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Yashar C, Khan AJ, Chen P, Einck J, Poppe M, Li L, Yehia ZA, Vicini FA, Moore D, Arthur D, Quinn TJ, Kowzun M, Simon L, Scanderbeg D, Shah C, Haffty BG, Kuske R. Three-Fraction Accelerated Partial Breast Irradiation (APBI) Delivered With Interstitial Brachytherapy Is Safe: First Results From the Tri-fraction Radiation Therapy Used to Minimize Patient Hospital Trips (TRIUMPH-T) Trial. Pract Radiat Oncol 2023:S1879-8500(23)00062-0. [PMID: 37140504 DOI: 10.1016/j.prro.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Shorter courses of breast radiotherapy are offered as an alternative to 4 weeks of whole-breast irradiation after lumpectomy, including brachytherapy. A prospective phase 2multi-institution clinical trial to study 3-fraction accelerated partial breast irradiation delivered by brachytherapy was conducted. METHODS AND MATERIALS The trial treated selected breast cancers after breast-conserving surgery with brachytherapy applicators that delivered 22.5 Gy in 3 fractions of 7.5 Gy. The planning treatment volume was 1 to 2 cm beyond the surgical cavity. Eligible women were age ≥45 years with unicentric invasive or in situ tumors ≤3 cm excised with negative margins and with positive estrogen or progesterone receptors and no metastases to axillary nodes. Strict dosimetric parameters were required to be met and follow up information was collected from the participating sites. RESULTS Two hundred patients were prospectively enrolled; however, a total of 185 patients who were enrolled were followed for a median of 3.63 years. Three-fraction brachytherapy was associated with low chronic toxicity. There was excellent or good cosmesis in 94% of patients. There were no grade 4 toxicities. Grade 3 fibrosis at the treatment site was present in 1.7% and 32% percent had grades 1 or 2 fibrosis at the treatment site. There was 1 rib fracture. Other late toxicities included 7.4% grade 1 hyperpigmentation, 2% grade 1 telangiectasias, 1.7% symptomatic seromas, 1.7% abscessed cavities, and 1.1% symptomatic fat necrosis. There were 2 (1.1%) ipsilateral local recurrences, 2 (1.1%) nodal recurrences and no distant recurrences. Other incidents included one contralateral breast cancer and 2 second malignancies (lung). CONCLUSIONS Ultra-short breast brachytherapy is feasible and has excellent toxicity and could be an alternative to standard 5-day, 10 fraction accelerated partial breast irradiation in eligible patients. Patients from this prospective trial will continue to be followed to evaluate long-term outcomes.
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Affiliation(s)
- Catheryn Yashar
- UC San Diego/Moores Cancer Center, La Jolla, California; Bryn Mawr Hospital, Bryn Mawr, Pennsylvania.
| | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Chen
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | - John Einck
- Kansas University Medical Center, Kansas City, Kansas
| | - Matthew Poppe
- Hunstman Cancer Center, University of Utah, Salt Lake City, Utah
| | - Linna Li
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | | | - Frank A Vicini
- Michigan Health care Professional, 21st Century Oncology, Farmington Hills, Michigan
| | - Dirk Moore
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Doug Arthur
- Virginia Commonwealth University, Massey Cancer Center, Richmond, Virginia
| | - T J Quinn
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | - Maria Kowzun
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Laurie Simon
- UC San Diego/Moores Cancer Center, La Jolla, California
| | | | - Chirag Shah
- Cleveland Clinic Cancer Center, Cleveland, Ohio
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, Arizona
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Anderson B, Vicini F, Wazer D, Arthur D. Breast brachytherapy: Building a bright future on the foundation of a rich history of advancement in technology, technique, and patient-centered care. Brachytherapy 2023; 22:368-380. [PMID: 36740541 DOI: 10.1016/j.brachy.2022.12.009] [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: 09/20/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 02/05/2023]
Abstract
For over 20 years, the concept of accelerated partial breast irradiation (APBI) has received considerable attention. Initially concentrating on the appropriateness of APBI as an alternative treatment to whole breast radiotherapy, investigation and innovation evolved towards dose delivery and technique appropriateness. The purpose of this article is to review the pertinent literature that supports the role brachytherapy serves in delivering APBI and the recognized brachytherapy techniques for dose delivery. Publications establishing techniques utilizing multicatheter brachytherapy, single-entry brachytherapy applicators, permanent breast seed implantation brachytherapy, noninvasive breast brachytherapy and electronic brachytherapy are described. The use of brachytherapy for repeat breast conservation therapy is additionally reviewed. A historical perspective and potential direction of future investigation and innovation are presented.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Vicini F, Broughman J, Halima A, Mayo Z, Obi E, Al-Hilli Z, Arthur D, Wazer D, Shah C. Delivery of Adjuvant Radiation in 5 Days or Less After Lumpectomy for Breast Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2021; 112:1090-1104. [PMID: 34921906 DOI: 10.1016/j.ijrobp.2021.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent data have been published supporting the application of ultra-short radiation therapy (RT) regimens for women with early stage breast cancer following breast conserving surgery (BCS). What has remained controversial is whether and how to apply accelerated whole breast irradiation (AWBI) or accelerated partial breast irradiation (APBI) approaches in these patients, as well as the consideration of intraoperative RT (IORT) for this population. METHODS We performed a systematic review of the literature searching for randomized and prospective data published evaluating ultra-short RT delivered in 5-days or less with APBI, AWBI, or IORT. RESULTS We identified two randomized studies applying AWBI (n=5,011 patients) with 5 to 10 year follow up, which supported the use of ultra-short course AWBI (5 fractions in one week) as compared to hypofractionated WBI. We identified six randomized trials evaluating APBI (as compared to WBI) in 5 days or less (n= 8,415) with numerous (n=55) prospective studies as well, with the data supporting short course APBI as compared to WBI. Finally, we identified two randomized trials evaluating IORT; however, both trials demonstrated elevated rates of recurrence with IORT as compared to WBI. CONCLUSIONS The current body of data available for ultra-short adjuvant RT regimens delivered in 5-days or less after BCS overwhelming support their utilization. While data for both exists, APBI regimens have, by far, greater numbers of patients and longer follow-up as compared to AWBI. Also, given increased rates of recurrence seen with IORT with long-term follow-up, this should not be considered a standard approach at this time.
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Affiliation(s)
| | - James Broughman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Halima
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zachary Mayo
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Obi
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - David Wazer
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Chirag Shah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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Xue H, Qiu B, Wang H, Jiang P, Sukocheva O, Fan R, Xue L, Wang J. Stereotactic Ablative Brachytherapy: Recent Advances in Optimization of Radiobiological Cancer Therapy. Cancers (Basel) 2021; 13:cancers13143493. [PMID: 34298703 PMCID: PMC8304109 DOI: 10.3390/cancers13143493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 02/07/2023] Open
Abstract
Brachytherapy (BT), a type of focal anti-cancer radiotherapy, delivers a highly focused radiation dose to localized tumors, sparing surrounding normal tissues. Recent technological advances have helped to increase the accuracy of BT and, thus, improve BT-based cancer treatment. Stereotactic ablative brachytherapy (SABT) was designed to improve the ablative effect of radiation, which was achieved via improved image guidance, and calculation of ablative dose, shorter treatment duration, and better organ preservation. Recently collected data characterized SABT as having the potential to cure various early-stage cancers. The method provides higher tumor control rate levels that were previously achievable only by surgical resection. Notably, SABT is suitable for application with unresectable malignancies. However, the pathological assessment of SABT irradiated tumors is limited due to difficulties in specimen acquisition. Prostate, lung, liver, and gynecological cancers are the most commonly reported SABT-treated malignancies. This study will give an overview of SABT, focusing on the advances in SABT optimization, and provide insights on the future benefits of the combined application of SABT with cancer immunotherapies.
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Affiliation(s)
- Hui Xue
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Bin Qiu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Hao Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
| | - Olga Sukocheva
- Discipline of Health Sciences, College of Nursing and Health Sciences, Flinders University of South Australia, Bedford Park, SA 5042, Australia;
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China;
| | - Lixiang Xue
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
- Correspondence: (L.X.); (J.W.); Tel.: +86-13701076310 (L.X.); +86-13701076310 (J.W.)
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China; (H.X.); (B.Q.); (H.W.); (P.J.)
- Correspondence: (L.X.); (J.W.); Tel.: +86-13701076310 (L.X.); +86-13701076310 (J.W.)
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Five-year results of accelerated partial breast irradiation: A single-institution retrospective review of 289 cases. Brachytherapy 2021; 20:807-817. [PMID: 33810984 DOI: 10.1016/j.brachy.2021.02.003] [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: 11/21/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of the study was to describe our institutional experience with accelerated partial breast irradiation (APBI) using multicatheter brachytherapy with high-dose-rate. We report 5-year survival outcomes, cosmesis, and treatment-related toxicity. METHODS AND MATERIALS This included a retrospective review of patients who underwent breast-conserving surgery followed by APBI at our institution from 2004 to 2017. RESULTS A total of 289 patients were evaluated. Median followup was 72 months. Median age was 70 years. APBI was the only primary treatment in 86.2% of cases with early-stage breast cancer and a second conservative treatment in 13.8%. The implant was performed postoperatively in 213 patients (73.7%) and intraoperatively in 76 (26.3%). The most common radiation schemes were 10 fractions of 3.4 Gy and eight fractions of 4 Gy. Elderly or frail patients (10%) received a single 16 Gy dose. Of the 289 patients, 215 met Groupe Européen de Curiethérapie-European Society for Radiotherapy and Oncology criteria for APBI; in this group, late side effects included Grade 2 (G2) fibrosis (14.8%), skin discoloration at the catheter points (8.8%), and telangiectasia (0.5%). The cosmetic result was considered excellent or good in 88.3% of cases. Five-year local control, disease-free, cancer-specific, and overall survival rates were 98.9%, 96.7%, 99.1%, and 95.6%, respectively. CONCLUSIONS Local control and survival outcomes at 5 years of followup in this group of well-selected patients were excellent, with low rates of treatment-related toxicity. These findings confirm the safety and effectiveness of APBI, even in elderly and frail patients. These results provide further support for the clinical use of APBI in suitable patients.
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Analysis of the electron-stream effect in patients treated with partial breast irradiation using the 1.5 T MR-linear accelerator. Clin Transl Radiat Oncol 2021; 27:103-108. [PMID: 33553697 PMCID: PMC7856390 DOI: 10.1016/j.ctro.2020.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/21/2020] [Accepted: 12/28/2020] [Indexed: 12/25/2022] Open
Abstract
The electron-stream effect is responsible of an out-of-field dose when performing partial breast irradiation at the MR-linac. The electron-stream effect is located to the patient́s chin and, for lateral targets, to the arm. The electron-stream effect is effectively minimized by a bolus. Novel concepts and clinical trials for breast cancer at the 1.5 T MR-linac can be tested.
Introduction The hybrid magnetic resonance linear accelerator (MRL) has the potential to test novel concepts in breast cancer patients such as daily MR-guided real-time plan adaptation. Before starting clinical trials, preparatory studies for example of the MR-dependent electron stream effect (ESE) are necessary. Material and Methods To prospectively investigate the ESE, data from 11 patients treated with partial breast irradiation (PBI) at the 1.5 T MRL were evaluated. A bolus was placed on the chin and in vivo dosimetry results were compared with the dose simulated by the treatment planning system (TPS). The same measurements were carried out for three patients treated at a conventional linac. Toxicity and cosmesis were evaluated. Results Median doses measured and simulated on top/ underneath the bolus were 1.91 / 0.62 Gy and 2.82 / 0.63 Gy, respectively. Median differences between calculations and measurements were 0.8 Gy and 0.1 Gy. At the conventional linac, median measured doses on top/ underneath the bolus were 0.98 and 1.37 Gy. No acute toxicity exceeding grade 2 was recorded. Cosmesis was good or excellent and patient reported outcome measures were mostly scored as none or mild. Conclusion The dose due to the ESE is low, correctly predicted by the TPS and effectively minimized by a bolus.
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Jiang W, Jiang P, Wei S, Jiang Y, Ji Z, Sun H, Fan J, Li W, Shao Y, Wang J. The accuracy and safety of CT-guided iodine-125 seed implantation assisted by 3D non-coplanar template for retroperitoneal recurrent carcinoma. World J Surg Oncol 2020; 18:307. [PMID: 33239023 PMCID: PMC7690097 DOI: 10.1186/s12957-020-02087-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 11/16/2020] [Indexed: 01/05/2023] Open
Abstract
PURPOSE To investigate the accuracy, dosimetric parameters, and safety of 3D-printing non-coplanar template (3D-PNCT)-assisted CT guidance for radioactive iodine-125 (125I) seed implantation brachytherapy (RSI-BT) for retroperitoneal recurrent carcinomas METHODS AND MATERIALS: We enrolled 15 patients with 17 retroperitoneal recurrent carcinomas after external beam radiotherapy (EBRT). All patients received CT-guided 125I RSI-BT assisted by 3D-PNCT successfully. We compared the original needle insertion position, angular, and the needle tip distance deviations of preoperative plan with that of intraoperative in brachytherapy treatment planning system (B-TPS). The dosimetric parameters of RSI-BT were evaluated on preoperative plan, intraoperative real-time plan, and postoperative plan, including D90, D100 (the dose to 90% and 100% of the target volume), V100, V150, and V200 (the volume receives 100%, 150%, and 200% of the prescribed doses). The quality assurance of RSI-BT evaluated on conformal index (CI), external index (EI), and homogeneity index (HI) of the targets were compared among preoperative plan, intraoperative real-time plan, and postoperative plan. The perioperation complications and RSI-BT-related toxicity were assessed. RESULTS The median follow-up was 8.2 months (range 1-18.5 months). One patient was lost to follow-up after RSI-BT. Fourteen patients were assessed for response rate and toxicity. The mean entrance point distance deviation for all 165 needles was 4.50 ± 4.10 mm (range, 0-30). The mean angular deviation was 2.70 ± 3.00° (range, 0-20). The needle tip distance deviation was 6.90 ± 6.00 mm (range, - 30-28). D90 for preoperative plan, intraoperative plan, and postoperative plan were 140.55 ± 23.93, 124.25 ± 28.04, and 128.98 ± 22.75, respectively. There was significant difference between D90 of preoperative plan with that of intraoperative plan (p = 0.036). Four lesions reached CR, six lesions reached PR, three lesions were SD, and three lesions were PD. Four patients with moderate pain became mild, and two with mild pain relieved completely after RSI-BT. The other parameters showed no differences among preoperative plan, intraoperative plan, and postoperative plan. The perioperative complications were observed in four patients, including three patients of grade 1 and one patient of grade 2. No ≥ grade 3 side effects were observed. CONCLUSION CT-guided 125I RSI-BT assisted by 3D-PNCT was a safe, accurate, and feasible strategy for recurrent carcinomas located in the retroperitoneal regions.
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Affiliation(s)
- Weijuan Jiang
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Shuhua Wei
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Yuliang Jiang
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Zhe Ji
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Haitao Sun
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Jinghong Fan
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Weiyan Li
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Yuxia Shao
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, No.49 Huayuan North Road, Haidian District, Beijing, 100191 People’s Republic of China
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Polgár C, Major T, Takácsi-Nagy Z, Fodor J. Breast-Conserving Surgery Followed by Partial or Whole Breast Irradiation: Twenty-Year Results of a Phase 3 Clinical Study. Int J Radiat Oncol Biol Phys 2020; 109:998-1006. [PMID: 33186620 DOI: 10.1016/j.ijrobp.2020.11.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/22/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To report the 20-year results of a phase 3 clinical trial comparing the survival and cosmetic results of breast-conserving surgery followed by partial breast irradiation (PBI) or whole breast irradiation (WBI). METHODS AND MATERIALS Between 1998 and 2004, 258 selected patients with low-risk invasive breast carcinoma (pT1 pN0-1mi, grade 1-2, nonlobular breast cancer) resected with negative margins were randomized after breast-conserving surgery to receive PBI (n = 128) or 50 Gy WBI (n = 130). Partial breast irradiation was given either by multicatheter high-dose-rate (HDR) brachytherapy (BT; n = 88) with 7 × 5.2 Gy twice daily or 50 Gy external beam irradiation with electron beams (n = 40). RESULTS Median follow-up time was 17 years. The 20-year actuarial rates of ipsilateral breast tumor recurrences were 9.6% versus 7.9% (P = .59) in the PBI and WBI arms, respectively. There was no significant difference in the 20-year probability of disease-free (79.7% vs 78.3%), cancer-specific (92.6% vs 88.1%), and overall survival (59.5% vs 59.7%). Significantly more patients had excellent or good cosmetic result in the PBI and WBI groups (79.2% vs 59.5%; P = .0007). CONCLUSIONS The 20-year updated results of our phase 3 clinical trial add further scientific evidence that PBI either with multicatheter HDR BT or electron beams for low-risk invasive breast carcinomas yield long-term local tumor control and survival comparable to those achieved with standard WBI. Interstitial HDR BT improved cosmetic results compared with WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - János Fodor
- Department of Oncology, Semmelweis University, Budapest, Hungary
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Predicting adherence of dose-volume constraints for personalized partial-breast irradiation technique. Brachytherapy 2020; 20:163-170. [PMID: 32741559 DOI: 10.1016/j.brachy.2020.06.018] [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: 05/28/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Multicatheter interstitial brachytherapy (MIB) and external-beam (EB) radiotherapy are established partial-breast irradiation (PBI) techniques. Although EB-PBI is widely available, it requires extra irradiated margins for target uncertainties. We examined the impact of EB-PBI on dose-volume constraints as compared to MIB-PBI. METHODS AND MATERIALS Among 653 patients receiving MIB-PBI between October 2008 and April 2020, consequent 159 patients after September 2018 were examined. Clinical target volume (CTV) included the lumpectomy cavity plus 1.0 cm. Planning target volume (PTV) for EB-PBI was defined as CTV with 1.0-cm expansion. Because the ratio of PTV to breast volume (RPB) was related to cosmesis, <25% of RPB was defined as suitable for the ipsilateral breast constraints. Preoperative breast size was classified as very small (<350 cm3), small (350-699 cm3), and medium or large (≥700 cm3). According to each category, the dose-volume constraints of the organs at risk were compared between the two PBI techniques. RESULTS Patients including 84 very small, 59 small, and 16 moderate to large breasts were examined. Although RPB was suitable in all patients receiving MIB-PBI, it was achieved in 74 patients (46.5%) receiving EB-PBI (p < 0.0001). The suitable RPB in patients with very small, small, and moderate to large breast was 32.1%, 55.9%, and 100%, respectively (p < 0.0001). Normal-tissue constraints for the other organs could be satisfied in patients with moderate to large breasts. CONCLUSION Although EB-PBI may be an appropriate option for patients with moderate to large breasts, MIB-PBI could still be a crucial technique, especially for patients with small breasts.
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Abstract
Breast brachytherapy represents a radiation technique that can be utilized as both monotherapy and as a tumor bed boost following breast conserving surgery. As monotherapy, the rationale for brachytherapy is that the majority of residual disease and therefore recurrences occur in close proximity to the lumpectomy cavity; for boost treatment, brachytherapy represents a technique that provided a more conformal approach prior to 3D treatment planning, and more recently can be used in conjunction with oncoplastic surgery. Multiple guidelines are available to assist clinicians with patient selection for accelerated partial breast irradiation (APBI), and recent guidelines support brachytherapy as an appropriate technique to deliver APBI. Modern breast brachytherapy can be performed with interstitial or applicator-based brachytherapy with multilumen and strut devices offering the ability to provide greater skin, chest wall, and normal breast sparing than previous devices. Novel strategies are being evaluated, including high dose rate perioperative/intraoperative radiotherapy, permanent breast seed implants, and noninvasive breast brachytherapy. Additionally, studies are evaluating shorter courses of brachytherapy. Multiple Level I studies are now available supporting interstitial brachytherapy to deliver APBI while prospective data and the National Surgical Adjuvant Breast and Bowel Project B-39/Radiation Therapy Oncology Group 0413 trial are available with applicator brachytherapy and provide standardized prescriptions, target volume definitions, and dosimetric goals.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Alvaro Martinez
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI
| | - Matthew Kolar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI.
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Yadav BS, Loganathan S, Sharma SC, Singh R, Dahiya D. Comparison of Toxicity and Cosmetic Outcomes After Accelerated Partial Breast Irradiation or Whole Breast Irradiation Using 3-Dimensional Conformal External Beam Radiation Therapy. Adv Radiat Oncol 2020; 5:171-179. [PMID: 32280816 PMCID: PMC7136642 DOI: 10.1016/j.adro.2019.09.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/30/2019] [Accepted: 09/18/2019] [Indexed: 01/28/2023] Open
Abstract
PURPOSE To compare rates of acute and late skin toxicities and cosmetic outcomes after accelerated partial breast irradiation (APBI) or whole breast irradiation (WBI) using 3-dimensional conformal external beam radiation therapy in women with breast cancer after breast conservation surgery (BCS). METHODS AND MATERIALS Women >35 years of age with invasive or noninvasive breast cancer ≤4 cm treated by BCS were randomized to 3D-CRT APBI (34 Gy/10 fractions/5 days) or WBI (40 Gy/16 fractions/3 weeks ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence. Important secondary outcomes were skin toxicities using Radiation Therapy Oncology Group scores, Late Effects Normal Tissue Task Force and Subjective, Objective, Management, Analytic scales, and adverse cosmetic outcome. This interim analysis focuses on the secondary endpoints of radiation toxicities and cosmesis. Patient and tumor characteristics and rates of adverse cosmetic outcomes and skin toxicities were compared using Fisher exact tests. All statistical tests were 2 sided, with P < .05 considered statistically significant. RESULTS Between June 2011 and December 2015, 133 women with breast cancer were randomized to 3D-CRT APBI or WBI. Patient and tumor characteristics were balanced between the 2 arms. Median follow-up was 60 months (range, 12-93 months). Grade 4 late toxicity was not seen in either of the treatment arms, and grade 3 toxicity was very low for each endpoint assessed in both the groups. The rates of grade ≥2 acute dermatitis were 8% and 15%, respectively, for APBI and WBI (P = .18). Rates of grade ≥1 late radiation toxicities were higher in the WBI arm compared with the APBI arm for breast shrinkage (P = .008), pigmentation (P = .028), fibrosis (P = .040), induration (P = .048), and edema (P = .33). Adverse cosmesis at last follow-up was significantly higher in patients treated with WBI: 33% compared with 6% with APBI (P < .001). CONCLUSIONS In women with breast cancer after BCS, APBI was associated with better cosmetic outcome and fewer late radiation toxicities than WBI.
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Affiliation(s)
- Budhi Singh Yadav
- Department of Radiation Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sofia Loganathan
- Department of Radiation Oncology, Government Medical College, Trichy, Tamilnadu, India
| | - Suresh C. Sharma
- Department of Radiation Oncology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Maharishi Markandeshwar University, Mullana (Ambala), India
| | - Rajinder Singh
- Department of General Surgery, Chautani Medical Centre, Chandigarh, India
| | - Divya Dahiya
- Department of General Surgery, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Forster T, Köhler CVK, Debus J, Hörner-Rieber J. Accelerated Partial Breast Irradiation: A New Standard of Care? Breast Care (Basel) 2020; 15:136-147. [PMID: 32398982 DOI: 10.1159/000506254] [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: 11/29/2019] [Accepted: 01/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Breast-conserving therapy including lumpectomy and adjuvant whole breast irradiation (WBI) has become the standard therapy for early-stage breast cancer (EBC). Without WBI, the recurrence rate is significantly increased. However, when selecting patients at a low a priori risk of local recurrence only a small breast-cancer-specific mortality benefit, but no overall survival improvement, was detected for WBI. As most recurrences occur close to the lumpectomy cavity, accelerated partial breast irradiation (APBI) delivered exclusively to a limited volume of tissue around the initial lumpectomy site, has gained increased attention and is now discussed as an alternative to WBI for selected EBC patients. Summary Numerous techniques for APBI (interstitial brachytherapy, external beam-based APBI, intraoperative radiotherapy, MR-guided radiotherapy) allow treatment delivery in a shorter period of time, and radiation oncologists expect to further reduce side effects by using these new techniques, with improvements in cosmetics and quality of life. In this review, we aim to describe the existing evidence for the feasibility and effectiveness of different APBI techniques used in modern radiotherapy. Key Messages APBI has provided outcomes similar to WBI combined with potentially reduced toxicity. While appropriate patient selection persists to be crucial for acceptable recurrence rates, the precise definition of patients suitable for APBI remains a matter of discussion. As long-term data are often still lacking, special attention should be paid to late side effects and long-term outcomes. Decision-making on appropriate treatment techniques should take into account not only local control rates, but also the impact on the patient's quality of life.
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Affiliation(s)
- Tobias Forster
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | | | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Heidelberg Ion-Beam Therapy Center (HIT), Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,German Cancer Consortium (DKTK), partner site Heidelberg, Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany.,Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.,National Center for Tumor Diseases (NCT), Heidelberg, Germany.,Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
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13
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Callaghan CM, Adams Q, Flynn RT, Wu X, Xu W, Kim Y. Systematic Review of Intensity-Modulated Brachytherapy (IMBT): Static and Dynamic Techniques. Int J Radiat Oncol Biol Phys 2019; 105:206-221. [DOI: 10.1016/j.ijrobp.2019.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 03/27/2019] [Accepted: 04/11/2019] [Indexed: 02/06/2023]
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Maranzano E, Arcidiacono F, Italiani M, Anselmo P, Casale M, Terenzi S, Di Marzo A, Fabiani S, Draghini L, Trippa F. Accelerated partial-breast irradiation with high-dose-rate brachytherapy: Mature results of a Phase II trial. Brachytherapy 2019; 18:627-634. [PMID: 31285131 DOI: 10.1016/j.brachy.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/31/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to report mature clinical and cosmetic results of accelerated partial-breast irradiation with interstitial multicatheter high-dose-rate brachytherapy (HDR-BRT) in patients with early breast cancer. METHODS AND MATERIALS 133 patients were recruited in a Phase II trial of exclusive HDR-BRT. Inclusion criteria were age ≥40 years, PS 0-2, unifocal invasive ductal cancer, intraductal cancer component <25%, negative axillary nodes, and tumor size ≤2.5 cm. Treatment schedule was 4 Gy twice a day up to a total dose of 32 Gy in eight fractions. RESULTS Median age was 67 years (range, 42-85). There were 7 (5%) pT1a, 48 (36%) pT1b, 72 (54%) pT1c, and 6 (5%) pT2. Estrogen and progesterone receptors were positive in 119 (89%) and 93 (70%) patients, respectively. The median followup was 110 months (range, 12-163). After HDR-BRT, there were 3 (2%) in-field breast recurrences and 1 (1%) out-field breast recurrence. 5 (4%) patients developed contralateral breast cancer, another one (1%) isolated regional relapse in axillary node and 3 (2%) distant progression of disease. 19 (14%) patients reported a second primary cancer. 5-, 10-, and 13-year overall survival and cancer-specific survival were 95% and 100%, 84.5% and 100%, and 81.4% and 100%, respectively. Cosmetic outcome was excellent in 80% of cases. Late toxicity was significantly related to the skin administered doses (≤55% vs. > 55% of the prescribed dose, p < 0.05). CONCLUSIONS Accelerated partial-breast irradiation delivered with HDR-BRT in selected patients with breast cancer was associated to high local control and survival with excellent cosmetic outcomes overall when skin dose was ≤55%.
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Affiliation(s)
| | | | - Marco Italiani
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Paola Anselmo
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | - Sara Terenzi
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | | | | | - Lorena Draghini
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
| | - Fabio Trippa
- Radiotherapy Oncology Centre, "S. Maria" Hospital, Terni, Italy
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15
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Three-Fraction Accelerated Partial Breast Irradiation (APBI) Delivered With Brachytherapy Applicators Is Feasible and Safe: First Results From the TRIUMPH-T Trial. Int J Radiat Oncol Biol Phys 2019; 104:67-74. [PMID: 30611839 DOI: 10.1016/j.ijrobp.2018.12.050] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 12/21/2018] [Accepted: 12/27/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE Shorter courses of accelerated partial-breast irradiation delivered as single-fraction intraoperative therapy are now offered as an alternative to 4 to 6 weeks of whole-breast irradiation after lumpectomy. However, this approach has potential shortcomings in patient selection and target volume definition and in dosimetric, radiobiological, and logistical issues. We designed a prospective, phase 2, multi-institution clinical trial to study 2- or 3-day accelerated partial breast irradiation delivered with brachytherapy applicators. METHODS AND MATERIALS This trial treats select breast cancers after breast-conserving surgery with brachytherapy applicators that deliver 22.5 Gy in 3 fractions of 7.5 Gy. The planning treatment volume was 1 to 1.5 cm beyond the surgical cavity. Eligible women were aged ≥45 years with unicentric invasive or in situ tumors ≤3.0 cm with positive estrogen or progesterone receptors and no metastasis to axillary nodes that have been excised with negative margins. Strict dosimetric parameters were required to be met before acceptance into the trial. RESULTS A group of 200 patients was prospectively enrolled and followed for a minimum of 6 months. Two- or 3-day brachytherapy was associated with low acute or subacute toxicity, 97.25% excellent or good cosmetic outcomes, and excellent local control in select breast cancers. CONCLUSIONS Ultrashort breast brachytherapy is dosimetrically feasible and can be delivered with excellent short-term tolerance and low toxicity.
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Bennion NR, Baine M, Granatowicz A, Wahl AO. Accelerated partial breast radiotherapy: a review of the literature and future directions. Gland Surg 2018; 7:596-610. [PMID: 30687631 DOI: 10.21037/gs.2018.11.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Breast conservation therapy exemplifies the tailoring of medicine in the care of patients with cancer. Akin to improvements in surgical approaches, accelerated partial breast irradiation (APBI) tailors the treatment volume and duration to the needs of well selected patients. Here, we examine the evidence supporting APBI as well as the lessons in patient selection, dose and delivery techniques. Examination of historical techniques and their associated outcomes will support more correct patient selection and treatment delivery in an era where we await the reports of several large prospective trials.
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Affiliation(s)
- Nathan R Bennion
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Baine
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Andrew O Wahl
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
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Imboden S, Knabben L, Mueller MD, Günthert AR, Lössl K. Bone in the breast? Long term toxicity 21 years after interstitial brachytherapy as a boost. Rep Pract Oncol Radiother 2018; 23:337-340. [PMID: 30127673 DOI: 10.1016/j.rpor.2018.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/02/2018] [Accepted: 06/23/2018] [Indexed: 11/17/2022] Open
Abstract
An 81-year-old patient developed an exulcerous tumor in her left breast 21 years after breast cancer treatment with lumpectomy and adjuvant radiotherapy. At the time of the initial treatment 21 years ago, whole breast irradiation was performed with a prescribed dose of 48 Gy and a maximal dose of 69 Gy. In addition, the patient received a 14.7 Gy boost with multicatheter brachytherapy as partial breast irradiation. In general, fat necrosis after radiotherapy, surgery or trauma is a minor problem for patients, but can lead to diagnostic difficulties. The incidence varies: the literature indicates that it occurs in up to 34% of cases. The direct pathogenesis is not clear; it can be due to high radiation dose to the breast, dosimetric inhomogeneities or surgical complications (seromas and inflammation). The tumor in the case described here, occurring more than two decades after the primary treatment, is a rarity in this extent and is an unusual clinical, radiological, and histological finding. It provides a good example of the need for an individualized approach to treatment.
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Affiliation(s)
- Sara Imboden
- Department of Obstetrics and Gynecology, University Hospital of Berne and University of Berne, 3010 Berne, Switzerland
| | - Laura Knabben
- Department of Obstetrics and Gynecology, University Hospital of Berne and University of Berne, 3010 Berne, Switzerland
| | - Michael D Mueller
- Department of Obstetrics and Gynecology, University Hospital of Berne and University of Berne, 3010 Berne, Switzerland
| | - Andreas R Günthert
- Department of Obstetrics and Gynecology, Cantonal Hospital, Lucerne, Switzerland
| | - Kristina Lössl
- Department of Radiooncology, University Hospital of Berne and University of Berne, 3010 Berne, Switzerland
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Ohri N, Haffty BG. Alternatives to Standard Fractionation Radiation Therapy After Lumpectomy: Hypofractionated Whole-Breast Irradiation and Accelerated Partial-Breast Irradiation. Surg Oncol Clin N Am 2018; 27:181-194. [PMID: 29132560 DOI: 10.1016/j.soc.2017.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Adjuvant whole-breast irradiation (WBI) after lumpectomy has been an established standard of care for decades. Standard-fractionation WBI delivered over 5 to 7 weeks can achieve durable tumor control with low toxicity but can be inconvenient for patients and cost ineffective. Hypofractionated WBI can be completed in 3 to 4 weeks and, based on long-term randomized data, is the preferred standard of care in select patients. Accelerated partial-breast irradiation can be delivered using even shorter treatment regimens. Although the available data on accelerated partial-breast irradiation is more limited, early results suggest it is an effective alternative to WBI in select patients.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA.
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19
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The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy 2018; 17:154-170. [DOI: 10.1016/j.brachy.2017.09.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022]
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20
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Shah S, Kyrillos A, Kuchta K, Habib H, Tobias M, Raghavan V, Shaikh A, Bloomer W, Pesce C, Yao K. A Single Institution Retrospective Comparison Study of Locoregional Recurrence After Accelerated Partial Breast Irradiation Using External Beam Fractionation Compared with Whole Breast Irradiation with 8 Years of Follow-Up. Ann Surg Oncol 2017; 24:2935-2942. [PMID: 28766205 DOI: 10.1245/s10434-017-5953-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) was developed to address disadvantages of overall treatment time and potentially unnecessary radiation associated with whole breast irradiation (WBI). We report updated results of our single institution study using an external beam APBI regimen with a median follow-up of 8 years. METHODS A total of 290 APBI patients with AJCC Stage 0-II breast cancer were compared with 290 WBI patients with matched tumor characteristics. Toxicities were scored based on the Common Terminology Criteria for Adverse Events (CTCAE v3.0). Cox regression models were used to predict likelihood of freedom from ipsilateral failure. RESULTS Median follow-up was 8 years in the APBI group and 7.5 years in the WBI group. In the APBI group, there were 18 (6.2%) ipsilateral breast tumor recurrence (IBTR), 13 (72%) had elsewhere failures (EF), and 5 (28%) had local failures (LF) with a median time to failure of 64.1 months. In the WBI group, there were three (1.0%) IBTR; one (33%) was an EF and two (67%) were LF with a median time to failure of 91 months. APBI was 4.6 times more likely (hazard ratio 4.57, 95% confidence interval 1.3-16.2, p = 0.02) to have an IBTR than WBI after adjusting for age, tumor size, histology, grade, and estrogen receptor status. Fatigue, erythema, and desquamation toxicities were significantly less in the APBI group then the WBI group. CONCLUSIONS IBTR rates were higher in external beam APBI group compared with WBI, but APBI had fewer toxicities. Clinicians must weigh the risks and benefits of APBI when making a recommendation for partial breast irradiation after lumpectomy.
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Affiliation(s)
- Shalin Shah
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alexandra Kyrillos
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Kristine Kuchta
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Hussain Habib
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Megan Tobias
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Vathsala Raghavan
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Arif Shaikh
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - William Bloomer
- Department of Radiation Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Catherine Pesce
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Katharine Yao
- Division of Surgical Oncology, Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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Hepel JT, Arthur D, Shaitelman S, Polgár C, Todor D, Zoberi I, Kamrava M, Major T, Yashar C, Wazer DE. American Brachytherapy Society consensus report for accelerated partial breast irradiation using interstitial multicatheter brachytherapy. Brachytherapy 2017; 16:919-928. [PMID: 28676428 DOI: 10.1016/j.brachy.2017.05.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 05/11/2017] [Accepted: 05/28/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE To develop a consensus report for the quality practice of accelerated partial breast irradiation (APBI) using interstitial multicatheter brachytherapy (IMB). METHODS AND MATERIALS The American Brachytherapy Society Board appointed an expert panel with clinical and research experience with breast brachytherapy to provide guidance for the current practice of IMB. This report is based on a comprehensive literature review with emphasis on randomized data and expertise of the panel. RESULTS Randomized trials have demonstrated equivalent efficacy of APBI using IMB compared with whole breast irradiation for select patients with early-stage breast cancer. Several techniques for placement of interstitial catheters are described, and importance of three-dimensional planning with appropriate optimization is reviewed. Optimal target definition is outlined. Commonly used dosing schemas include 50 Gy delivered in pulses of 0.6-0.8 Gy/h using pulsed-dose-rate technique and 34 Gy in 10 fractions, 32 Gy in eight fractions, or 30 Gy in seven fractions using high-dose-rate technique. Potential toxicities and strategies for toxicity avoidance are described in detail. Dosimetric constraints include limiting whole breast volume that receives ≥50% of prescription dose to <60%, skin dose to ≤100% of prescription dose (≤60-70% preferred), chest wall dose to ≤125% of prescription dose, Dose Homogeneity Index to >0.75 (>0.85 preferred), V150 < 45 cc, and V200 < 14 cc. Using an optimal implant technique coupled with optimal planning and appropriate dose constraints, a low rate of toxicity and a good-to-excellent cosmetic outcome of ≥90% is expected. CONCLUSIONS IMB is an effective technique to deliver APBI for appropriately selected women with early-stage breast cancer. This consensus report has been created to assist clinicians in the appropriate practice of APBI using IMB.
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Affiliation(s)
- Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, RI; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, MA.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Simona Shaitelman
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | - Csaba Polgár
- Department of Radiation Oncology, National Institute of Oncology, Budapest, Hungary
| | - Dorin Todor
- Department of Radiation Oncology, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO
| | - Mitchell Kamrava
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA
| | - Tibor Major
- Department of Radiation Oncology, National Institute of Oncology, Budapest, Hungary
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California San Diego, La Jolla, CA
| | - David E Wazer
- Department of Radiation Oncology, Rhode Island Hospital, Brown University, Providence, RI; Department of Radiation Oncology, Tufts Medical Center, Tufts University, Boston, MA
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High-dose-rate interstitial brachytherapy for accelerated partial breast irradiation - trial results of Azerbaijan National Center of Oncology. J Contemp Brachytherapy 2017; 9:106-111. [PMID: 28533797 PMCID: PMC5437082 DOI: 10.5114/jcb.2017.67145] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/11/2017] [Indexed: 01/30/2023] Open
Abstract
Purpose To describe early results of two cohorts of patients with low and intermediate risk of early breast cancer treated with accelerated partial breast irradiation (APBI) using different schedules of multicatheter brachytherapy. Material and methods Patients with early stage breast cancer after breast conserving surgery were enrolled for a prospective analysis. The APBI, using multicatheter brachytherapy, was delivered either eight times 4 Gy in five days with a planned total dose of 32 Gy, or seven times 5 Gy in four days with a planned total dose of 35 Gy. Primary endpoints were side effects. Results Forty-eight patients were enrolled between 2012 and 2014. Patients characteristics were as follow: median age of patients was 55 years, early breast cancer was defined according GEC-ESTRO recommendations. With a median follow-up period of 37 months, no significant differences regarding late side effects and cosmesis between two cohorts of patients were documented. In total, cosmesis was excellent in 13/48 (27.1%) patients, good in 34/48 (70.8%) patients, and moderate in 1/48 patient (2.1%). Conclusions Accelerated partial breast irradiation using multicatheter brachytherapy with 32 Gy/8 fractions and 35 Gy/7 fractions for early breast cancer seems to be similar in terms of late side effects. According to our findings, APBI was also feasible for intermediate-risk of early breast cancer patients.
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23
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Shaitelman SF, Amendola B, Khan A, Beriwal S, Rabinovitch R, Demanes DJ, Kim LH, Cuttino L. American Brachytherapy Society Task Group Report: Long-term control and toxicity with brachytherapy for localized breast cancer. Brachytherapy 2017; 16:13-21. [DOI: 10.1016/j.brachy.2016.04.392] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 01/22/2023]
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24
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Sanford NN, Taghian AG. Accelerated Partial Breast Irradiation. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Rabinovitch R, Moughan J, Vicini F, Pass H, Wong J, Chafe S, Petersen I, Arthur DW, White J. Long-Term Update of NRG Oncology RTOG 0319: A Phase 1 and 2 Trial to Evaluate 3-Dimensional Conformal Radiation Therapy Confined to the Region of the Lumpectomy Cavity for Stage I and II Breast Carcinoma. Int J Radiat Oncol Biol Phys 2016; 96:1054-1059. [PMID: 27869081 PMCID: PMC5226218 DOI: 10.1016/j.ijrobp.2016.08.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/02/2016] [Accepted: 09/20/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE NRG Oncology RTOG 0319 was the first cooperative group trial in the United States to evaluate 3-dimensional conformal radiation therapy (3D-CRT) accelerated partial breast irradiation (APBI). This report updates secondary endpoints of toxicity and efficacy. METHODS AND MATERIALS Patients with stage I or II invasive breast cancer (tumor size ≤3 cm, ≤3 positive lymph nodes, negative margins) were eligible for 3D-CRT APBI: 38.5 Gy in 10 twice-daily fractions. Patient characteristics and treatment details have previously been reported. Adverse events were graded with CTCAE v3.0 (National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0). This analysis updates the rates of ipsilateral breast recurrence (IBR), contralateral breast recurrence, ipsilateral node recurrence (INR), metastatic sites (distant metastases [DM]), mastectomy, disease-free survival, mastectomy-free survival, and overall survival. RESULTS Of 58 enrolled patients, 52 were eligible, with a median age of 61 years; 94% had stage I cancer and 83% had estrogen receptor positive disease. The median follow-up period was 8 years (minimum-maximum, 1.7-9.0 years). The 7-year estimate of isolated IBR (no DM) was 5.9%. The 7-year estimates of all IBRs, INR, mastectomy rate, and DM were 7.7%, 5.8%, 7.7%, and 7.7%, respectively. All 4 IBRs were invasive, of which 3 had a component within the planning target volume. The patterns of failure were as follows: 3 IBRs, 1 INR, 2 DM, 1 INR plus DM, and 1 IBR plus INR plus DM. The 7-year estimates of mastectomy-free survival, disease-free survival, and overall survival were 71.2%, 71.2%, and 78.8%, respectively. Thirteen patients died: 3 of breast cancer and 10 of other causes. Grade 3 (G3) treatment-related adverse events were reported by 4 patients (7.7%). No G3 pain or pulmonary or cardiac toxicities were reported. CONCLUSIONS This phase 1 and 2 trial of 3D-CRT APBI continues to show durable tumor control and minimal G3 toxicity, comparable to other APBI techniques. Mature phase 3 results will determine the appropriateness and limitations of this noninvasive APBI technique.
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Affiliation(s)
| | - Jennifer Moughan
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Frank Vicini
- Radiation Oncology, St Joseph Mercy Oakland, Pontiac, Michigan
| | - Helen Pass
- Surgery, Stamford Hospital, Stamford, Connecticut
| | - John Wong
- Medical Physics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Susan Chafe
- Radiation Oncology, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Ivy Petersen
- Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Douglas W Arthur
- Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Julia White
- Radiation Oncology, The Ohio State University Medical Center, Columbus, Ohio
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Cihoric N, Tsikkinis A, Miguelez CG, Strnad V, Soldatovic I, Ghadjar P, Jeremic B, Dal Pra A, Aebersold DM, Lössl K. Portfolio of prospective clinical trials including brachytherapy: an analysis of the ClinicalTrials.gov database. Radiat Oncol 2016; 11:48. [PMID: 27005770 PMCID: PMC4804566 DOI: 10.1186/s13014-016-0624-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/15/2016] [Indexed: 11/24/2022] Open
Abstract
Background To evaluate the current status of prospective interventional clinical trials that includes brachytherapy (BT) procedures. Methods The records of 175,538 (100 %) clinical trials registered at ClinicalTrials.gov were downloaded on September 2014 and a database was established. Trials using BT as an intervention were identified for further analyses. The selected trials were manually categorized according to indication(s), BT source, applied dose rate, primary sponsor type, location, protocol initiator and funding source. We analyzed trials across 8 available trial protocol elements registered within the database. Results In total 245 clinical trials were identified, 147 with BT as primary investigated treatment modality and 98 that included BT as an optional treatment component or as part of the standard treatment. Academic centers were the most frequent protocol initiators in trials where BT was the primary investigational treatment modality (p < 0.01). High dose rate (HDR) BT was the most frequently investigated type of BT dose rate (46.3 %) followed by low dose rate (LDR) (42.0 %). Prostate was the most frequently investigated tumor entity in trials with BT as the primary treatment modality (40.1 %) followed by breast cancer (17.0 %). BT was rarely the primary investigated treatment modality for cervical cancer (6.8 %). Conclusion Most clinical trials using BT are predominantly in early phases, investigator-initiated and with low accrual numbers. Current investigational activities that include BT mainly focus on prostate and breast cancers. Important questions concerning the optimal usage of BT will not be answered in the near future. Electronic supplementary material The online version of this article (doi:10.1186/s13014-016-0624-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nikola Cihoric
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
| | - Alexandros Tsikkinis
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | | | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Ivan Soldatovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Pirus Ghadjar
- Department of Radiation Oncology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Branislav Jeremic
- Institute of Lung Diseases, Sremska Kamenica, Serbia.,Centre for Biomedical Research, BioIRC, Kragujevac, Serbia
| | - Alan Dal Pra
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Daniel M Aebersold
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Kristina Lössl
- Department of Radiation Oncology, Inselspital, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
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Breast Brachytherapy: Interstitial Breast Brachytherapy. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Huo J, Giordano SH, Smith BD, Shaitelman SF, Smith GL. Contemporary Toxicity Profile of Breast Brachytherapy Versus External Beam Radiation After Lumpectomy for Breast Cancer. Int J Radiat Oncol Biol Phys 2015; 94:709-18. [PMID: 26972643 DOI: 10.1016/j.ijrobp.2015.12.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 11/25/2015] [Accepted: 12/02/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We compared toxicities after brachytherapy versus external beam radiation therapy (EBRT) in contemporary breast cancer patients. METHODS AND MATERIALS Using MarketScan healthcare claims, we identified 64,112 women treated from 2003 to 2012 with lumpectomy followed by radiation (brachytherapy vs EBRT). Brachytherapy was further classified by multichannel versus single-channel applicator approach. We identified the risks and predictors of 1-year infectious and noninfectious postoperative adverse events using logistic regression and temporal trends using Cochran-Armitage tests. We estimated the 5-year Kaplan-Meier cumulative incidence of radiation-associated adverse events. RESULTS A total of 4522 (7.1%) patients received brachytherapy (50.2% multichannel vs 48.7% single-channel applicator). The overall risk of infectious adverse events was higher after brachytherapy than after EBRT (odds ratio [OR] = 1.21; 95% confidence interval [CI] 1.09-1.34, P<.001). However, over time, the frequency of infectious adverse events after brachytherapy decreased, from 17.3% in 2003 to 11.6% in 2012, and was stable after EBRT at 9.7%. Beyond 2007, there were no longer excess infections with brachytherapy (P=.97). The overall risk of noninfectious adverse events was higher after brachytherapy than after EBRT (OR=2.27; 95% CI 2.09-2.47, P<.0001). Over time, the frequency of noninfectious adverse events detected increased: after multichannel brachytherapy, from 9.1% in 2004 to 18.9% in 2012 (Ptrend = .64); single-channel brachytherapy, from 12.8% to 29.8% (Ptrend<.001); and EBRT, from 6.1% to 10.3% (Ptrend<.0001). The risk was significantly higher with single-channel than with multichannel brachytherapy (hazard ratio = 1.32; 95% CI 1.03-1.69, P=.03). Of noninfectious adverse events, 70.9% were seroma. Seroma significantly increased breast pain risk (P<.0001). Patients with underlying diabetes, cardiovascular disease, and treatment with chemotherapy had increased infectious and noninfectious adverse events. The 5-year incidences of fat necrosis, breast pain, and rib fracture were slightly higher after brachytherapy than after EBRT (13.7% vs 8.1%, 19.4% vs 16.0%, and 1.6% vs 1.3%, respectively), but the risks were not significantly different for multichannel versus single-channel applicators. CONCLUSION Toxicities after breast brachytherapy were distinct from those after EBRT. Temporal toxicity trends may reflect changing technology and evolving practitioner experience with brachytherapy.
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Affiliation(s)
- Jinhai Huo
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benjamin D Smith
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Grace L Smith
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Proton partial breast irradiation in the supine position: Treatment description and reproducibility of a multibeam technique. Pract Radiat Oncol 2015; 5:e283-90. [DOI: 10.1016/j.prro.2015.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 12/02/2014] [Accepted: 01/29/2015] [Indexed: 11/22/2022]
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Budrukkar A, Gurram L, Upreti RR, Munshi A, Jalali R, Badwe R, Parmar V, Shet T, Gupta S, Wadasadawala T, Sarin R. Clinical outcomes of prospectively treated 140 women with early stage breast cancer using accelerated partial breast irradiation with 3 dimensional computerized tomography based brachytherapy. Radiother Oncol 2015; 115:349-54. [DOI: 10.1016/j.radonc.2015.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 03/02/2015] [Accepted: 03/02/2015] [Indexed: 11/16/2022]
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Kamrava M, Kuske RR, Anderson B, Chen P, Hayes J, Quiet C, Wang PC, Veruttipong D, Snyder M, Jeffrey Demanes D. Outcomes of Breast Cancer Patients Treated with Accelerated Partial Breast Irradiation Via Multicatheter Interstitial Brachytherapy: The Pooled Registry of Multicatheter Interstitial Sites (PROMIS) Experience. Ann Surg Oncol 2015; 22 Suppl 3:S404-11. [DOI: 10.1245/s10434-015-4563-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Indexed: 11/18/2022]
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Quality of life and cosmesis after breast cancer: whole breast radiotherapy vs partial breast high-dose-rate brachytherapy. TUMORI JOURNAL 2015; 101:161-7. [PMID: 25768319 DOI: 10.5301/tj.5000233] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2014] [Indexed: 12/24/2022]
Abstract
AIM AND BACKGROUND Conservative surgery and radiotherapy for early breast cancer offers a better quality of life than mastectomy. As 80-85% of breast relapses develop close to the tumour bed, partial breast irradiation was developed to overcome drawbacks with standard radiotherapy. This study compares quality of life and cosmesis after partial breast multi-catheter high-dose rate interstitial brachytherapy or standard radiotherapy. METHODS A questionnaire, exploring body image, fear of recurrence, satisfaction with treatment and cosmesis, was administered to 39 partial and 78 whole breast patients at a median of 20 and 80 months after radiotherapy. Patients' and physicians' cosmetic assessments were compared. RESULTS Groups were well-matched, except for: a higher percentage of chemotherapy-treated patients in the whole breast group and a older median age and a higher percentage of infiltrating ductal carcinoma G1 in partial breast group. At first and second analysis no significant inter-group difference emerged on body image and fear of recurrence, while partial breast patients were more satisfied with cosmetic outcome and at first analysis with treatment. Comparing results from first and second analysis into each treatment group, body image was significantly better at the first analysis in both groups. Fear of recurrence was unchanged. No differences were found in cosmesis as assessed by patients. At first and second analyses physicians' assessment of cosmesis was significantly better in the partial breast group. CONCLUSIONS Even at longer follow-up, quality of life is similar after partial or whole breast irradiation. Cosmesis is better after partial breast irradiation.
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The incidence of fat necrosis in balloon-based breast brachytherapy. J Contemp Brachytherapy 2015; 7:29-34. [PMID: 25829934 PMCID: PMC4371067 DOI: 10.5114/jcb.2015.49443] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 11/19/2014] [Accepted: 12/16/2014] [Indexed: 11/25/2022] Open
Abstract
Purpose To investigate the incidence of and potential risk factors for fat necrosis in high dose-rate (HDR) balloon-based breast brachytherapy (BBB). Material and methods Fifty-four patients were treated postoperatively with HDR-BBB between May 2007 and December 2010. Median age was 71 years (range: 50-88 years). Median tumor size was 1 cm (range: 0.1-2.7 cm). Forty-four had invasive histology; 43% were grade 1, 24% grade 2, and 15% grade 3. The median margin size was 0.7 cm (range: 0.1-1.5 cm). Results With a median follow-up of 2.9 years (range: 0.5-5.2 years), local control was 98% with one in-breast failure, and overall survival was 89%. Fifty percent of patients experienced fat necrosis. Seven patients were symptomatic, with the remainder detected by mammography alone. Two patients required surgical resection with pathology confirming fat necrosis; 1 required i.v. steroids. At 1, 3, and 5 years following treatment, estimated cumulative incidences of fat necrosis were 7.5%, 52.7%, and 60.6%. Breast laterality, location, tumor size, histology, margin size, balloon volume, skin distance, skin dose, and number of dwell positions were not significantly associated with fat necrosis on univariate analysis. Conclusions In this retrospective review of HDR-BBB, we found a 50% incidence of both asymptomatic and symptomatic fat necrosis. Only three patients, however, required intervention. None of the risk factors considered were significantly associated with fat necrosis. Further studies evaluating factors associated with fat necrosis for patients undergoing HDR-BBB are necessary to appropriately assess the risks associated with treatment.
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34
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Radiation Treatment Strategies in Patients Undergoing Breast-Conserving Surgery. CURRENT BREAST CANCER REPORTS 2015. [DOI: 10.1007/s12609-014-0171-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ozyigit G, Gultekin M. Current role of modern radiotherapy techniques in the management of breast cancer. World J Clin Oncol 2014; 5:425-439. [PMID: 25114857 PMCID: PMC4127613 DOI: 10.5306/wjco.v5.i3.425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/07/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Breast cancer is the most common type of malignancy in females. Advances in systemic therapies and radiotherapy (RT) provided long survival rates in breast cancer patients. RT has a major role in the management of breast cancer. During the past 15 years several developments took place in the field of imaging and irradiation techniques, intensity modulated RT, hypofractionation and partial-breast irradiation. Currently, improvements in the RT technology allow us a subsequent decrease in the treatment-related complications such as fibrosis and long-term cardiac toxicity while improving the loco-regional control rates and cosmetic results. Thus, it is crucial that modern radiotherapy techniques should be carried out with maximum care and efficiency. Several randomized trials provided evidence for the feasibility of modern radiotherapy techniques in the management of breast cancer. However, the role of modern radiotherapy techniques in the management of breast cancer will continue to be defined by the mature results of randomized trials. Current review will provide an up-to-date evidence based data on the role of modern radiotherapy techniques in the management of breast cancer.
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Mellon EA, Sreeraman R, Gebhardt BJ, Mierzejewski A, Correa CR. Impact of radiation treatment parameters and adjuvant systemic therapy on cosmetic outcomes after accelerated partial breast irradiation using 3-dimensional conformal radiation therapy technique. Pract Radiat Oncol 2014; 4:e159-e166. [DOI: 10.1016/j.prro.2013.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 08/02/2013] [Accepted: 08/05/2013] [Indexed: 01/23/2023]
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Jagsi R. Progress and controversies: radiation therapy for invasive breast cancer. CA Cancer J Clin 2014; 64:135-52. [PMID: 24357525 DOI: 10.3322/caac.21209] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 01/29/2023] Open
Abstract
Radiation therapy is a critical component of the multidisciplinary management of invasive breast cancer. In appropriately selected patients, radiation not only improves local control, sparing patients the morbidity and distress of local recurrence, but it also improves survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. In recent years, considerable progress has been made toward improving our ability to select patients most likely to benefit from radiotherapy and to administer treatment in ways that maximize clinical benefit while minimizing toxicity and burden. This article reviews the role of radiation therapy in invasive breast cancer management, both after breast-conserving surgery and after mastectomy. It focuses particularly on emerging evidence that helps to define the clinical situations in which radiotherapy is indicated, the appropriate targets of treatment, and optimal approaches for minimizing both the toxicity and the burden of treatment, all in the context of the evolving surgical and systemic management of this common disease. It includes a discussion of new approaches in breast cancer radiotherapy, including hypofractionation and intensity modulation, as well as a discussion of promising avenues for future research.
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Affiliation(s)
- Reshma Jagsi
- Associate Professor, Department of Radiation Oncology, Research Investigator, Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor, MI
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38
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Russo AL, Taghian AG. Fat necrosis of the breast in the accelerated partial breast irradiation era: the need for a universal grading system. Breast Cancer Res Treat 2014; 140:1-11. [PMID: 23797180 DOI: 10.1007/s10549-013-2611-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 06/11/2013] [Indexed: 12/01/2022]
Abstract
Fat necrosis of the breast is increasingly reported and used as a trial endpoint in the treatment of breast cancer with accelerated partial breast irradiation (APBI). Yet, there is no universal toxicity scoring system within the latest version of the Common Terminology Criteria for Adverse Events (CTCAE v4.0). This requires investigators to adopt their own scoring system or improperly use those that exist, and limits accurate reporting of this entity. Fat necrosis of the breast also creates diagnostic uncertainty among clinicians and concern of recurrence among patients. In this review, we address the question of increasing incidence of fat necrosis through the comparison of recent APBI trials and literature. The pathogenesis, symptoms, clinical and radiologic diagnosis, clinical predictors of developing fat necrosis, management and follow-up are also discussed.Lastly, we propose a simplified and universal scoring system for the reporting of fat necrosis.
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Hepel JT. Late toxicity and cosmetic outcomes related to interstitial multicatheter brachytherapy for partial breast irradiation. Brachytherapy 2014; 13:23-6. [DOI: 10.1016/j.brachy.2013.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 09/05/2013] [Indexed: 11/25/2022]
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40
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Lei RY, Leonard CE, Howell KT, Henkenberns PL, Johnson TK, Hobart TL, Fryman SP, Kercher JM, Widner JL, Kaske T, Carter DL. Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Res Treat 2013; 140:119-33. [PMID: 23824363 PMCID: PMC3706719 DOI: 10.1007/s10549-013-2623-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 06/22/2013] [Indexed: 01/03/2023]
Abstract
This prospective Phase II single-arm study gathered data on the use of intensity-modulated radiotherapy (IMRT) to deliver accelerated partial breast irradiation (APBI). Four-year efficacy, cosmesis, and toxicity results are presented. Between February 2004 and September 2007, 136 consecutive patients with Stage 0/I breast cancer and negative margins ≥0.2 cm were treated on protocol. Patients received 38.5 Gy in 10 equal fractions delivered twice daily. Breast pain and cosmesis were rated by patient, and cosmesis was additionally evaluated by physician per Radiation Therapy Oncology Group (RTOG) criteria. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE v3.0) was used to grade toxicities. 136 patients (140 breasts) with median follow-up of 53.1 months (range, 8.9-83.2) were evaluated. Population characteristics included median age of 61.9 years and Tis (13.6 %), T1a (18.6 %), T1b (36.4 %), and T1c (31.4 %). Kaplan-Meier estimates at 4 years: ipsilateral breast tumor recurrence 0.7 %; contralateral breast failure 0 %; distant failure 0.9 %; overall survival 96.8 %; and cancer-specific survival 100 %. At last follow-up, patients and physicians rated cosmesis as excellent/good in 88.2 and 90.5 %, respectively; patients rated breast pain as none/mild in 97.0 %. Other observations included edema (1.4 %), telangiectasia (3.6 %), five cases of grade 1 radiation recall (3.6 %), and two cases of rib fractures (1.4 %). This analysis represents the largest cohort and longest follow-up of APBI utilizing IMRT reported to date. Four-year results continue to demonstrate excellent local control, survival, cosmetic results, and toxicity profile.
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Affiliation(s)
- Rachel Y. Lei
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
- Rocky Mountain Cancer Center, 1700 S. Potomac Street, Aurora, CO 80012 USA
| | - Charles E. Leonard
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | - Kathryn T. Howell
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | | | - Timothy K. Johnson
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | - Tracy L. Hobart
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
| | - Shannon P. Fryman
- Rocky Mountain Cancer Centers, 22 W. Dry Creek Circle, Littleton, CO 80120 USA
- Rocky Mountain Cancer Center, 1700 S. Potomac Street, Aurora, CO 80012 USA
| | | | | | - Terese Kaske
- Sally Jobe Diagnostic Breast Center, Greenwood Village, CO USA
| | - Dennis L. Carter
- Rocky Mountain Cancer Center, 1700 S. Potomac Street, Aurora, CO 80012 USA
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Brachytherapy-based partial breast irradiation is associated with low rates of complications and excellent cosmesis. Brachytherapy 2013; 12:278-84. [DOI: 10.1016/j.brachy.2013.04.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 04/04/2013] [Accepted: 04/05/2013] [Indexed: 11/18/2022]
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Polgár C, Fodor J, Major T, Sulyok Z, Kásler M. Breast-conserving therapy with partial or whole breast irradiation: ten-year results of the Budapest randomized trial. Radiother Oncol 2013; 108:197-202. [PMID: 23742961 DOI: 10.1016/j.radonc.2013.05.008] [Citation(s) in RCA: 264] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 05/03/2013] [Accepted: 05/11/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE To report the long-term results of a single-institution randomized study comparing the results of breast-conserving treatment with partial breast irradiation (PBI) or conventional whole breast irradiation (WBI). PATIENTS AND METHODS Between 1998 and 2004, 258 selected women with pT1 pN0-1mi M0, grade 1-2, non-lobular breast cancer without the presence of extensive intraductal component and resected with negative margins were randomized after BCS to receive 50 Gy WBI (n=130) or PBI (n=128). The latter consisted of either 7 × 5.2 Gy high-dose-rate (HDR) multi-catheter brachytherapy (BT; n=88) or 50 Gy electron beam (EB) irradiation (n=40). Primary endpoint was local recurrence (LR) as a first event. Secondary endpoints were overall survival (OS), cancer-specific survival (CSS), disease-free survival (DFS), and cosmetic results. RESULTS After a median follow up of 10.2 years, the ten-year actuarial rate of LR was 5.9% and 5.1% in PBI and WBI arms, respectively (p=0.77). There was no significant difference in the ten-year probability of OS (80% vs 82%), CSS (94% vs 92%), and DFS (85% vs 84%), either. The rate of excellent-good cosmetic result was 81% in the PBI, and 63% in the control group (p<0.01). CONCLUSIONS Partial breast irradiation delivered by interstitial HDR BT or EB for a selected group of early-stage breast cancer patients produces similar ten-year results to those achieved with conventional WBI. Significantly better cosmetic outcome can be achieved with HDR BT implants compared with the outcome after WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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Shah C, Wilkinson JB, Saini H, Nanavati A, Arthur D, Julian T, Cuttino L, Badiyan S, Vicini F. Is Partial Breast Irradiation a Safe and Effective Treatment Approach for Women with Early-Stage Breast Cancer? CURRENT BREAST CANCER REPORTS 2013. [DOI: 10.1007/s12609-013-0102-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Vrana D, Gatek J, Lukesova L, Vazan T, Melichar B, Pospiskova M, Svach I. Omission of adjuvant radiation therapy in elderly patients with low risk breast cancer undergoing breast-conserving surgery--two center experience. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013; 158:461-4. [PMID: 23681308 DOI: 10.5507/bp.2013.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/18/2013] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Breast cancer is, now often diagnosed in patients older than 70 years due to longer life expectancy. The usual treatment is mastectomy to obviate radiotherapy or breast-conserving surgery followed by radiotherapy. The aim of this study was to investigate the need for adjuvant radiotherapy in older patients and the consequences of omitting radiotherapy following conservative surgery. METHODS An extensive database search was made of patients who had been treated for breast cancer at the Department of Oncology, University Hospital Olomouc and the Atlas Hospital in Zlin (2004-2008). We identified 738 patients of whom 190 patients (25.7%) were older than 70 years of age. These were followed up for progression-free and overall survival. The cause of death was checked for breast cancer relapse. RESULTS In total only 9 patients undergoing breast saving surgery were ultimately identified. No patient had confirmed local recurrence during the follow up period: Two patients have died due to distant metastasis without local relapse and one patient has died for reasons other than breast cancer. CONCLUSION Omitting radiotherapy after breast saving surgery provides an opportunity for women to undergo breast saving surgery and avoid 7 weeks of radiotherapy. This could significantly improve patient quality of life. In our of many years experience and from published randomized data, this procedure is safe for a select group of patients 70 years of age and older.
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Affiliation(s)
- David Vrana
- Department of Oncology, Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
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Shah C, Vicini F, Wazer DE, Arthur D, Patel RR. The American Brachytherapy Society consensus statement for accelerated partial breast irradiation. Brachytherapy 2013; 12:267-77. [PMID: 23619524 DOI: 10.1016/j.brachy.2013.02.001] [Citation(s) in RCA: 130] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 01/21/2013] [Accepted: 02/01/2013] [Indexed: 01/08/2023]
Abstract
PURPOSE To develop clinical guidelines for the quality practice of accelerated partial breast irradiation (APBI) as part of breast-conserving therapy for women with early-stage breast cancer. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in breast cancer and breast brachytherapy in particular devised updated guidelines for appropriate patient evaluation and selection based on an extensive literature search and clinical experience. RESULTS Increasing numbers of randomized and single and multi-institution series have been published documenting the efficacy of various APBI modalities. With more than 10-year followup, multiple series have documented excellent clinical outcomes with interstitial APBI. Patient selection for APBI should be based on a review of clinical and pathologic factors by the clinician with particular attention paid to age (≥50 years old), tumor size (≤3cm), histology (all invasive subtypes and ductal carcinoma in situ), surgical margins (negative), lymphovascular space invasion (not present), and nodal status (negative). Consistent dosimetric guidelines should be used to improve target coverage and limit potential for toxicity following treatment. CONCLUSIONS These guidelines have been created to provide clinicians with appropriate patient selection criteria to allow clinicians to use APBI in a manner that will optimize clinical outcomes and patient satisfaction. These guidelines will continue to be evaluated and revised as future publications further stratify optimal patient selection.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Washington University School of Medicine, Saint Louis, MO, USA
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Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Controversies and Current Indications for Use. Curr Treat Options Oncol 2012. [DOI: 10.1007/s11864-012-0213-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Khan AJ, Vicini FA, Brown S, Haffty BG, Kearney T, Dale R, Lyden M, Arthur D. Dosimetric Feasibility and Acute Toxicity in a Prospective Trial of Ultrashort-Course Accelerated Partial Breast Irradiation (APBI) Using a Multi-Lumen Balloon Brachytherapy Device. Ann Surg Oncol 2012; 20:1295-301. [DOI: 10.1245/s10434-012-2671-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Indexed: 11/18/2022]
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Hattangadi JA, Powell SN, Mauceri T, Taghian AG. In Reply to Hannoun-Levi et al. Int J Radiat Oncol Biol Phys 2012; 84:306-7. [DOI: 10.1016/j.ijrobp.2012.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 05/27/2012] [Indexed: 10/28/2022]
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