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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
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Rummel KA, Gao RW, Francis LN, Petersen IA, Mutter RW, Corbin KS. Secondary breast angiosarcoma following accelerated partial breast irradiation with intracavitary multicatheter applicator brachytherapy. Brachytherapy 2023; 22:487-490. [PMID: 37217416 DOI: 10.1016/j.brachy.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023]
Abstract
PURPOSE Secondary angiosarcoma of the breast is a rare complication of breast radiotherapy and is associated with a poor prognosis. There are many reported cases of secondary angiosarcoma following whole breast irradiation (WBI), however development of secondary angiosarcoma following brachytherapy-based accelerated partial breast irradiation (APBI) is not as well characterized. METHODS AND MATERIALS We reviewed and reported a case of a patient who developed secondary angiosarcoma of the breast following intracavitary multicatheter applicator brachytherapy APBI. RESULTS A 69-year-old female was originally diagnosed with T1N0M0 invasive ductal carcinoma of the left breast and treated with lumpectomy followed by adjuvant intracavitary multicatheter applicator brachytherapy APBI. Seven years following her treatment, she developed secondary angiosarcoma. However, the diagnosis of secondary angiosarcoma was delayed due to nonspecific imaging findings and a negative biopsy. CONCLUSIONS Our case highlights the need for secondary angiosarcoma to be considered in the differential diagnosis when patients present with symptoms such as breast ecchymosis and skin thickening following WBI or APBI. Prompt diagnosis and referral to a high-volume sarcoma treatment center for multidisciplinary evaluation is vital.
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Affiliation(s)
- Keaton A Rummel
- University of North Dakota School of Medicine and Health Sciences, Bismarck, ND.
| | - Robert W Gao
- Mayo Clinic Department of Radiation Oncology, Rochester, MN
| | - Leah N Francis
- Mayo Clinic Department of Radiation Oncology, Rochester, MN
| | - Ivy A Petersen
- Mayo Clinic Department of Radiation Oncology, Rochester, MN
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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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Montalvo SK, Collins B, Vicini F, Rahimi A. Stereotactic Partial Breast Irradiation: What Does the Future Hold? Am J Clin Oncol 2023; 46:20-24. [PMID: 36477344 DOI: 10.1097/coc.0000000000000970] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Breast irradiation has evolved significantly over the last several decades. Accelerated partial breast and stereotactic breast irradiation have evolved as strategies to reduce irradiated volumes, preserve appropriate oncologic control, and improve cosmetic outcome. The sequencing and/or combination of stereotactic partial breast irradiation with novel systemic agents is of great interest to the oncologic community. Here we explore the landscape of modern trials and opine on the future of partial breast irradiation.
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Affiliation(s)
- Steven K Montalvo
- Department of Radiation Oncology, Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
| | - Brian Collins
- Department of Radiation Oncology, Tampa General Hospital, Tampa, FL
| | - Frank Vicini
- Department of Radiation Oncology, Genesis Care, Farmington Hills, MI
| | - Asal Rahimi
- Department of Radiation Oncology, Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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Rahimi A, Morgan HE, Kim DW, Zhang Y, Leitch M, Wooldridge R, Goudreau S, Haley B, Rao R, Rivers A, Spangler AE, Jones RT, Stevenson S, Staley J, Albuquerque K, Ahn C, Neufeld S, Alluri PG, Ding C, Garwood D, Seiler S, Zhao B, Gu X, Timmerman R. Cosmetic Outcomes of a Phase 1 Dose Escalation Study of 5-Fraction Stereotactic Partial Breast Irradiation for Early Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2021; 110:772-782. [PMID: 33476737 DOI: 10.1016/j.ijrobp.2021.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Our purpose was to evaluate cosmetic changes after 5-fraction adjuvant stereotactic partial breast irradiation (S-PBI). METHODS AND MATERIALS Seventy-five women with in situ or invasive breast cancer stage 0, I, or II, with tumor size ≤3 cm, were enrolled after lumpectomy in a phase 1 dose escalation trial of S-PBI into cohorts receiving 30, 32.5, 35, 37.5, or 40 Gy in 5 fractions. Before S-PBI, 3 to 4 gold fiducial markers were placed in the lumpectomy cavity for tracking with the Synchrony respiratory tracking system. S-PBI was delivered with a CyberKnife robotic radiosurgery system. Patients and physicians evaluated global cosmesis using the Harvard Breast Cosmesis Scale. Eight independent panelists evaluated digital photography for global cosmesis and 10 subdomains at baseline and follow-up. McNemar tests were used to evaluate change in cosmesis, graded as excellent/good or fair/poor, from baseline to year 3. Wilcoxon signed rank tests were used to evaluate change in subdomains. Cohen's kappa (κ) statistic was used to estimate interobserver agreement (IOA) between raters, and Fleiss' κ was used to estimate IOA between panelists. RESULTS Median cosmetic follow-up was 5, 5, 5, 4, and 3 years for the 30, 32.5, 35, 37.5, and 40 Gy cohorts. Most patients reported excellent/good cosmesis at both baseline (86.3%) and year 3 (89.8%). No dose cohort had significantly worsened cosmesis by year 3 on McNemar analysis. No cosmetic subdomain had significant worsening by year 3. IOA was fair for patient-physician (κ = 0.300, P < .001), patient-panel (κ = 0.295, P < .001), physician-panel (κ = 0.256, P < .001), and individual panelists (Fleiss κ = 0.327, P < .001). CONCLUSIONS Dose escalation of S-PBI from 30 to 40 Gy in 5 fractions for early stage breast cancer was not associated with a detectable change in cosmesis by year 3. S-PBI is a promising modality for treatment of early stage breast cancer.
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Affiliation(s)
- Asal Rahimi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Howard E Morgan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dong W Kim
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yuanyuan Zhang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Marilyn Leitch
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rachel Wooldridge
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sally Goudreau
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Barbara Haley
- Department of Medicine, Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roshni Rao
- Department of Surgery, Columbia University, New York, New York
| | - Aeisha Rivers
- Department of Surgery, Memorial Health Care System, Pembroke Pines, Florida
| | - Ann E Spangler
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan T Jones
- Department of Radiation Oncology, Tennessee Oncology, Nashville, Tennessee
| | - Stella Stevenson
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason Staley
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chul Ahn
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah Neufeld
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prasanna G Alluri
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chuxiong Ding
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dan Garwood
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephen Seiler
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bo Zhao
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, Uniondale, New York
| | - Xuejun Gu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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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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Is it important to define skin sub-volumes in breast brachytherapy? JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AbstractAim:To evaluate clinically pertinent skin dose and volume parameters for the development of toxicities following accelerated partial breast irradiation (APBI).Methods:Three skin structures of various thicknesses inside the body (2 mm, 3 mm, 4 mm) were contoured over the treated breast retrospectively in a cohort of 62 women who underwent APBI using multi-catheter interstitial brachytherapy. The correlation statistics between the various skin structures and acute and late skin sequelae were evaluated using the Mann–Whitney U test and receiver-operating characteristic analysis. A p-value of <0·05 was considered significant.Results:At a median follow-up period of 54 months (range: 28–86), a significant correlation was seen between dose received by 0·2 (D0·2) cc of skin 4 mm inside the body as well as volume receiving 100% dose (V100) of skin 3 mm inside the body with cosmesis at 2 years and at last follow-up. The threshold for the two parameters for prediction of excellent or good cosmesis was 90% of the prescribed dose and 0·05 cc, respectively. No significant dosimetric or volumetric correlation was seen with other sequelae like wound dehiscence, fat necrosis, telangiectasia and atrophy.Conclusion:The results of this study support the use of dose and volumetric indices of the sub-volumes of the skin for correlation with clinical endpoints. However, the same should be validated prospectively in a larger cohort of women undergoing breast brachytherapy.
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Lee WH, Chang JS, Kim MJ, Park VY, Yoon JH, Kim SY, Kim JY, Park HS, Kim SI, Cho YU, Park BW, Kim YB. First Experience in Korea of Stereotactic Partial Breast Irradiation for Low-Risk Early-Stage Breast Cancer. Front Oncol 2020; 10:672. [PMID: 32411612 PMCID: PMC7201053 DOI: 10.3389/fonc.2020.00672] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/09/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose: Accelerated partial breast irradiation (A-PBI) in Korean women has been considered impracticable, owing to small breast volume and lack of high-precision radiotherapy experience. We present the first experience of stereotactic-PBI (S-PBI) with CyberKnife M6 to investigate feasibility of use and early toxicities in Korean women with early breast cancers. Materials and Methods: A total of 104 breasts receiving S-PBI at our institution between September 2017 and October 2018 were reviewed. Patients were selected based on the American Society for Radiation Oncology (ASTRO), American Brachytherapy Society, American Society of Breast Surgeons, and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology guidelines. A dose of 30 Gy in 5 fractions (NCT01162200) was used. Gold fiducials were routinely inserted near the tumor bed for tracking. Constraints regarding organs-at-risk followed the NSABP-B39/RTOG 0413 protocol. Results: Median follow-up was for 13 months. Patients were categorized as “suitable” (71.2%) or “cautionary” (28.8%) according to 2017 the ASTRO guidelines. No tracking failure of inserted gold fiducials occurred. Median planning target volume (PTV) and PTV-to-whole breast volume ratio was 73.6 mL (interquartile range, 58.8–103.9 mL) and 17.0% (13.3–19.1%), respectively. Median PTV V95%, PTV Dmax, and ipsilateral breast V50% were 97.8% (96.2–98.8%), 105.3% (104.2–106.4%), and 35.5% (28.3–39.8%), respectively. No immediate post-S-PBI toxicity ≥ grade 2 was reported, except grade 2 induration in three breasts. All patients remain disease-free to date. Conclusion: The first use of S-PBI in Korean women was feasible and safe for selected early breast cancer. Based on these results, we have initiated a prospective study (NCT03568981) to test S-PBI in whole-breast irradiation for low-risk early breast cancer.
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Affiliation(s)
- Won Hee Lee
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Jung Kim
- Department of Radiology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Vivian Youngjean Park
- Department of Radiology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Hyun Yoon
- Department of Radiology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Se Young Kim
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Ye Kim
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung Seok Park
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Il Kim
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Up Cho
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong Woo Park
- Department of Surgery, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Breast Cancer Center, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
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Jamalludin Z, Jong WL, Ho GF, Rosenfeld AB, Ung NM. In vivo dosimetry using MOSkin detector during Cobalt-60 high-dose-rate (HDR) brachytherapy of skin cancer. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 42:1099-1107. [PMID: 31650362 DOI: 10.1007/s13246-019-00809-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/16/2019] [Indexed: 01/10/2023]
Abstract
The MOSkin, a metal-oxide semiconductor field-effect transistor based detector, is suitable for evaluating skin dose due to its water equivalent depth (WED) of 0.07 mm. This study evaluates doses received by target area and unavoidable normal skin during a the case of skin brachytherapy. The MOSkin was evaluated for its feasibility as detector of choice for in vivo dosimetry during skin brachytherapy. A high-dose rate Cobalt-60 brachytherapy source was administered to the tumour located at the medial aspect of the right arm, complicated with huge lymphedema thus limiting the arm motion. The source was positioned in the middle of patients' right arm with supine, hands down position. A 5 mm lead and 5 mm bolus were sandwiched between the medial aspect of the arm and lateral chest to reduce skin dose to the chest. Two calibrated MOSkin detectors were placed on the target and normal skin area for five treatment sessions for in vivo dose monitoring. The mean dose to the target area ranged between 19.9 and 21.1 Gy and was higher in comparison with the calculated dose due to contribution of backscattered dose from lead. The mean measured dose at normal skin chest area was 1.6 Gy (1.3-1.9 Gy), less than 2 Gy per fraction. Total dose in EQD2 received by chest skin was much lower than the recommended skin tolerance. The MOSkin detector presents a reliable real-time dose measurement. This study has confirmed the applicability of the MOSkin detector in monitoring skin dose during brachytherapy treatment due to its small sensitive volume and WED 0.07 mm.
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Affiliation(s)
- Z Jamalludin
- Medical Physics Unit, University of Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia
- Department of Clinical Oncology, University of Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia
- Clinical Oncology Unit, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - W L Jong
- Department of Clinical Oncology, University of Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia
- Clinical Oncology Unit, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - G F Ho
- Department of Clinical Oncology, University of Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia
- Clinical Oncology Unit, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - A B Rosenfeld
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - N M Ung
- Department of Clinical Oncology, University of Malaya Medical Centre, 59100, Kuala Lumpur, Malaysia.
- Clinical Oncology Unit, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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11
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Six-Year Results From a Phase I/II Trial for Hypofractionated Accelerated Partial Breast Irradiation Using a 2-Day Dose Schedule. Am J Clin Oncol 2019; 41:986-991. [PMID: 28787281 DOI: 10.1097/coc.0000000000000402] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND To report 6-year outcomes from a phase I/II trial using balloon-based brachytherapy to deliver APBI in 2 days. METHODS A total of 45 patients with early-stage breast cancer received adjuvant APBI in 2 days with high-dose rate (HDR) brachytherapy totaling 2800 cGy in 4 fractions (700 cGy BID) using a balloon-based applicator as part of a prospective phase I/II clinical trial. All patients had negative margins and skin spacing ≥8 mm. We evaluated toxicities (CTCAE v3) as well as ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), distant metastasis, disease-free survival, cause-specific survival, and overall survival. RESULTS Median age and tumor size were 66 years old (48 to 83) and 0.8 cm (0.2 to 2.3 cm), respectively. Four percent of patients were N1 (n=2) and 73% were estrogen receptor (ER) positive (n=32). Median follow-up was 6.2 years (2.4 to 8.0 y). Nearly all toxicities at 6 years were grade 1 to 2 except 1 instance of grade 3 telangiectasia (2%). Eleven percent (n=5) of patients had chronic asymptomatic fat necrosis whereas asymptomatic seromas were noted on mammogram in 13% of cases (n=6). Cosmesis at last follow-up was good or excellent in 91% of cases (n=40) and fair in 9% (n=4). Two of the previously reported rib fractures healed with conservative measures. There were no IBTR or RNF (6 y IBTR/RNF rate 0%); however, 2 patients experienced distant metastasis (4% at 6 y). The 6-year actuarial disease-free survival, cause-specific survival, and overall survival were 96%, 100%, and 93%, respectively. CONCLUSIONS Hypofractionated 2-day APBI using brachytherapy resulted in excellent clinical outcomes with acceptable chronic toxicities.
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Haque W, Verma V, Hsiao KY, Hatch S, Arentz C, Szeja S, Schwartz M, Niravath P, Bonefas E, Miltenburg D, Brian Butler E, Teh BS. Omission of radiation therapy following breast conservation in older (≥70 years) women with T1-2N0 triple-negative breast cancer. Breast J 2019; 25:1126-1133. [PMID: 31273872 DOI: 10.1111/tbj.13443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/08/2019] [Accepted: 01/09/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Although randomized data support omitting adjuvant radiotherapy (RT) following breast conservation for T1-2N0 estrogen receptor positive breast cancer in ≥70-year-old women, there remains a knowledge gap regarding its omission for triple-negative BC (TNBC). METHODS AND MATERIALS The National Cancer Database (NCDB) was queried for ≥70-year-old females with newly diagnosed T1-2N0M0 TNBC treated with breast conservation. Multivariable logistic regression ascertained factors associated with adjuvant RT administration. Overall survival (OS) between patients treated with or without adjuvant RT was estimated using the Kaplan-Meier method. Cox proportional hazards modeling determined variables associated with OS. RESULTS Of 8526 patients, 6283 (74%) patients received adjuvant RT, and 2243 (26%) did not. RT was more frequently withheld in older patients, those with higher comorbidities, lower income, pT2 disease, following margin-positive resection, receipt of chemotherapy, and at academic centers (P < 0.05 for all). Median follow-up was 38.0 months. Five-year OS was greater in the adjuvant RT group (77.2% vs 55.3%, P < 0.001); these differences persisted when stratifying for age, T stage, and chemotherapy utilization (P < 0.001 for all). Omission of RT was also independently associated with poorer OS on multivariate analysis (P < 0.001). CONCLUSIONS This investigation, the largest known such study to date, observed that omission of adjuvant RT for elderly women with T1-2N0 TNBC was associated with poorer OS; this was observed across a range of age groups, as well as following stratification by T stage and chemotherapy usage. Although these results do not imply causation, caution must be exercised when considering omission of adjuvant RT in node-negative TNBC patients.
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Affiliation(s)
- Waqar Haque
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Kuan-Yin Hsiao
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Sandra Hatch
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Candy Arentz
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Sean Szeja
- Department of Radiation Oncology, City of Hope, Duarte, California, USA
| | - Mary Schwartz
- Department of Pathology, Houston Methodist Hospital, Houston, Texas, USA
| | - Polly Niravath
- Department of Medical Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Elizabeth Bonefas
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Edward Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Bin S Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas, USA
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Lv Y, He L, Wang C, Zhang L, Zhang B, Song Y. A systematic review of clinical outcomes and radiotherapy-associated toxicity in multicatheter accelerated partial breast irradiation. Medicine (Baltimore) 2019; 98:e14407. [PMID: 30732191 PMCID: PMC6380720 DOI: 10.1097/md.0000000000014407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/26/2018] [Accepted: 01/14/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To integrate relevant clinical data of multicatheter accelerated partial breast irradiation (mAPBI) for reaching a comprehensive conclusion. METHODS We did 3 meta-analyses for clinical outcomes including 1740 women from 4 articles, for acute radiotherapy (RT)-associated toxicity including 1255 patients from 5 articles, and for late RT-related toxicity involving 1565 patients from 9 papers. Clinical outcomes analyses were stratified by molecular subtypes, lymph nodes status, receptor status, and human epidermal growth factor receptor 2 (HER2) status. RESULTS For the Luminal A/B phenotypes, the disease relapse and failure in survival significantly decreased when compared with triple negative (TN)/HER2-amplified subtypes (P < .00001). The 5-year regional nodal recurrence (RNR), 5-year distant metastasis-free survival (DMFS) and 5-year disease free-survival (DFS) of TN patients were significantly superior to HER2-overexpression patients (P < .00001). The 5-year cause-specific survival (CSS), 5-year DMFS and 5-year overall survival (OS) in women with lymph nodes-negative were significantly improved versus patients with lymph nodes-positive (P = .0001). Conversely, the positive status of HER2 compared with negative one significantly increased the rate of local recurrence (LR) (P = .02). For acute toxicity, the morbidity of dermatitis was significantly higher than hematoma and implant infection (P = .01, P < .0001, respectively). For late toxicity, the occurrences of fibrosis (32%) and telangiectasia (14%) were significantly higher than other complications (P < .0001). CONCLUSION HER2-enriched subtype compared with other subtypes has significantly increased disease relapse and failure in survival. HER2-positive status is positively associated with an increased incidence of LR. Dermatitis is the most common acute RT-related toxicity and fibrosis is the first rife late RT-related toxicity.
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Affiliation(s)
- Yang Lv
- Department of Oncology, The PLA Navy Anqing Hospital, Anqing, Anhui Province
| | - Lin He
- Breast Center B ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province
| | - Chao Wang
- The Second Hospital of Anhui Medical University, Hefei, Anhui
| | - Lijiu Zhang
- The Second Hospital of Anhui Medical University, Hefei, Anhui
| | - Biyuan Zhang
- Department of Radiotherapy, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, People's Republic of China
| | - Yuhua Song
- Breast Center B ward, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province
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Struik GM, Godart J, Verduijn GM, Kolkman-Deurloo IK, de Vries KC, de Boer R, Koppert LB, Birnie E, Ghandi A, Klem TM, Pignol JP. A randomized controlled trial testing a hyaluronic acid spacer injection for skin toxicity reduction of brachytherapy accelerated partial breast irradiation (APBI): a study protocol. Trials 2018; 19:689. [PMID: 30558672 PMCID: PMC6298013 DOI: 10.1186/s13063-018-3035-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) is a treatment option for selected early stage breast cancer patients. Some APBI techniques lead to skin toxicity with the skin dose as main risk factor. We hypothesize that a spacer injected between the skin and target volume reduces the skin dose and subsequent toxicity in permanent breast seed implant (PBSI) patients. METHODS In this parallel-group, single-center, randomized controlled trial, the effect of a subcutaneous spacer injection on skin toxicity among patients treated with PBSI is tested. Eligibility for participation is derived from international guidelines for suitable patients for partial breast radiotherapy, e.g. women aged ≥ 50 years with a histologically proven non-lobular breast carcinoma and/or ductal carcinoma in situ (DCIS), tumor size ≤ 3 cm, node-negative, and PBSI technically feasible. Among exclusion criteria are neoadjuvant chemotherapy, lymphovascular invasion, and allergy for hyaluronic acid. For the patients allocated to receive spacer, after the PBSI procedure, 4-10 cc of biodegradable hyaluronic acid (Barrigel™, Palette Life Sciences, Santa Barbara, CA, USA or Restylane SubQ®, Galderma Benelux, Breda, the Netherlands) is injected directly under the skin using ultrasound guidance to create an extra 0.5-1 cm space between the treatment volume and the skin. The primary outcome is the rate of telangiectasia at two years, blindly assessed using Bentzen's 4-point scale. Secondary outcomes include: local recurrence; disease-free and overall survival rates; adverse events (pain, redness, skin/subcutaneous induration, radiation dermatitis, pigmentation, surgical site infection); skin dose; cosmetic and functional results; and health-related quality of life. A Fisher's exact test will be used to test differences between groups on the primary outcome. Previous studies found 22.4% telangiectasia at two years. We expect the use of a spacer could reduce the occurrence of telangiectasia to 7.7%. A sample size of 230 patients will allow for a 10% lost to follow-up rate. DISCUSSION In this study, the effect of a subcutaneous spacer injection on the skin dose, late skin toxicity, and cosmetic outcome is tested in patients treated with PBSI in the setting of breast-conserving therapy. Our results will be relevant for most forms of breast brachytherapy as well as robotic radiosurgery, as skin spacers could protect the skin with these other techniques. TRIAL REGISTRATION Netherlands Trial Register, NTR6549 . Registered on 27 June 2017.
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MESH Headings
- Brachytherapy/adverse effects
- Brachytherapy/methods
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Dermal Fillers/administration & dosage
- Dermal Fillers/adverse effects
- Female
- Humans
- Hyaluronic Acid/administration & dosage
- Hyaluronic Acid/adverse effects
- Hyaluronic Acid/analogs & derivatives
- Injections, Subcutaneous
- Mastectomy, Segmental
- Middle Aged
- Netherlands
- Radiation Dosage
- Radiodermatitis/diagnosis
- Radiodermatitis/etiology
- Radiodermatitis/prevention & control
- Radiotherapy, Adjuvant
- Randomized Controlled Trials as Topic
- Telangiectasis/diagnosis
- Telangiectasis/etiology
- Telangiectasis/prevention & control
- Time Factors
- Treatment Outcome
- Tumor Burden
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Affiliation(s)
- Gerson M. Struik
- Department of Surgery, Franciscus Gasthuis and Vlietland, PO Box 10900, 3004 BA Rotterdam, The Netherlands
- Department of Radiation Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Jeremy Godart
- Department of Radiation Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Gerda M. Verduijn
- Department of Radiation Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | | | - Kim C. de Vries
- Department of Radiation Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Raymond de Boer
- Department of Radiation Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Linetta B. Koppert
- Department of Surgery, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
| | - Erwin Birnie
- Department of Statistics and Education, Franciscus Gasthuis and Vlietland, PO Box 10900, 3004 BA Rotterdam, the Netherlands
- Department of Genetics, UMC Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, the Netherlands
| | - Ali Ghandi
- Department of Radiology, Franciscus Gasthuis and Vlietland, PO Box 10900, 3004 BA Rotterdam, the Netherlands
| | - Taco M. Klem
- Department of Surgery, Franciscus Gasthuis and Vlietland, PO Box 10900, 3004 BA Rotterdam, The Netherlands
| | - Jean-Philippe Pignol
- Department of Radiation Oncology, Erasmus MC Cancer Institute, PO Box 5201, 3008 AE Rotterdam, The Netherlands
- Department of Radiation Oncology, Dalhousie University, 5820 University Avenue, Halifax, NS B3H1V7 Canada
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Struik GM, Pignol JP, Kolkman-Deurloo IK, Godart J, Verduijn GM, Koppert LB, Birnie E, Ghandi A, Klem TM. Subcutaneous spacer injection to reduce skin toxicity in breast brachytherapy: A pilot study on mastectomy specimens. Brachytherapy 2018; 18:204-210. [PMID: 30528494 DOI: 10.1016/j.brachy.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/23/2018] [Accepted: 11/05/2018] [Indexed: 01/16/2023]
Abstract
PURPOSE Accelerated partial breast irradiation is a treatment option for selected patients with early-stage breast cancer. Some accelerated partial breast irradiation techniques lead to skin toxicity with the skin dose as a main risk factor. Biodegradable spacers are effective and safe in prostate brachytherapy to protect the rectum. We hypothesize that a subcutaneous spacer injection reduces the skin dose in breast brachytherapy. METHODS AND MATERIALS Ultrasound-guided spacer injections, either hyaluronic acid (HA) or iodined polyethylene glycol (PEG), were performed on fresh mastectomy specimens. Success was defined as a spacer thickness of ≥5 mm in the high-dose skin area. Usability was scored using the system usability scale. Pre and postinjection CT scans were used to generate low-dose-rate seed brachytherapy treatment plans after defining a clinical target volume. Maximum dose to small skin volumes (D0.2cc) and existence of hotspots (isodose ≥90% on 1 cm2 of skin) were calculated as skin toxicity indicators. RESULTS We collected 22 mastectomy specimens; half had HA and half had PEG injection. Intervention success was 100% for HA and 90.9% for PEG (p = NS). Hydrodissection was feasible in 81.8% with HA and 63.6% with PEG. Median system usability scale score was 97.5 for HA and 82.5 for PEG (p < 0.001). Mean D0.2cc was 80.8 Gy without spacer and 53.7 Gy with spacer (p < 0.001). Skin hotspots were present in 40.9% without spacer but none with spacer (p < 0.001). CONCLUSIONS A spacer injection in mastectomy specimens is feasible. An extra 5 mm space is always achieved, thereby potentially reducing the skin dose dramatically in low-dose-rate seed breast brachytherapy.
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Affiliation(s)
- Gerson M Struik
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands; Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Jean-Philippe Pignol
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands; Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Jeremy Godart
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Gerda M Verduijn
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Erwin Birnie
- Department of Statistics and Education, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands; Division of Woman and Baby, Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ali Ghandi
- Department of Radiology, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
| | - Taco M Klem
- Department of Surgery, Franciscus Gasthuis and Vlietland, Rotterdam, The Netherlands
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Radiation therapy utilization and outcomes for older women with breast cancer: Impact of molecular subtype and tumor grade. Breast 2017. [DOI: 10.1016/j.breast.2017.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Altman MB, Mooney KE, Edward S, Garcia-Ramirez JL, Dewees TA, Thomas MA, Zoberi I, Zoberi JE. Efficiency of using the day-of-implant CT for planning of SAVI APBI. Brachytherapy 2017; 17:40-49. [PMID: 28869144 DOI: 10.1016/j.brachy.2017.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of the study was to develop an optimized, efficient workflow for using the day-of-implant (DOI) CT for treatment planning of accelerated partial breast irradiation brachytherapy using the strut-adjusted volume implant (SAVI) device. METHODS AND MATERIALS For 62 consecutive SAVI patients, a DOI CT was acquired and used for treatment planning. A "verification" CT was acquired 24-72 h after implant and immediately before the first fraction, then registered to the DOI CT. If the DOI CT-based plan was no longer optimal, a replan was performed. An array of metrics describing the geometry of the device and its relative position in the patient from the DOI CTs for these patients was collected. These metrics from the DOI CT were evaluated to determine what features could predict for the need to replan before the first treatment fraction. Logistical regression analysis including χ2 tests was used to determine if different factors correlated with replanning. RESULTS Twenty-two of 62 patients (35%) required replanning. Only the presence of splayed struts, where splay was toward the skin, and the use of a nine strut ("8-1") SAVI were significantly correlated (p < 0.05) with replanning. Within these individual populations, no additional factors showed a significant statistical correlation for requiring replanning. CONCLUSIONS For strut-based accelerated partial breast irradiation brachytherapy, it was feasible to treat with a plan based on the DOI CT for a majority (65%) of patients. Some factors correlate to needing replanning; recognizing these could be used to optimize treatment workflow for certain patients, increasing clinical efficiency while enhancing the quality of patient care.
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Affiliation(s)
- Michael B Altman
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO.
| | - Karen E Mooney
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Sharbacha Edward
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
| | | | - Todd A Dewees
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
| | - Imran Zoberi
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
| | - Jacqueline E Zoberi
- Department of Radiation Oncology, Washington University in St. Louis, St. Louis, MO
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Clinical implementation of a novel Double-Balloon single-entry breast brachytherapy applicator. Brachytherapy 2017; 16:1239-1245. [PMID: 28844820 DOI: 10.1016/j.brachy.2017.07.015] [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: 06/16/2017] [Revised: 07/28/2017] [Accepted: 07/28/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE The purpose of the study was to describe the clinical utilization of a novel Double-Balloon applicator for accelerated partial breast irradiation (APBI). METHODS AND MATERIALS The Double-Balloon single-entry breast applicator contains a single central treatment catheter, as well as four peripheral catheters that can be differentially loaded to customize radiation dose coverage. An inner balloon is filled with up to 7-30 cm3 of saline to increase separation between the peripheral catheters, and an outer balloon is filled with up to 37-115 cm3 of saline to displace breast tissue from the peripheral catheters. Treatment planning objectives include coverage of the breast planning target volume to a minimum of V90 > 90%, limiting dose heterogeneity such that V200 < 10 cm3 and V150 < 50 cm3, and limiting maximum dose to skin (<100% of prescription dose) and ribs (<145% of prescription dose). RESULTS High-dose-rate APBI was delivered to 11 women using this device (34 Gy in 10 twice daily fractions). The mean V90 was 98.2% (range 94.2-99.4%). The mean skin Dmax with the Double-Balloon applicator was 83.3% (range 75.6-99.5%). The mean breast V200 was 5.8 cm3 (range 2.3-10.2 cm3), and the mean breast V150 was 32.9 cm3 (range 25.0-41.7 cm3). Pretreatment quality assurance was performed using CT prior to each morning fraction and ultrasound prior to each afternoon fraction. CONCLUSIONS The Double-Balloon applicator can be easily introduced into a previously existing brachytherapy program. APBI plans created with this applicator achieve excellent planning target volume coverage, while limiting skin dose and maintaining breast V200 < 10 cm3.
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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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Cuaron JJ, MacDonald SM, Cahlon O. Novel applications of proton therapy in breast carcinoma. Chin Clin Oncol 2017; 5:52. [PMID: 27558253 DOI: 10.21037/cco.2016.06.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/28/2016] [Indexed: 12/18/2022]
Abstract
This review will focus on the indications, clinical experience, and technical considerations of proton beam radiation therapy in the treatment of patients with breast cancer. For patients with early stage disease, proton therapy delivers less dose to non-target breast tissue for patients receiving partial breast irradiation (PBI) therapy, which may result in improved cosmesis but requires further investigation. For patients with locally advanced breast cancer requiring treatment to the regional lymph nodes, proton therapy allows for an improved dosimetric profile compared with conventional photon and electron techniques. Early clinical results demonstrate acceptable toxicity. The possible reduction in cardiopulmonary events as a result of reduced dose to organs at risk will be tested in a randomized control trial of protons vs. photons.
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Affiliation(s)
- John J Cuaron
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Shannon M MacDonald
- Massachusetts General Hospital, Francis H. Burr Proton Therapy Center, Boston, MA 02114-7250, USA
| | - Oren Cahlon
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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New Techniques for Irradiating Early Stage Breast Cancer: Stereotactic Partial Breast Irradiation. Semin Radiat Oncol 2017; 27:279-288. [PMID: 28577835 DOI: 10.1016/j.semradonc.2017.02.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Several improvements in breast cancer radiation delivery have been realized using new techniques over the past several decades. As an example, for early stage disease, there has been active investigation of partial breast irradiation (PBI) vs whole breast irradiation. Although still investigational, PBI reduces the treatment volumes, doses to organs at risk, and may improve cosmesis. Over the past 2 decades PBI has been delivered via interstitial brachytherapy, intracavitary brachytherapy, intraoperative radiation therapy, or 3-dimensional external beam radiation therapy. More recently, there has been growing evidence that supports stereotactic body radiation therapy as a safe and effective new treatment for early stage breast cancer. This article describes this new treatment opportunity and reviews the emerging data of stereotactic partial breast irradiation.
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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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Brachytherapy-based Accelerated Partial Breast Irradiation Provides Equivalent 10-Year Outcomes to Whole Breast Irradiation. Am J Clin Oncol 2016; 39:468-72. [DOI: 10.1097/coc.0000000000000082] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Shah S, Holzwanger E, Khwaja R, Fang D, Figueroa-Bodine J, Iannuzzi C, Shi C. A Single-Site Retrospective, Nonrandomized Study of Accelerated Partial Breast Irradiation Brachytherapy for Early-Stage Breast Cancer Treatment to Evaluate Local Tumor Control, Cosmetic Outcome, and Toxicities. Technol Cancer Res Treat 2016. [DOI: 10.1177/1533034615595724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose: To evaluate the efficacy and safety of the accelerated partial breast irradiation brachytherapy with a combination of applicators at a community hospital cancer center. Methods and Materials: Between 2005 and 2009, 120 patients with early-stage breast cancer were being followed after treatment with accelerated partial breast irradiation brachytherapy using MammoSite, single or multilumen balloon, or Contura multilumen balloon. After their lumpectomy surgery, each patient was treated with Ir-192 high-dose rate unit following radiation therapy oncology group 0413 guidelines. The patients had multiple follow-ups at 6 months, 1 year, 2 years, 3 years, or more. Results: Based on the Harvard Breast Cosmesis Scale, 95.00% of patients described their cosmetic evaluation as the treated breast essentially the same as the opposite side (excellent) or minimal but identifiable effects were noticed from radiation (good). After a median follow-up of 36 months, the local recurrence rate was 1.66% and a disease-free survival is 98.3%. Forty-two patients reported 85 adverse events, which were fibrosis: 24.70%, hyperpigmentation: 20.00%, radiation skin reaction: 7.05%, seroma: 7.05%, breast pain: 7.05%, erythema: 5.88%, and other events were less than 5.00%. Of all the adverse events recorded, grade 1 to 3 events are 95.29% (n = 81), 2.35% (n = 2), and 2.35% (n = 2). There was no grade 4 or 5 events recorded. Conclusions: Our study has shown promising results for delivering radiation with MammoSite, single or multilumen balloon, or Contura multilumen balloon and has been successful in achieving local control in patients with early-stage breast cancer.
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Affiliation(s)
- Shalin Shah
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | - Erik Holzwanger
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | - Radhika Khwaja
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | - Deborah Fang
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | | | | | - Chengyu Shi
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
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Verma V. Relationship and interactions of curcumin with radiation therapy. World J Clin Oncol 2016; 7:275-283. [PMID: 27298767 PMCID: PMC4896895 DOI: 10.5306/wjco.v7.i3.275] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/11/2016] [Accepted: 03/23/2016] [Indexed: 02/06/2023] Open
Abstract
Curcumin is widely reported to have remarkable medicinal - and antineoplastic - properties. This review details curcumin’s relationship with radiotherapy (RT), principally as a radiosensitizer for various malignancies and a radioprotector for normal tissues. First, examples of radiosensitization are provided for various cancers: Pediatric, lymphoma, sarcoma, prostate, gynecologic, pancreas, liver, colorectal, breast, lung, head/neck, and glioma. It is not the purpose of this article to comprehensively review all radiosensitization data; however, high-quality studies are discussed in relationship to currently-controversial RT questions for many cancers, and thus the importance of developing a natural radiosensitizer. Attention is then shifted to radioprotection, for which supporting research is discussed for the following RT toxicities: Dermatitis, pneumonitis, cataractogenesis, neurocognition, myelosuppression, secondary malignancies, and mucositis/enteritis. Though there is fewer data for radioprotection, the overall quality of clinical evidence is higher, and small clinical trials implicating the efficacy of curcumin for RT toxicities (vs placebo/current therapies) are also detailed. Though the overall level of evidence for curcumin as a radiosensitizer and radioprotector is low, it must be recognized that risks of adverse effects are exceedingly low, and clinicians may need to judge the yet-unproven rewards with low toxicity risks.
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Excellent Long-term Breast Preservation Rate After Accelerated Partial Breast Irradiation Using a Balloon Device. Clin Breast Cancer 2016; 16:217-22. [DOI: 10.1016/j.clbc.2016.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 12/14/2015] [Accepted: 02/03/2016] [Indexed: 01/08/2023]
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Clinical Outcomes and Toxicity of Proton Radiotherapy for Breast Cancer. Clin Breast Cancer 2016; 16:145-54. [DOI: 10.1016/j.clbc.2016.02.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/16/2015] [Accepted: 02/03/2016] [Indexed: 12/15/2022]
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Ebert MA, Dhal B, Prunster J, McLaren S, Zeps N, House M, Reniers B, Verhaegen F, Corica T, Saunders C, Joseph DJ. Theoretical versus Ex Vivo Assessment of Radiation Damage Repair: An Investigation in Normal Breast Tissue. Radiat Res 2016; 185:393-401. [PMID: 27023258 DOI: 10.1667/rr14235.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
In vivo validation of models of DNA damage repair will enable their use for optimizing clinical radiotherapy. In this study, a theoretical assessment was made of DNA double-strand break (DSB) induction in normal breast tissue after intraoperative radiation therapy (IORT), which is now an accepted form of adjuvant radiotherapy for selected patients with early breast cancer. DSB rates and relative biological effectiveness (RBE) were calculated as a function of dose, radiation quality and dose rate, each varying based on the applicator size used during IORT. The spectra of primary electrons in breast tissue adjacent to each applicator were calculated using measured X-ray spectra and Monte Carlo methods, and were used to inform a Monte Carlo damage simulation code. In the absence of repair, asymptotic RBE values (relative to (60)Co) were approximately 1.5. Beam-quality changes led to only minor variations in RBE among applicators, though differences in dose rate and overall dose delivery time led to larger variations and a rapid decrease in RBE. An experimental assessment of DSB induction was performed ex vivo using pre- and postirradiation tissue samples from patients receiving breast intraoperative radiation therapy. Relative DSB rates were assessed via γ-H2AX immunohistochemistry using proportional staining. Maximum-likelihood parameter estimation yielded a DSB repair halftime of 25.9 min (95% CI, 21.5-30.4 min), although the resulting model was not statistically distinguishable from one where there was no change in DSB yield among patients. Although the model yielded an in vivo repair halftime of the order of previous estimates for in vitro repair halftimes, we cannot conclude that it is valid in this context. This study highlights some of the uncertainties inherent in population analysis of ex vivo samples, and of the quantitative limitations of immunohistochemistry for assessment of DSB repair.
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Affiliation(s)
- Martin A Ebert
- a Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia; Schools of.,b Physics
| | | | - Janelle Prunster
- a Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia; Schools of
| | - Sally McLaren
- e St. John of God Subiaco Hospital, Western Australia
| | - Nikolajs Zeps
- c Surgery and.,e St. John of God Subiaco Hospital, Western Australia
| | | | - Brigitte Reniers
- f Research Group NuTeC, CMK, Hasselt University, Diepenbeek, Belgium; and
| | | | - Tammy Corica
- a Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia; Schools of.,d Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia
| | | | - David J Joseph
- a Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia; Schools of.,c Surgery and
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Verma V, Mishra MV, Mehta MP. A systematic review of the cost and cost-effectiveness studies of proton radiotherapy. Cancer 2016; 122:1483-501. [DOI: 10.1002/cncr.29882] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 01/20/2023]
Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology; University of Nebraska Medical Center; Omaha Nebraska
| | - Mark V. Mishra
- Department of Radiation Oncology; University of Maryland Medical Center; Baltimore Maryland
| | - Minesh P. Mehta
- Department of Radiation Oncology; University of Maryland Medical Center; Baltimore Maryland
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Todor DA. Balloon Brachytherapy Physics. Brachytherapy 2016. [DOI: 10.1007/978-3-319-26791-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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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Trajectory Modulated Arc Therapy: A Fully Dynamic Delivery With Synchronized Couch and Gantry Motion Significantly Improves Dosimetric Indices Correlated With Poor Cosmesis in Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2015; 92:1148-1156. [DOI: 10.1016/j.ijrobp.2015.04.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/14/2015] [Accepted: 04/21/2015] [Indexed: 11/23/2022]
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Comparative dosimetric findings using accelerated partial breast irradiation across five catheter subtypes. Radiat Oncol 2015; 10:160. [PMID: 26227388 PMCID: PMC4521502 DOI: 10.1186/s13014-015-0468-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 07/17/2015] [Indexed: 11/16/2022] Open
Abstract
Purpose Accelerated partial breast irradiation (APBI) with balloon and strut adjusted volume implants (SAVI) show promising results with excellent tumor control and minimal toxicity. Knowing the factors that contribute to a high skin dose, rib dose, and D95 coverage may reduce toxicity, improve tumor control, and help properly predict patient outcomes following APBI. Methods and materials A retrospective analysis of 594 patients treated with brachytherapy based APBI at a single institution from May 2008 to September 2014 was grouped by applicator subtype. Patients were treated to a total of 34 Gy (3.4 Gy x 10 fractions over 5 days delivered BID) targeting a planning target volume (PTV) 1.0 cm beyond the lumpectomy cavity using a high dose rate source. Results SAVI devices had the lowest statistically significant values of DmaxSkin (81.00 ± 29.83), highest values of D90 (101.50 ± 3.66), and D95 (96.09 ± 4.55). SAVI-mini devices had the lowest statistically significant values of DmaxRib (77.66 ± 32.92) and smallest V150 (18.01 ± 3.39). Multi-lumen balloons were able to obtain the smallest V200 (5.89 ± 2.21). Strut-based applicators were more likely to achieve a DmaxSkin and a DmaxRib less than or equal to 100 %. The effect of PTV on V150 showed a strong positive relationship (p < .001). PTV and DmaxSkin showed a weak negative relationship in multi-lumen applicators (p = .016) and SAVI-mini devices (p < .001). PTV and DmaxRib showed a weak negative relationship in multi-lumen applicators (p = .009), SAVI devices (p < .001), and SAVI-mini devices (p < .001). Conclusion PTV volume is strongly correlated with V150 in all devices and V200 in strut based devices. Larger PTV volumes result in greater V150 and V200, which could help predict potential risks for hotspots and resulting toxicities in these devices. PTV volume is also weakly negatively correlated with max skin dose and max rib dose, meaning that as the PTV volumes increase one can expect slightly smaller max skin and rib doses. Strut based applicators are significantly more effective in keeping skin and rib dose constraints under 125 and 100 % when compared to any balloon based applicator.
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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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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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Intraoperative Radiotherapy: Is it Ready for Prime Time? CURRENT BREAST CANCER REPORTS 2015. [DOI: 10.1007/s12609-014-0174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nath SK, Chen ZJ, Rowe BP, Blitzblau RC, Aneja S, Grube BJ, Horowitz NR, Weidhaas JB. A PHASE II TRIAL OF BALLOON-CATHETER PARTIAL BREAST BRACHYTHERAPY OPTIMIZATION IN THE TREATMENT OF STAGE 0, I AND IIA BREAST CARCINOMA. JOURNAL OF RADIATION ONCOLOGY 2014; 3:371-378. [PMID: 25485042 DOI: 10.1007/s13566-014-0153-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES (a) To prospectively determine if multidwell position dose delivery can decrease skin dose and resultant toxicity over single dwell balloon-catheter partial breast irradiation, and (b) to evaluate whether specific skin parameters could be safely used instead of skin-balloon distance alone for predicting toxicity and treatment eligibility. METHODS A single-arm phase II study using a Simon two-stage design was performed on 28 women with stage 0-II breast cancer. All patients were treated with multiple dwell position balloon-catheter brachytherapy. The primary endpoint was ≥ grade 2 skin toxicity. Initial entry required a balloon-skin distance ≥ 7 mm. Based on the toxicity in the first 16 patients, additional patients were treated irrespective of skin-balloon distance as long as the Dmax to 1 mm skin thickness was < 130%. RESULTS Compared to the phantom single dwell plans, multidwell planning yielded superior PTV coverage as per median V90, V95 and V100, but had slightly worse V150, V200 and DHI. Dmax to skin was decreased by multidwell planning at multiple skin thicknesses. The most common acute toxicity was grade 1 erythema (57%), and only two patients (7%) developed acute grade 2 toxicity (erythema). Late grade 1 fibrosis was seen in 32%. No patients experienced grade 3, 4, or 5 toxicity. CONCLUSIONS Multidwell position planning for balloon-catheter brachytherapy results in lower skin doses with equal to superior PTV coverage and an overall low rate of initial skin toxicity. Our data suggest that limiting the Dmax to < 130% to 1 mm thick skin is achievable and results in minimal toxicity.
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Affiliation(s)
- Sameer K Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Zhe J Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Bryan P Rowe
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Rachel C Blitzblau
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC
| | - Sanjay Aneja
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
| | - Baiba J Grube
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Nina R Horowitz
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Joanne B Weidhaas
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT
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Lee CD. Recent developments and best practice in brachytherapy treatment planning. Br J Radiol 2014; 87:20140146. [PMID: 24734939 PMCID: PMC4453147 DOI: 10.1259/bjr.20140146] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/10/2014] [Accepted: 04/14/2014] [Indexed: 12/20/2022] Open
Abstract
Brachytherapy has evolved over many decades, but more recently, there have been significant changes in the way that brachytherapy is used for different treatment sites. This has been due to the development of new, technologically advanced computer planning systems and treatment delivery techniques. Modern, three-dimensional (3D) imaging modalities have been incorporated into treatment planning methods, allowing full 3D dose distributions to be computed. Treatment techniques involving online planning have emerged, allowing dose distributions to be calculated and updated in real time based on the actual clinical situation. In the case of early stage breast cancer treatment, for example, electronic brachytherapy treatment techniques are being used in which the radiation dose is delivered during the same procedure as the surgery. There have also been significant advances in treatment applicator design, which allow the use of modern 3D imaging techniques for planning, and manufacturers have begun to implement new dose calculation algorithms that will correct for applicator shielding and tissue inhomogeneities. This article aims to review the recent developments and best practice in brachytherapy techniques and treatments. It will look at how imaging developments have been incorporated into current brachytherapy treatment and how these developments have played an integral role in the modern brachytherapy era. The planning requirements for different treatments sites are reviewed as well as the future developments of brachytherapy in radiobiology and treatment planning dose calculation.
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Affiliation(s)
- C D Lee
- Physics Department, Clatterbridge Cancer Centre, Bebington, Wirral, UK
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Jiang YR, Sykes ER. A 3D computer-assisted treatment planning system for breast cancer brachytherapy treatment. Int J Comput Assist Radiol Surg 2014; 10:373-81. [PMID: 25001868 PMCID: PMC4379415 DOI: 10.1007/s11548-014-1092-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 06/11/2014] [Indexed: 11/03/2022]
Abstract
PURPOSE Brachytherapy is an option for treatment of breast cancer in some cases. This modality requires patient-specific dosimetry based on CT simulator scans. A 3D computer-assisted breast brachytherapy treatment planning system called Vision was developed and tested. METHODS The brachytherapy treatment planning system used volume estimation and dose analysis with advanced 3D visualization. The patient treatment volume reconstruction was designed to ensure high-volume accuracy requirement of radioactive seed implantation procedure for this treatment. The system enables interactive placement of radioactive seeds embedded in original patient CT images with 3D display. RESULTS The system achieved 99.73% accuracy in volume estimation measured against the true volume and is statistically significantly more accurate than current existing commercial software at the p = 0.05 level. CONCLUSION A virtual 3D environment was developed to perform volume measurements, seed placements, and dose distribution planning and analysis based on 2D contours on patient CT images. This system was demonstrated to be feasible and accurate in a clinical setting.
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Affiliation(s)
- Yuchong Rachel Jiang
- Faculty of Applied Science and Technology, Sheridan College Institute of Technology and Advanced Learning, 1430 Trafalgar Road, Oakville, Ontario, Canada,
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White SA, Landry G, Fonseca GP, Holt R, Rusch T, Beaulieu L, Verhaegen F, Reniers B. Comparison of TG-43 and TG-186 in breast irradiation using a low energy electronic brachytherapy source. Med Phys 2014; 41:061701. [DOI: 10.1118/1.4873319] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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