM. Radiation-induced heart disease: an under-recognized entity? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:317. [PMID: 24756471 DOI: 10.1007/s11936-014-0317-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Radiation-induced heart disease (RIHD) represents a spectrum of cardiovascular disease in patients who have undergone mediastinal, thoracic, or breast radiotherapy (RT). RIHD may involve any cardiac structure and is a major cause of morbidity and mortality in cancer survivors. While large cohort studies have demonstrated that symptomatic RIHD is a common late finding in this population, the incidence of asymptomatic disease is likely to be even higher. Long-term follow-up with regular screening for RIHD plays an important role in the management of cancer survivors who have undergone RT. Aggressive modification of traditional cardiovascular risk factors such as hypertension, dyslipidemia, and cigarette smoking is essential in patients at risk for RIHD, as these have been shown to potentiate the risks of radiation. In patients with symptomatic RIHD, medical and/or percutaneous therapies are often preferable to surgical interventions in view of the increased surgical risk associated with radiation damage to surrounding tissues. Percutaneous revascularization should generally be favored over surgical revascularization. Transcatheter valve replacements have not been widely used in this population but may offer an alternative to high-risk surgical valve procedures. Pericardiectomy is usually associated with extremely poor short-term and long-term outcomes in patients with RIHD and should be avoided in most cases. Heart transplantation is also higher risk in patients with RIHD than in patients with other etiologies of heart failure, but may be considered in young patients without other comorbidities.
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Affiliation(s)
- Margot Davis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Falk Cardiovascular Research Center #273, Stanford, CA, 94305-5406, USA
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High incidence of ischemic stroke occurrence in irradiated lung cancer patients: a population-based surgical cohort study. PLoS One 2014; 9:e94377. [PMID: 24709837 PMCID: PMC3978039 DOI: 10.1371/journal.pone.0094377] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 03/15/2014] [Indexed: 12/27/2022] Open
Abstract
Background and Purpose A high risk of stroke occurrence has been reported in several types of irradiated cancer patients. However, clinical data are lacking in irradiated lung cancer patients. The present study intended to explore a risk level of ischemic stroke occurrence in irradiated lung cancer patients. Methods A nationwide population-based database obtained from the Taiwan National Health Insurance was analyzed. Between 2003 and 2006, we recruited 560 resected lung cancer patients into two study groups: surgery-plus-irradiation (n = 112) and surgery-alone (n = 448). Patients treated with chemotherapy were excluded. Propensity score match was used for pairing cases with a ratio of 1∶4. Two-year ischemic-stroke-free survival was defined as the primary endpoint. Results Three observations supported a high risk of ischemic stroke occurrence in patients with postoperative irradiation when compared with those patients with surgery alone: first, a high incidence per 1,000 person-year (22.3 versus 11.2, 1.99 folds); second, a low two-year ischemic-stroke-free survival rate (92.2% versus 98.1%, P = 0.019); and third, a high adjusted hazard ratio (HR, 4.19; 95% CI, 1.44–12.22; P = 0.009). More notably, the highest risk of ischemic stroke occurrence was found in irradiated patients who had diabetes mellitus (HR, 34.74; 95% CI, 6.35->100; P<0.0001). Conclusions A high incidence of ischemic stroke was observed in irradiated lung cancer patients, especially in those with diabetes mellitus. For these patients, close clinical surveillance and strict diabetes control should be considered. Further studies to define detail biological mechanisms are encouraged.
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Adjuvant Hypofractionated Versus Conventional Whole Breast Radiation Therapy for Early-Stage Breast Cancer: Long-Term Hospital-Related Morbidity From Cardiac Causes. Int J Radiat Oncol Biol Phys 2014; 88:786-92. [DOI: 10.1016/j.ijrobp.2013.11.243] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/20/2013] [Accepted: 11/25/2013] [Indexed: 11/16/2022]
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Use of sentinel lymph node biopsy to select patients for local-regional therapy after neoadjuvant chemotherapy. CURRENT BREAST CANCER REPORTS 2014; 6:10-16. [PMID: 24683440 DOI: 10.1007/s12609-013-0135-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Use of sentinel lymph node biopsy for axillary staging of patients with breast cancer treated with neoadjuvant chemotherapy has been widely debated. Questions arise regarding the accuracy of sentinel lymph node biopsy in axillary staging for these patients and its use to determine further local-regional therapy, including surgery and radiation therapy. For patients who are clinically node-negative at presentation, sentinel lymph node biopsy enables accurate staging of the axilla after neoadjuvant chemotherapy, and determination of which patients should go on to further axillary surgery and regional nodal radiation therapy. Importantly, performing axillary staging after completion of chemotherapy, rather than before chemotherapy, enables assessment of response to chemotherapy and the extent of residual disease. This information can assist the planning of adjuvant treatment. Recent data indicate that sentinel node biopsy can also be used to assess disease response after neoadjuvant chemotherapy for patients with clinical N1 disease at presentation.
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Steingart RM, Yadav N, Manrique C, Carver JR, Liu J. Cancer Survivorship: Cardiotoxic Therapy in the Adult Cancer Patient; Cardiac Outcomes With Recommendations for Patient Management. Semin Oncol 2013; 40:690-708. [DOI: 10.1053/j.seminoncol.2013.09.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Hsieh TC, Wu YC, Yen KY, Chen SW, Kao CH. Early changes in brain FDG metabolism during anticancer therapy in patients with pharyngeal cancer. J Neuroimaging 2013; 24:266-72. [PMID: 23320861 DOI: 10.1111/jon.12006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 10/16/2012] [Accepted: 10/28/2012] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The current study aimed to evaluate whether therapy-related changes occurred in brain metabolism at an earlier stage during the course of anticancer therapy. METHODS We recruited 14 non-diabetic male patients with newly diagnosed pharyngeal squamous cell carcinoma. We analyzed the patients' serial brain FDG PET/CT scans by SPM8 to establish whether any therapy-related changes had occurred in brain FDG metabolism, either during or after the course of therapy. RESULTS Decreased metabolism was noted during the anticancer therapy, displaying a symmetric pattern involving bilateral basal ganglia and bilateral occipital lobes. The decrease in FDG metabolism in these regions persisted after the anticancer therapy had terminated. However, relative recovery of the metabolism was noted in the bilateral occipital lobes, whereas further deterioration was noted in bilateral basal ganglia. CONCLUSIONS The current study revealed that unappreciable changes in brain metabolism can occur during the early course of anticancer therapy, and persist even after therapy has terminated. Although the exact mechanism remains unclear, these changes may be related to the systemic effects of chemotherapy or radiotherapy as well as subclinical cancer-related depressive or adjustment mood disorder.
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Affiliation(s)
- Te-Chun Hsieh
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung City, Taiwan; Department of Biomedical Imaging and Radiological Science, College of Medicine, China Medical University, Taichung City, Taiwan
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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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Wright JL, Takita C, Reis IM, Zhao W, Saigal K, Wolfson A, Markoe A, Moller M, Hurley J. Predictors of locoregional outcome in patients receiving neoadjuvant therapy and postmastectomy radiation. Cancer 2012; 119:16-25. [DOI: 10.1002/cncr.27717] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 05/16/2012] [Accepted: 05/25/2012] [Indexed: 11/10/2022]
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