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Ott OJ, Stillkrieg W, Lambrecht U, Schweizer C, Lamrani A, Sauer TO, Strnad V, Bert C, Hack CC, Beckmann MW, Fietkau R. External-Beam-Accelerated Partial-Breast Irradiation Reduces Organ-at-Risk Doses Compared to Whole-Breast Irradiation after Breast-Conserving Surgery. Cancers (Basel) 2023; 15:3128. [PMID: 37370738 DOI: 10.3390/cancers15123128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
In order to evaluate organ-at-risk (OAR) doses in external-beam-accelerated partial-breast irradiation (APBI) compared to standard whole-breast irradiation (WBI) after breast-conserving surgery. Between 2011 and 2021, 170 patients with early breast cancer received APBI within a prospective institutional single-arm trial. The prescribed dose to the planning treatment volume was 38 Gy in 10 fractions on 10 consecutive working days. OAR doses for the contralateral breast, the ipsilateral, contralateral, and whole lung, the whole heart, left ventricle (LV), and the left anterior descending coronary artery (LAD), and for the spinal cord and the skin were assessed and compared to a control group with real-world data from 116 patients who underwent WBI. The trial was registered at the German Clinical Trials Registry, DRKS-ID: DRKS00004417. Compared to WBI, APBI led to reduced OAR doses for the contralateral breast (0.4 ± 0.6 vs. 0.8 ± 0.9 Gy, p = 0.000), the ipsilateral (4.3 ± 1.4 vs. 9.2 ± 2.5 Gy, p = 0.000) and whole mean lung dose (2.5 ± 0.8 vs. 4.9 ± 1.5 Gy, p = 0.000), the mean heart dose (1.6 ± 1.6 vs. 1.7 ± 1.4 Gy, p = 0.007), the LV V23 (0.1 ± 0.4 vs. 1.4 ± 2.6%, p < 0.001), the mean LAD dose (2.5 ± 3.4 vs. 4.8 ± 5.5 Gy, p < 0.001), the maximum spinal cord dose (1.5 ± 1.1 vs. 4.5 ± 5.7 Gy, p = 0.016), and the maximum skin dose (39.6 ± 1.8 vs. 49.1 ± 5.8 Gy, p = 0.000). APBI should be recommended to suitable patients to minimize the risk of secondary tumor induction and the incidence of consecutive major cardiac events.
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Affiliation(s)
- Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Wilhelm Stillkrieg
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Claudia Schweizer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Allison Lamrani
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Tim-Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Carolin C Hack
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
- Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Matthias W Beckmann
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
- Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
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Vogel M, Gade J, Timm B, Schürmann M, Auerbach H, Nüsken F, Rübe C, Melchior P, Dzierma Y. Comparison of Breast Cancer Radiotherapy Techniques Regarding Secondary Cancer Risk and Normal Tissue Complication Probability - Modelling and Measurements Using a 3D-Printed Phantom. Front Oncol 2022; 12:892923. [PMID: 35965556 PMCID: PMC9365503 DOI: 10.3389/fonc.2022.892923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Radiotherapy after breast-conserving therapy is a standard postoperative treatment of breast cancer, which can be carried out with a variety of irradiation techniques. The treatment planning must take into consideration detrimental effects on the neighbouring organs at risk-the lung, the heart, and the contralateral breast, which can include both short- and long-term effects represented by the normal tissue complication probability and secondary cancer risk. Patients and Methods In this planning study, we investigate intensity-modulated (IMRT) and three-dimensional conformal (3D-CRT) radiotherapy techniques including sequential or simultaneously integrated boosts as well as interstitial multicatheter brachytherapy boost techniques of 38 patients with breast-conserving surgery retrospectively. We furthermore develop a 3D-printed breast phantom add-on to allow for catheter placement and to measure the out-of-field dose using thermoluminescent dosimeters placed inside an anthropomorphic phantom. Finally, we estimate normal tissue complication probabilities using the Lyman-Kutcher-Burman model and secondary cancer risks using the linear non-threshold model (out-of-field) and the model by Schneider et al. (in-field). Results The results depend on the combination of primary whole-breast irradiation and boost technique. The normal tissue complication probabilities for various endpoints are of the following order: 1%-2% (symptomatic pneumonitis, ipsilateral lung), 2%-3% (symptomatic pneumonitis, whole lung), and 1%-2% (radiation pneumonitis grade ≥ 2, whole lung). The additional relative risk of ischemic heart disease ranges from +25% to +35%. In-field secondary cancer risk of the ipsilateral lung in left-sided treatment is around 50 per 10,000 person-years for 20 years after exposure at age 55. Out-of-field estimation of secondary cancer risk results in approximately 5 per 10,000 person-years each for the contralateral lung and breast. Conclusions In general, 3D-CRT shows the best risk reduction in contrast to IMRT. Regarding the boost concepts, brachytherapy is the most effective method in order to minimise normal tissue complication probability and secondary cancer risk compared to teletherapy boost concepts. Hence, the 3D-CRT technique in combination with an interstitial multicatheter brachytherapy boost is most suitable in terms of risk avoidance for treating breast cancer with techniques including boost concepts.
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Affiliation(s)
- Marc Vogel
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Jonas Gade
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Bernd Timm
- Siemens Healthcare GmbH, Technical Service, Erlangen, Germany
| | - Michaela Schürmann
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Hendrik Auerbach
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Frank Nüsken
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Christian Rübe
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Patrick Melchior
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
| | - Yvonne Dzierma
- Department of Radiotherapy and Radiation Oncology, Saarland University Medical Centre, Homburg, Germany
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Comparison of skin doses of treated and contralateral breasts during whole breast radiotherapy for different treatment techniques using optically stimulated luminescent dosimeters. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractPurpose:To measure and compare the skin doses received by treated left breast and contralateral breast (CB) during whole breast radiotherapy using five treatment techniques in an indigenously prepared wax breast phantom.Materials and methods:Computed tomography (CT) images of the breast phantom were used for treatment planning and comparison of skin dose calculated from treatment planning system (TPS) with measured dose. Planning target volume (PTV) and the CB were drawn arbitrarily on the CT images acquired for the breast phantom with 10 numbers of calibrated optically stimulated luminescent dosimeters (OSLDs) fixed on the surface of both breasts. The TPS calculated surface doses of PTV breast and CB for five treatment planning techniques, viz., conventional wedge (CW), irregular surface compensator-based (ISC), field-in-field (FiF), intensity-modulated radiotherapy (IMRT) and rapid arc (RA) techniques were obtained for comparison. The plans were executed in Clinac iX Linear Accelerator with the OSLDs fixed at the same locations on the phantom as in simulation. The TPS calculated mean dose at the surface of the treated left breast and CB was noted for the 10 OSLDs from dose-volume histogram (DVH) and compared with the measured dose. Also, the mean chamber dose at the centre of the left breast was noted from the DVH for comparing with ion chamber measured dose.Results:With reference to the results, it is seen that the dose to the CB is lowest in ISC technique and FiF technique and greatest in IMRT technique. The CW technique also delivered a dose comparable to IMRT to the CB of the phantom. The dose to the surface of PTV breast was highest and comparable in CW plans and FiF plans (68% and 67%) and lowest in IMRT and RA plans (50% each).Findings:Analysis of the results shows that the FiF and ISC techniques are preferred while planning breast radiotherapy due to the reduced dose to the CB.
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Katz LM, Perez CA, Gerber NK, Purswani J, McCarthy A, Das IJ. Skin recurrence in the radiation treatment of breast cancer. Adv Radiat Oncol 2018; 3:458-462. [PMID: 30202813 PMCID: PMC6128028 DOI: 10.1016/j.adro.2018.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/23/2018] [Accepted: 04/29/2018] [Indexed: 11/02/2022] Open
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Jagsi R, Griffith KA, Moran JM, Ficaro E, Marsh R, Dess RT, Chung E, Liss AL, Hayman JA, Mayo CS, Flaherty K, Corbett J, Pierce L. A Randomized Comparison of Radiation Therapy Techniques in the Management of Node-Positive Breast Cancer: Primary Outcomes Analysis. Int J Radiat Oncol Biol Phys 2018; 101:1149-1158. [PMID: 30012527 DOI: 10.1016/j.ijrobp.2018.04.075] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/23/2018] [Accepted: 04/25/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Although inverse-planned intensity modulated radiotherapy (IMRT) and deep inspiration breath hold (DIBH) may allow for more conformal dose distributions, it is unknown whether using these technologies reduces cardiac or pulmonary toxicity of breast radiotherapy. METHODS AND MATERIALS A randomized controlled trial compared IMRT-DIBH versus standard, free-breathing, forward-planned, three-dimensional conformal radiotherapy in patients with left-sided, node-positive breast cancer in whom the internal mammary nodal region was targeted. Endpoints included dosimetric parameters and changes in pulmonary and cardiac perfusion and function, measured by single photon emission computed tomography (SPECT) scans and pulmonary function testing performed at baseline and 1 year post treatment. RESULTS Of 62 patients randomized, 54 who completed all follow-up procedures were analyzed. Mean doses to the ipsilateral lung, left ventricle, whole heart, and left anterior descending coronary artery were lower with IMRT-DIBH; the percent of left ventricle receiving ≥5 Gy averaged 15.8% with standard radiotherapy and 5.6% with IMRT-DIBH (P < .001). SPECT revealed no differences in perfusion defects in the left anterior descending coronary artery territory, the study's primary endpoint, but did reveal statistically significant differences (P = .02) in left ventricular ejection fraction (LVEF), a secondary endpoint. No differences were found for lung perfusion or function. CONCLUSION The small but statistically significant benefit in preservation of cardiac LVEF observed here should motivate future studies that include LVEF as a potentially meaningful endpoint. Future studies should disaggregate the impact of IMRT from that of DIBH. Clinical practice should recognize the importance of minimizing cardiac dose, even when already low in comparison to historical levels.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Kent A Griffith
- Center for Cancer Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Edward Ficaro
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Robin Marsh
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Eugene Chung
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Adam L Liss
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Charles S Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kevin Flaherty
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - James Corbett
- Department of Radiology, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Lori Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Kry SF, Bednarz B, Howell RM, Dauer L, Followill D, Klein E, Paganetti H, Wang B, Wuu CS, George Xu X. AAPM TG 158: Measurement and calculation of doses outside the treated volume from external-beam radiation therapy. Med Phys 2017; 44:e391-e429. [DOI: 10.1002/mp.12462] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 05/17/2017] [Accepted: 05/25/2017] [Indexed: 12/14/2022] Open
Affiliation(s)
- Stephen F. Kry
- Department of Radiation Physics; MD Anderson Cancer Center; Houston TX 77054 USA
| | - Bryan Bednarz
- Department of Medical Physics; University of Wisconsin; Madison WI 53705 USA
| | - Rebecca M. Howell
- Department of Radiation Physics; MD Anderson Cancer Center; Houston TX 77054 USA
| | - Larry Dauer
- Departments of Medical Physics/Radiology; Memorial Sloan-Kettering Cancer Center; New York NY 10065 USA
| | - David Followill
- Department of Radiation Physics; MD Anderson Cancer Center; Houston TX 77054 USA
| | - Eric Klein
- Department of Radiation Oncology; Washington University; Saint Louis MO 63110 USA
| | - Harald Paganetti
- Department of Radiation Oncology; Massachusetts General Hospital and Harvard Medical School; Boston MA 02114 USA
| | - Brian Wang
- Department of Radiation Oncology; University of Louisville; Louisville KY 40202 USA
| | - Cheng-Shie Wuu
- Department of Radiation Oncology; Columbia University; New York NY 10032 USA
| | - X. George Xu
- Department of Mechanical, Aerospace, and Nuclear Engineering; Rensselaer Polytechnic Institute; Troy NY 12180 USA
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Hybrid intensity-modulated radiation therapy (IMRT) simultaneous integrated boost (SIB) technique versus three-dimensional (3D) conformal radiotherapy with SIB for breast radiotherapy: a planning comparison. JOURNAL OF RADIOTHERAPY IN PRACTICE 2016. [DOI: 10.1017/s146039691600008x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
AbstractAimThis study aims to compare conventional simultaneous integrated boost (SIB) planning technique with a hybrid SIB intensity-modulated radiation therapy (IMRT) technique with varying open tangent to IMRT field dose ratios. Furthermore, we investigated which of the dose ratios proves the most favourable as a class solution across a sample.MethodsIn total, 15 patients with conventional SIB treatment plans were re-planned with hybrid SIB IMRT technique using three differing open field:IMRT dose ratios, that is, 80:20, 70:30 and 60:40. Plans were compared using dosimetric comparison of organs at risk (OARs) and homogeneity and conformity indexes across target structures.ResultsAll hybrid plans reduced dose maximums and showed a reduction of high doses to both lungs but increased lower doses, that is, V5, with similar results discovered for the heart. Contralateral breast dose was shown to decrease V5 and V1 measures by hybrid arms, whereas increasing the V2. Left anterior descending artery dose and non-irradiated structures were reduced by all hybrid arms. The homogeneity and conformity increased across all hybrid arms. Qualitative assessment of all plans also favoured hybrid plans.FindingsHybrid plans produced superior dose conformity, homogeneity, reduced dose maximums and showed an improvement in most OAR parameters. The 70:30 hybrid technique exhibited greater benefits as a class solution to the sample than conventional plans due to superior dose conformity and homogeneity to target volumes.
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Planning Hybrid Intensity Modulated Radiation Therapy for Whole-breast Irradiation. Int J Radiat Oncol Biol Phys 2012; 84:e115-22. [DOI: 10.1016/j.ijrobp.2012.02.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 02/10/2012] [Accepted: 02/10/2012] [Indexed: 12/25/2022]
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Becker SJ, Elliston C, DeWyngaert K, Jozsef G, Brenner D, Formenti S. Breast radiotherapy in the prone position primarily reduces the maximum out-of-field measured dose to the ipsilateral lung. Med Phys 2012; 39:2417-23. [DOI: 10.1118/1.3700402] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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