1
|
Fan Y, Chen R, Lu Y, Lin Y, Zhang Y, Shao N, Wang S, Nie D, Shan Z. The Efficacy of Low-Kilovoltage X-Rays Intraoperative Radiation as Boost for Breast Cancer: A Systematic Review and Meta-Analysis. Breast J 2023; 2023:9035266. [PMID: 37435101 PMCID: PMC10332922 DOI: 10.1155/2023/9035266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/05/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Background Intraoperative radiotherapy (IORT) is a novel promising technology that may replace external beam radiation therapy (EBRT) as boost for patients receiving breast-conserving surgery. To better evaluate the efficacy of IORT using low-kilovoltage (low-kV) X-rays as boost, we presented this meta-analysis according to the PRISMA checklist. Methods Studies reported survival outcomes of intraoperative radiation using low-kilovoltage X-rays system (Intrabeam®, Carl Zeiss Meditec, Dublin, CA, USA) as boost were identified through electronic bibliographic database: PUBMED. The meta-analysis module in Stata (16.0) is used to pool the studies. A Poisson regression model is used to predict a 5-year local recurrence rate. Results Twelve studies including 3006 cases were included in the final analysis, with a median follow-up of 55 months weighted by sample size. The pooled local recurrence rate is 0.39% per person-year (95% CI: 0.15%-0.71%), with a low degree of heterogeneity (I2 = 0%). The predicted 5-year local recurrence rate was 3.45%. No difference in pooled local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies (0.41% per person-year vs. 0.58% per person-year, P = 0.580). Conclusions This study shows that low-kV IORT is an effective method as boost in breast cancer patients, with a low pooled local recurrence rate and low predicted 5-year local recurrence rate. Besides, no difference in the local recurrence rate was found between non-neoadjuvant patients studies and neoadjuvant patients studies. Low-kV IORT boost may be a promising alternative to EBRT boost in the future, which is being tested in the ongoing TARGIT-B trial.
Collapse
Affiliation(s)
- Yuanjian Fan
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ruiwan Chen
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Lu
- Department of Ultrasound, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ying Lin
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yunjian Zhang
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Nan Shao
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shenming Wang
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Dahong Nie
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Zhen Shan
- Center of Vascular-Thyroid-Breast Surgery, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
2
|
Leonardi MC, Kouloura A, Rojas DP, Zaffaroni M, Intra M, Veronesi P, Morra A, Gerardi MA, Fodor CI, Zerella MA, Camarda AM, Cattani F, Luraschi R, Viola A, Riva G, Miglietta E, Orecchia R, Dicuonzo S, Jereczek-Fossa BA. The POLO (Partially Omitted Lobe) approach to safely treat in-breast recurrence after intraoperative radiotherapy with electrons. Br J Radiol 2021; 95:20210405. [PMID: 34919420 DOI: 10.1259/bjr.20210405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES The aim of this study is to evaluate feasibility of salvage 4-week hypofractionated whole breast radiotherapy (WBRT) in patients with in-breast recurrence after receiving intraoperative radiotherapy with electrons (IOERT) for primary breast cancer (BC). METHODS BC patients who had repeated quadrantectomy underwent modified WBRT with intensity-modulated radiotherapy using Helical Tomotherapy to underdose the IOERT region. This approach, called POLO (Partially Omitted Lobe), excluded the IOERT volume from receiving the full prescription dose. RESULTS Nine patients were treated with this approach, receiving 45 Gy in 20 fractions. A simultaneous integrated boost of 2.5 Gy in 20 fractions was delivered in 6/9 patients. Dose constraints and planning objectives were reported. No severe toxicity was reported while local control and overall survival were 100%. CONCLUSION The POLO approach is technically feasible and capable to achieve a significant reduction of radiation dose delivered to the previous treated IOERT area. ADVANCES IN KNOWLEDGE The study demonstrates the technical and dosimetric feasibility of conservative salvage whole breast radiotherapy, while sparing the area already treated with IORT, in patients with in-breast recurrence.
Collapse
Affiliation(s)
| | - Andriana Kouloura
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Maria Camarda
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Viola
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Giulia Riva
- Clinical Department, National Center for Oncological Hadrontherapy (CNAO), Pavia, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| |
Collapse
|
3
|
Hypofractionated whole breast irradiation after IORT treatment is safe in patients receiving adjuvant chemotherapy. Clin Transl Oncol 2021; 23:2579-2583. [PMID: 34091868 DOI: 10.1007/s12094-021-02648-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hypofractionated whole breast irradiation (hWBI) and intraoperative radiotherapy (IORT) could be associated in breast cancer patients showing high-risk factors of local recurrence after breast conserving therapy (BSC). The aim of this trial was to evaluate, for the first time, the toxicity and cosmesis of hWBI after photon-IORT in high-risk patients treated by adjuvant chemotherapy. MATERIALS AND METHODS Thirty-one high-risk localized breast cancer patients treated by BCS, IORT (20 Gy), and adjuvant chemotherapy were included from February 2019 to August 2020 in this prospective trial, of hWBI (40.5 Gy/2.67 Gy/15 fractions). Acute and late toxicity (CTCAEv5.0) and cosmesis (Harvard scale), were assessed after treatment. RESULTS All patients completed their treatment and were evaluable after treatment. No patients showed severe (G3) acute/late toxicity. Excellent/good cosmesis at least 6 months after completing the treatment, was present in 93.6% of the patients. CONCLUSION hWBI in high-risk localized breast cancer patients treated by chemotherapy seems to have similar toxicity and cosmetic results than conventionally fractionated WBI in combination to photon-IORT after BCS.
Collapse
|
4
|
Intraoperative radiotherapy boost as part of breast-conservation therapy for breast cancer: a single-institution retrospective analysis. Strahlenther Onkol 2021; 197:812-819. [PMID: 33938966 PMCID: PMC8397646 DOI: 10.1007/s00066-021-01785-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/07/2021] [Indexed: 11/24/2022]
Abstract
Background There are currently no data from randomized controlled trials on the use of intraoperative radiotherapy (IORT) as a tumor bed boost as part of a breast-conservation approach for breast cancer. This study retrospectively reviewed the safety and efficacy of IORT as a boost treatment at a tertiary cancer center. Methods From 2015 to 2019, patients underwent breast-conserving surgery with axillary lymph node staging and a single dose of 20 Gy IORT with 50-kV photons, followed by whole-breast irradiation (WBI) and adjuvant systemic therapy (if applicable). Patients were followed for assessment of acute and late toxicities (using the Common Terminology Criteria for Adverse Events version 5.0) at 3–6-month intervals. Outcomes included ipsilateral (IBTR) and contralateral breast progression-free survival (CBE), distant metastasis-free survival (DMFS), and overall survival (OS). Results Median follow-up for the 214 patients was 28 (range 2–59) months. Most patients had T1 disease (n = 124) and were clinically node negative. Only few patients had high-grade and/or triple-negative disease. The vast majority of patients underwent sentinel node biopsy, and 32 (15%) required re-resection for initially positive margins. Finally, all tumor bed margins were clear. Nine (4.2%) and 48 (22.4%) patients underwent neoadjuvant and adjuvant chemotherapy, respectively. WBI was predominantly performed as conventionally fractionated WBI (n = 187, 87.4%), and the median time from BCS to WBI was 54.5 days. IORT was delivered with a single dose of 20 Gy. The median WBI dose was 50 Gy (range 29.4–50.4 Gy). No patients experienced grade 4 events; acute grade 3 toxicities were limited to 17 (8%) cases of radiation dermatitis. Postoperative toxicities were mild. After WBI only one case of late grade ≥ 2 events was reported. There were two recurrences in the tumor bed and one contralateral breast event. Conclusion This investigation provides additional preliminary data supporting the using of IORT in the boost setting and corroborates the existing literature. These encouraging results should be prospectively validated by the eventual publication of randomized studies such as TARGIT‑B.
Collapse
|
5
|
Comparison of IORT (Radical and Boost Dose) and EBRT in Terms of Disease-Free Survival and Overall Survival according to Demographic, Pathologic, and Biological Factors in Patients with Breast Cancer. Int J Surg Oncol 2021; 2021:2476527. [PMID: 33953982 PMCID: PMC8064796 DOI: 10.1155/2021/2476527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 03/31/2021] [Accepted: 04/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background The standard treatment for breast cancer is breast-conserving surgery (BCS) with radiotherapy. If external beam radiation therapy (EBRT) can be safely replaced with intraoperative radiotherapy (IORT), it will help patients to save their breast and to have equivocal or better results in DFS and overall survival (OS). Methods A total of 2022 patients with breast cancer treated during 6 years were enrolled in the current study. A total of 657, 376, and 989 patients received EBRT, radical, and boost dose by IORT, respectively, according to the IRIORT consensus protocol. The primary endpoint was recurrence and death. The secondary endpoint was the role of variables in recurrence and death. Results With a mean follow-up of 34.5 and 40.18 months for the IORT and EBRT groups, respectively, there was a significant difference in DFS between electron boost and X-ray boost groups (P=0.037) and the electron radical group compared with EBRT (P=0.025), but there was no significant difference between other boost and radical groups in DFS and OS. Conclusions IORT can be a preferred treatment modality because of its noninferior outcomes, and in some special conditions, it has superior outcomes compared to EBRT, particularly in delivering radical dose with IORT.
Collapse
|
6
|
Casey DL, Gupta GP, Ollila DW. The Role of Intraoperative Radiation in Early-stage Breast Cancer. Clin Breast Cancer 2021; 21:103-111. [PMID: 34030857 DOI: 10.1016/j.clbc.2020.12.007] [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: 10/05/2020] [Revised: 12/01/2020] [Accepted: 12/21/2020] [Indexed: 11/17/2022]
Abstract
Intraoperative radiation therapy (IORT) is a specialized form of accelerated partial breast irradiation in which a single dose of radiation is delivered to the tumor bed at the time of breast conserving surgery. With completion of radiation to the tumor bed at the time of surgery, IORT promises improved patient convenience, compliance, and quality of life. In addition, with its potentially skin-sparing properties and ability to deliver a high biologically effective dose to the tumor bed while reducing dose to nontarget tissues, IORT results in different but overall less toxicities compared with other modalities of radiation for breast cancer. However, skepticism over the role of IORT in breast cancer exists, and the 2 randomized trials that have analyzed IORT as the definitive radiation component of breast conservation therapy have shown an increase in local recurrence rates with IORT compared with whole breast irradiation, but similar rates of overall survival. In this review, we discuss the practicalities of IORT, the prospective data supporting and negating the role of IORT in lieu of whole breast irradiation, and the toxicity after IORT in early-stage breast cancer. We also review the role of IORT as a radiation boost and specific strategies for successful implementation of IORT in breast cancer.
Collapse
Affiliation(s)
- Dana L Casey
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC.
| | - Gaorav P Gupta
- Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - David W Ollila
- Division of Surgical Oncology, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
| |
Collapse
|
7
|
Onthong K, Chakkabat C, Nantavithya C, Shotelersuk K, Denariyakoon S, Vongsaisuwon M, Chulakadabbav A, Chatamra K, Saksornchai K. Results of intraoperative radiotherapy given as a boost after breast conserving-surgery. Gland Surg 2020; 9:1389-1395. [PMID: 33224814 DOI: 10.21037/gs-20-249] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Whole breast irradiation after breast-conserving surgery (BCS) with an external beam boost of 10-16 Gy is currently the standard treatment in breast cancer. Various modalities have been used for tumor bed boost irradiation. This study aimed to evaluate the local recurrence rate, overall survival rate (OSR), toxicity and cosmetic outcome of intraoperative radiotherapy (IORT) as a boost followed by whole breast irradiation in patients who received BCS. Methods This is a retrospective study. Between December 2009 and March 2017, 81 patients who underwent BCS with IORT as a boost were enrolled in this study. For IORT, a single dose of 20 Gy was delivered using a 30-50 kV photon beam, intraoperatively. All patients received whole breast radiation therapy (WBRT) of 42.5-50 Gy over 4-5 weeks. The primary endpoint was a 3-year local recurrence rate. Secondary endpoints included the OSR, toxicity and cosmetic outcome at 6 months after radiation treatment. Results At a median follow-up of 43 months, ipsilateral local recurrence was observed in one of the 81 patients (1.2%) which occurred in the same quadrant of the breast index. The 3-year OSR was 89.8%. Treatment was well-tolerated with no grade 3-4 acute and late toxicity, and 87% of patients were recorded as excellent-good cosmesis. Conclusions The use of BCS with IORT as a boost resulted in a low local recurrence rate and excellent cosmetic outcome in early breast cancer. Thus, IORT as a boost could be considered as an alternative to an external beam boost. Prospective studies are needed to confirm this data.
Collapse
Affiliation(s)
- Kraiwut Onthong
- Division of Therapeutic Radiology and Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chakapong Chakkabat
- Division of Therapeutic Radiology and Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chonnipa Nantavithya
- Division of Therapeutic Radiology and Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanjana Shotelersuk
- Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sikrit Denariyakoon
- The Queen Sirikit Center for Breast Cancer, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Mawin Vongsaisuwon
- Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Adhisabandh Chulakadabbav
- The Queen Sirikit Center for Breast Cancer, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Kris Chatamra
- The Queen Sirikit Center for Breast Cancer, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Kitwadee Saksornchai
- Division of Therapeutic Radiology and Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Therapeutic Radiology and Oncology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
8
|
Pez M, Keller A, Welzel G, Abo-Madyan Y, Ehmann M, Tuschy B, Berlit S, Sütterlin M, Wenz F, Giordano FA, Sperk E. Long-term outcome after intraoperative radiotherapy as a boost in breast cancer. Strahlenther Onkol 2019; 196:349-355. [PMID: 31641788 DOI: 10.1007/s00066-019-01525-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate long-term oncological outcome and incidence of chronic side effects in patients with breast cancer and intraoperative radiotherapy given as an upfront boost (IORT boost). METHODS Retrospective analysis of 400 patients with an IORT boost with low-energy X‑rays (20 Gy), subsequent whole-breast irradiation (46-50 Gy), and annual oncological follow-up. Side effects were prospectively evaluated (LENT-SOMA scales) over a period of up to 15 years. Side effects scored ≥grade 2 at least three times during follow-up were judged to be chronic. RESULTS The median age was 63 years (30-85) and the median follow-up was 78 months (2-180) after IORT boost. In 15 patients a local recurrence occurred, resulting in a local recurrence rate at 5, 10, and 15 years of 2.0%, 6.6%, and 10.1%, respectively. The overall survival rates at 5, 10, and 15 years were 92.1%, 81.8%, and 80.7%, respectively. The most common high-grade side effects were fibrosis (21%) and pain (8.6%). The majority of side effects occurred within the first 3 years. The actuarial rates of chronic fibrosis were 19.1% and 21.1% at 5 and ≥8 years, of chronic pain 8.6% at ≥4 years, of chronic edema of the breast 2.4% at ≥2 years, of chronic lymphedema 0.0% at 5 and 10 years, and of chronic hyperpigmentation 0.5% at ≥2 years. Side effects were similar or less than expected from an external beam boost. CONCLUSION IORT boost appears to be a highly efficient and safe method for upfront delivery of the tumor bed boost in high-risk breast cancer patients.
Collapse
Affiliation(s)
- Matthias Pez
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Anke Keller
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Grit Welzel
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Yasser Abo-Madyan
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Ehmann
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Benjamin Tuschy
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Gynecology and Obstetrics, Heidelberg University, Mannheim, Germany
| | - Sebastian Berlit
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Gynecology and Obstetrics, Heidelberg University, Mannheim, Germany
| | - Marc Sütterlin
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Gynecology and Obstetrics, Heidelberg University, Mannheim, Germany
| | - Frederik Wenz
- University Medical Center Freiburg, Freiburg, Germany
| | - Frank A Giordano
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Elena Sperk
- University Medical Center Mannheim, Medical Faculty Mannheim, Department of Radiation Oncology, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| |
Collapse
|
9
|
Fabbrizi MR, Warshowsky KE, Zobel CL, Hallahan DE, Sharma GG. Molecular and epigenetic regulatory mechanisms of normal stem cell radiosensitivity. Cell Death Discov 2018; 4:117. [PMID: 30588339 PMCID: PMC6299079 DOI: 10.1038/s41420-018-0132-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/01/2018] [Accepted: 11/20/2018] [Indexed: 12/14/2022] Open
Abstract
Ionizing radiation (IR) therapy is a major cancer treatment modality and an indispensable auxiliary treatment for primary and metastatic cancers, but invariably results in debilitating organ dysfunctions. IR-induced depletion of neural stem/progenitor cells in the subgranular zone of the dentate gyrus in the hippocampus where neurogenesis occurs is considered largely responsible for deficiencies such as learning, memory, and spatial information processing in patients subjected to cranial irradiation. Similarly, IR therapy-induced intestinal injuries such as diarrhea and malabsorption are common side effects in patients with gastrointestinal tumors and are believed to be caused by intestinal stem cell drop out. Hematopoietic stem cell transplantation is currently used to reinstate blood production in leukemia patients and pre-clinical treatments show promising results in other organs such as the skin and kidney, but ethical issues and logistic problems make this route difficult to follow. An alternative way to restore the injured tissue is to preserve the stem cell pool located in that specific tissue/organ niche, but stem cell response to ionizing radiation is inadequately understood at the molecular mechanistic level. Although embryonic and fetal hypersensity to IR has been very well known for many decades, research on embryonic stem cell models in culture concerning molecular mechanisms have been largely inconclusive and often in contradiction of the in vivo observations. This review will summarize the latest discoveries on stem cell radiosensitivity, highlighting the possible molecular and epigenetic mechanism(s) involved in DNA damage response and programmed cell death after ionizing radiation therapy specific to normal stem cells. Finally, we will analyze the possible contribution of stem cell-specific chromatin's epigenetic constitution in promoting normal stem cell radiosensitivity.
Collapse
Affiliation(s)
- Maria Rita Fabbrizi
- Cancer Biology Division, Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park, Saint Louis, MO 63108 USA
| | - Kacie E. Warshowsky
- Cancer Biology Division, Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park, Saint Louis, MO 63108 USA
| | - Cheri L. Zobel
- Cancer Biology Division, Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park, Saint Louis, MO 63108 USA
| | - Dennis E. Hallahan
- Cancer Biology Division, Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park, Saint Louis, MO 63108 USA
- Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO 63108 USA
| | - Girdhar G. Sharma
- Cancer Biology Division, Department of Radiation Oncology, Washington University School of Medicine, 4511 Forest Park, Saint Louis, MO 63108 USA
- Siteman Cancer Center, Washington University School of Medicine, Saint Louis, MO 63108 USA
| |
Collapse
|
10
|
Bradley JA. The current status of intraoperative radiation therapy in breast cancer: Challenges and promises. Breast J 2018; 24:713-714. [PMID: 30221437 DOI: 10.1111/tbj.13071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Julie A Bradley
- Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, USA
| |
Collapse
|
11
|
Barrou J, Tallet A, Cohen M, Bannier M, Buttarelli M, Gonzague L, Jauffret C, Lambaudie E, Rua S, Tyran M, Varela L, Houvenaeghel G. Contribution of intraoperative radiotherapy (IORT) for therapeutic de-escalation in early breast cancer: Report of a single institution's experience. Breast J 2018; 24:715-723. [DOI: 10.1111/tbj.12993] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 06/16/2017] [Accepted: 06/21/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Julien Barrou
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Agnes Tallet
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Monique Cohen
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Marie Bannier
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Max Buttarelli
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Laurence Gonzague
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Camille Jauffret
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Eric Lambaudie
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Sandrine Rua
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Margueritte Tyran
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Leonel Varela
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| | - Gilles Houvenaeghel
- Institut Paoli Calmette and CRCM; Aix Marseille University; Marseille France
| |
Collapse
|
12
|
Harris EER, Small W. Intraoperative Radiotherapy for Breast Cancer. Front Oncol 2017; 7:317. [PMID: 29312887 PMCID: PMC5743678 DOI: 10.3389/fonc.2017.00317] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/06/2017] [Indexed: 01/15/2023] Open
Abstract
Intraoperative radiotherapy (IORT) for early stage breast cancer is a technique for partial breast irradiation. There are several technologies in clinical use to perform breast IORT. Regardless of technique, IORT generally refers to the delivery of a single dose of radiation to the periphery of the tumor bed in the immediate intraoperative time frame, although some protocols have performed IORT as a second procedure. There are two large prospective randomized trials establishing the safety and efficacy of breast IORT in early stage breast cancer patients with sufficient follow-up time on thousands of women. The advantages of IORT for partial breast irradiation include: direct visualization of the target tissue ensuring treatment of the high-risk tissue and eliminating the risk of marginal miss; the use of a single dose coordinated with the necessary surgical excision thereby reducing omission of radiation and the selection of mastectomy for women without access to a radiotherapy facility or unable to undergo several weeks of daily radiation; favorable toxicity profiles; patient convenience and cost savings; radiobiological and tumor microenvironment conditions which lead to enhanced tumor control. The main disadvantage of IORT is the lack of final pathologic information on the tumor size, histology, margins, and nodal status. When unexpected findings on final pathology such as positive margins or positive sentinel nodes predict a higher risk of local or regional recurrence, additional whole breast radiation may be indicated, thereby reducing some of the convenience and low-toxicity advantages of sole IORT. However, IORT as a tumor bed boost has also been studied and appears to be safe with acceptable toxicity. IORT has potential efficacy advantages related to overall survival related to reduced cardiopulmonary radiation doses. It may also be very useful in specific situations, such as prior to oncoplastic reconstruction to improve accuracy of adjuvant radiation delivery, or when used as a boost in higher risk patients to improve tumor control. Ongoing international clinical trials are studying these uses and follow-up data are accumulating on completed studies.
Collapse
Affiliation(s)
- Eleanor E R Harris
- Department of Radiation Oncology, Brody School of Medicine, East Carolina University, Greenville, NC, United States
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University, Chicago, IL, United States
| |
Collapse
|
13
|
Key S, Miglierini P, Dupré PF, Guilbert S, Lucia AS, Abgral R, Conan-Charlet V, Uguen A, Pradier O, Schick U. Cosmetic Outcome and Chronic Breast Toxicity After Intraoperative Radiation Therapy (IORT) as a Single Modality or as a Boost Using the Intrabeam® Device: A Prospective Study. Ann Surg Oncol 2017; 24:2547-2555. [DOI: 10.1245/s10434-017-5920-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Indexed: 11/18/2022]
|
14
|
Mellon EA, Orman A, Joya LE, Montejo ME, Laronga C, Hoover SJ, Lee MC, Khakpour N, Kubal PF, Diaz R. Frequency of whole breast radiation therapy after intraoperative radiation therapy due to criteria identified by lumpectomy. Brachytherapy 2017; 16:174-180. [DOI: 10.1016/j.brachy.2016.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 11/16/2022]
|
15
|
Correa C, Harris EE, Leonardi MC, Smith BD, Taghian AG, Thompson AM, White J, Harris JR. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-Based Consensus Statement. Pract Radiat Oncol 2016; 7:73-79. [PMID: 27866865 DOI: 10.1016/j.prro.2016.09.007] [Citation(s) in RCA: 427] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To update the accelerated partial breast irradiation Consensus Statement published in 2009 and provide guidance on use of intraoperative radiation therapy (IORT) for partial breast irradiation in early-stage breast cancer, based on published evidence complemented by expert opinion. METHODS AND MATERIALS A systematic PubMed search using the same terms as the original Consensus Statement yielded 419 articles; 44 articles were selected. The authors synthesized the published evidence and, through a series of conference calls and e-mails, reached consensus regarding the recommendations. RESULTS The new recommendations include lowering the age in the "suitability group" from 60 to 50 years and in the "cautionary group" to 40 years for patients who meet all other elements of suitability (Table 1). Patients with low-risk ductal carcinoma in situ, as per Radiation Therapy Oncology Group 9804 criteria, were categorized in the "suitable" group. The task force agreed to maintain the current criteria based on margin status. Recommendations for the use of IORT for breast cancer patients include: counseling patients regarding the higher risk of ipsilateral breast tumor recurrence with IORT compared with whole breast irradiation; the need for prospective monitoring of long-term local control and toxicity with low-energy radiograph IORT given limited follow-up; and restriction of IORT to women with invasive cancer considered "suitable." CONCLUSION These recommendations will provide updated clinical guidance regarding use of accelerated partial breast irradiation for radiation oncologists and other specialists participating in the care of breast cancer patients.
Collapse
Affiliation(s)
- Candace Correa
- Department of Radiation Oncology, Faxton St. Luke's Healthcare, Utica, New York
| | - Eleanor E Harris
- Department of Radiation Oncology, East Carolina University, Greenville, North Carolina
| | | | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alastair M Thompson
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julia White
- Department of Radiation Oncology, Ohio State University Cancer Center, Columbus, Ohio
| | - Jay R Harris
- Department of Radiation Oncology, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
| |
Collapse
|
16
|
Abstract
Ionizing radiation is an important treatment modality for a variety of malignant conditions. However, development of radiation-induced skin changes is a significant adverse effect of radiation therapy (RT). Cutaneous repercussions of RT vary considerably in severity, course, and prognosis. When they do occur, cutaneous changes to RT are commonly graded as acute, consequential-late, or chronic. Acute reactions can have severe sequelae that impact quality of life as well as cancer treatment. Thus, dermatologists should be informed about these adverse reactions, know how to assess their severity and be able to determine course of management. The majority of measures currently available to prevent these acute reactions are proper skin hygiene and topical steroids, which limit the severity and decrease symptoms. Once acute cutaneous reactions develop, they are treated according to their severity. Treatments are similar to those used in prevention, but incorporate wound care management that maintains a moist environment to hasten recovery. Chronic changes are a unique subset of adverse reactions to RT that may develop months to years following treatment. Chronic radiation dermatitis is often permanent, progressive, and potentially irreversible with substantial impact on quality of life. Here, we also review the etiology, clinical manifestations, pathogenesis, prevention, and management of late-stage cutaneous reactions to radiotherapy, including chronic radiation dermatitis and radiation-induced fibrosis.
Collapse
|
17
|
Massa M, Franchelli S, Panizza R, Massa T. Is current clinical practice modified about intraoperative breast irradiation? Chin J Cancer Res 2016; 28:146-9. [PMID: 27199511 PMCID: PMC4865606 DOI: 10.21147/j.issn.1000-9604.2016.02.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
After the results obtained in the two randomized clinical trial, the ELIOT trial and the TARGIT-A trial, a heated debate is going on concerning the question of applying intraoperative radiotherapy (IORT) instead of postoperative whole breast irradiation (WBI) after breast conservative treatment. Currently, many centers are applying the IORT following the strict selection criteria dictated by the working groups American Society for Radiation Oncology (ASTRO) and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) and monitoring the oncological outcome together with radiation toxicity on breast tissue. The clinical experience of the Geneva University Hospital regarding the use of the Intrabeam system is evaluated and compared with current evidences.
Collapse
Affiliation(s)
- Michela Massa
- 1Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Simonetta Franchelli
- 2Plastic and Reconstructive Surgery, IRCCS AOU San Martino-IST, National Institute of Cancer Research, L.go Rosanna Benzi 10, 16132, Genoa, Italy
| | - Renzo Panizza
- 1Plastic and Reconstructive Surgery, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Tiberio Massa
- 3Diagnostic Mammography Department, IRCCS AOU San Martino-IST, National Institute of Cancer Research, L.go Rosanna Benzi 10, 16132, Genoa, Italy
| |
Collapse
|
18
|
Falco M, Masojć B, Rolla M, Czekała A, Pietruszewska J, Rubik-Leszczyńska A, Lewocki M, Łukowiak M, Kram A. Risk factors for seroma evacuation in breast cancer patients treated with intraoperative radiotherapy. Rep Pract Oncol Radiother 2016; 21:225-31. [PMID: 27601955 PMCID: PMC5002024 DOI: 10.1016/j.rpor.2016.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 03/04/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Novel techniques in oncology provide new treatment opportunities but also introduce different patterns of side effects. Intraoperative radiotherapy (IORT) allows a shortened overall treatment time for early breast cancer either combined with whole breast radiotherapy (WBRT), or alone. Although the early side effects of IORT are well known, data on clinically important late side effects, which require medical intervention, are scarce. AIM In this study, we analyze risk factors for seroma evacuation more than 6 months after IORT. MATERIALS AND METHODS We evaluated 120 patients with a mean follow-up of 27.8 months (range: 7-52 months). Fifty-one patients received IORT only and 69 were additionally treated with WBRT. RESULTS Seroma evacuation was performed 6-38 months after IORT. Two (3.9%) events were observed in the IORT group and 14 (20%) in the IORT + WBRT group. Univariate (Kaplan-Meier) analysis showed that addition of WBRT to IORT increased the risk of seroma evacuation [hazard ratio = 5.5, 95% confidence interval: 2.0-14.7, P = 0.011]. In a multivariate analysis (Cox proportional hazards regression), WBRT and axillary lymph node dissection were significant risk factors for seroma evacuation (model P value = 0.0025). CONCLUSIONS WBRT applied after IORT is associated with increased risk of seroma evacuation, which might be considered as a late side effect.
Collapse
Affiliation(s)
- Michał Falco
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Bartłomiej Masojć
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Rolla
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Agnieszka Czekała
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Jolanta Pietruszewska
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | | | - Mirosław Lewocki
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Magdalena Łukowiak
- Radiation Oncology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| | - Andrzej Kram
- Pathology Department, West Pomeranian Oncology Center, Strzałowska 22, 71-730 Szczecin, Poland
| |
Collapse
|
19
|
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]
|