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Park JB, Jang BS, Chang JH, Kim JH, Choi CH, Hong KY, Jin US, Chang H, Myung Y, Jeong JH, Heo CY, Kim IA, Shin KH. The impact of the new ESTRO-ACROP target volume delineation guidelines for postmastectomy radiotherapy after implant-based breast reconstruction on breast complications. Front Oncol 2024; 14:1373434. [PMID: 38846971 PMCID: PMC11153655 DOI: 10.3389/fonc.2024.1373434] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 04/29/2024] [Indexed: 06/09/2024] Open
Abstract
The European Society for Radiotherapy and Oncology-Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) updated a new target volume delineation guideline for postmastectomy radiotherapy (PMRT) after implant-based reconstruction. This study aimed to evaluate the impact on breast complications with the new guideline compared to the conventional guidelines. In total, 308 patients who underwent PMRT after tissue expander or permanent implant insertion from 2016 to 2021 were included; 184 received PMRT by the new ESTRO-ACROP target delineation (ESTRO-T), and 124 by conventional target delineation (CONV-T). The endpoints were major breast complications (infection, necrosis, dehiscence, capsular contracture, animation deformity, and rupture) requiring re-operation or re-hospitalization and any grade ≥2 breast complications. With a median follow-up of 36.4 months, the cumulative incidence rates of major breast complications at 1, 2, and 3 years were 6.6%, 10.3%, and 12.6% in the ESTRO-T group, and 9.7%, 15.4%, and 16.3% in the CONV-T group; it did not show a significant difference between the groups (p = 0.56). In multivariable analyses, target delineation is not associated with the major complications (sHR = 0.87; p = 0.77). There was no significant difference in any breast complications (3-year incidence, 18.9% vs. 23.3%, respectively; p = 0.56). Symptomatic RT-induced pneumonitis was developed in six (3.2%) and three (2.4%) patients, respectively. One local recurrence occurred in the ESTRO-T group, which was within the ESTRO-target volume. The new ESTRO-ACROP target volume guideline did not demonstrate significant differences in major or any breast complications, although it showed a tendency of reduced complication risks. As the dosimetric benefits of normal organs and comparable oncologic outcomes have been reported, further analyses with long-term follow-up are necessary to evaluate whether it could be connected to better clinical outcomes.
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Affiliation(s)
- Jung Bin Park
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bum-Sup Jang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hyun Chang
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang Heon Choi
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Young Hong
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yujin Myung
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jae Hoon Jeong
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chan Yeong Heo
- Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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Novick K, Chadha M, Daroui P, Freedman G, Gao W, Hunt K, Park C, Rewari A, Suh W, Walker E, Wong J, Harris EE. American Radium Society Appropriate Use Criteria Postmastectomy Radiation Therapy: Executive Summary of Clinical Topics. Int J Radiat Oncol Biol Phys 2024; 118:458-465. [PMID: 37478956 DOI: 10.1016/j.ijrobp.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 07/06/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To conduct an appropriate use criteria expert panel update on clinical topics relevant to current clinical practice regarding postmastectomy radiation therapy (PMRT). METHODS AND MATERIALS An analysis of the medical literature from peer-reviewed journals was conducted from May 4, 2010 to May 4, 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to search the PubMed database to retrieve a comprehensive set of relevant articles. A well-established methodology (modified Delphi) was used by the expert panel to rate the appropriate use of procedures. RESULTS Evidence for key questions in PMRT regarding benefit in special populations and technical considerations for delivery was examined and described. Risk factors for local-regional recurrence in patients with intermediate-risk disease that indicate benefit of PMRT include molecular subtype, age, clinical stage, and pathologic response to neoadjuvant chemotherapy. Use of hypofractionated radiation in PMRT has been examined in several recent randomized trials and is under investigation for patients with breast reconstruction. The use of bolus varies significantly by practice region and has limited evidence for routine use. Adverse effects occurred with both PMRT preimplant and postimplant exchange in 2-staged breast reconstruction. CONCLUSIONS Most patients with even limited nodal involvement will likely benefit from PMRT with significant reduction in local-regional recurrence and potential survival. Patients with initial clinical stage III disease and/or any residual disease after neoadjuvant chemotherapy should be strongly considered for PMRT. Growing evidence supports the use of hypofractionated radiation for PMRT with equivalent efficacy and decreased acute side effects, but additional evidence is needed for special populations. There is limited evidence to support routine use of bolus in all patients. Timing of PMRT regarding completion of 2-staged breast reconstruction requires a discussion of increased risks with radiation postimplant exchange compared with increased risk of failure of reconstruction or surgical complications with radiation preimplant exchange.
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Affiliation(s)
- Kristina Novick
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Manjeet Chadha
- Department of Radiation Oncology, Mount Sinai, New York, New York
| | - Parima Daroui
- Department of Radiation Oncology, Southern California Permanente Medical Group, Los Angeles, California
| | - Gary Freedman
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wendy Gao
- Tacoma Valley Radiation Oncology Centers, Tacoma, Washington
| | - Kelly Hunt
- Department of Breast Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Catherine Park
- Department of Radiation Oncology, University of California, San Francisco, California
| | - Amar Rewari
- Department of Radiation Oncology, Ann Arundel Medical Center, Annapolis, Maryland
| | - Warren Suh
- Department of Radiation Oncology, Ridely Tree Cancer Center, Santa Barbara, California
| | - Eleanor Walker
- Department of Radiation Oncology, Henry Ford Health, Detroit, Michigan
| | - Julia Wong
- Department of Radiation Oncology, Dana Farber Brigham Cancer Center, Boston, Massachusetts
| | - Eleanor E Harris
- Department of Radiation Oncology, St. Luke's University Health Network, Easton, Pennsylvania
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Copeland-Halperin LR, Lyatskaya Y, Bellon JR, Dey T, Carty MJ, Barbie T, Erdmann-Sager J. Impact of Prepectoral vs. Subpectoral Tissue Expander Placement on Post-mastectomy Radiation Therapy Delivery: A Retrospective Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5434. [PMID: 38115839 PMCID: PMC10730031 DOI: 10.1097/gox.0000000000005434] [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: 01/09/2023] [Accepted: 10/05/2023] [Indexed: 12/21/2023]
Abstract
Background Implant-based reconstruction is the most common method of postmastectomy reconstruction. Many patients require postmastectomy radiation (PMRT). Tissue expanders (TEs), typically inserted as a first stage, have historically been placed subpectorally. More recently, prepectoral reconstruction has gained popularity, but its impact on PMRT is unknown. Prior studies focus on complication rates and aesthetic outcomes. This study examines whether there is a difference in radiation dosimetry among patients undergoing prepectoral versus subpectoral TE reconstruction. Methods Electronic medical records and radiation plans of 50 patients (25 prepectoral, 25 subpectoral) who underwent mastectomy with immediate TE reconstruction at our institution or affiliate site were reviewed. Pectoralis major muscle and chest wall structures were contoured and mean percentage volumes of these structures receiving less than 95%, 100%, and more than 105% target radiation dose were calculated, as were heart and ipsilateral lung doses. Welch two sample t test, Fisher exact test, and Pearson chi-squared tests were performed. Results The groups had comparable patient and tumor characteristics and underwent similar ablative and reconstructive procedures and radiation dosimetry. Subpectoral patients had larger mean areas receiving less than 95% target dose ("cold spots"); prepectoral patients had larger mean areas receiving greater than 105% ("hot spots") and 100% target doses. There were no differences in chest wall, heart, and lung doses. Conclusions Our results demonstrate an increased mean percentage area of pectoralis cold spots with subpectoral reconstruction and increased area of hot spots and 100% dose delivery to the pectoralis in prepectoral patients. Larger studies should analyze long-term effects of prepectoral reconstruction on radiation dosing and recurrence rates.
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Affiliation(s)
| | - Yulia Lyatskaya
- Department of Radiation Oncology, Brigham and Women’s Hospital, Boston, Mass
| | - Jennifer R. Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Mass
| | - Tanujit Dey
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Mass
| | - Matthew J. Carty
- Department of Surgery, Brigham and Women’s Hospital, Boston, Mass
| | - Thanh Barbie
- Department of Surgery, Brigham and Women’s Hospital, Boston, Mass
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Schad MD, Richman AH, Diego EJ, McAuliffe PF, Johnson RR, Steiman J, Vargo JA, Beriwal S. Dosimetry and Toxicity Outcomes in Patients Treated with Hypofractionated Regional Nodal Irradiation for Breast Cancer: What is the Best Dose-Volume Limit to Minimize Risks of Radiation Pneumonitis? Pract Radiat Oncol 2023; 13:291-300. [PMID: 36332799 PMCID: PMC11189663 DOI: 10.1016/j.prro.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Although published data have supported the use of hypofractionated regional nodal irradiation (HF-RNI) for breast cancer, limited dosimetric data exist to evaluate predictors of lung toxicity. The ongoing RT CHARM trial limits the percentage of ipsilateral lung volume that receives ≥18 Gy to 35 to 40%. We assessed dosimetry, toxicity, and disease outcomes in patients with breast cancer treated with HF-RNI with a particular focus on pneumonitis. METHODS AND MATERIALS We retrospectively reviewed all patients with breast cancer treated with HF-RNI (40-43 Gy in 15-16 fractions) after either lumpectomy or mastectomy at The University of Pittsburgh Medical Center from September 2018 to December 2021 to collect dosimetric and outcomes data. All post-radiation therapy chest computed tomography (CT) scans were manually reviewed for evidence of acute (≤6 months postradiation) or chronic (>6 months postradiation) pneumonitis. RESULTS One-hundred-ninety-one patients qualified with a median follow-up of 20.3 months (range, 5.1-42.2). Acute grade 1 (G1) pneumonitis was observed in 6.8% of the overall cohort (13 of 191 patients) and 39.4% of the patients (13 of 33) who received a chest CT ≤6 months postradiation therapy. Only 1 patient developed acute G2 pneumonitis. Chronic G1 pneumonitis was observed in 29.8% of the overall cohort (57 of 191 patients) and 77% of patients (57 of 74 patients) who received a chest CT >6 months postradiation therapy. No patients developed acute G3+ or chronic G2+ pneumonitis. CONCLUSIONS Rates of symptomatic pneumonitis were low in this cohort of patients treated with HF-RNI, even with integration of HER2/neu-directed therapy, chemotherapy, hormone therapy, and internal mammary nodal irradiation. Lung V20Gy <26% appeared safe in this cohort to limit symptomatic pneumonitis, though this is not meant to represent the safe upper limit. Given the low event rate of symptomatic pneumonitis, data from larger cohorts will be needed to assess dosimetric predictors and the safe upper limit of lung dose.
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Affiliation(s)
- Michael D Schad
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Adam H Richman
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Emilia J Diego
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Priscilla F McAuliffe
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ronald R Johnson
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Steiman
- Department of Breast Surgical Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John A Vargo
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sushil Beriwal
- Department of Radiation Oncology, Allegheny Health Network, Pittsburgh, Pennsylvania; Varian Medical Systems, Palo Alto, California.
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Prasun P, Kharade V, Pal V, Gupta M, Das S, Pasricha R. Dosimetric Comparison of Hypofractionated Regimen in Breast Cancer Using Two Different Techniques: Intensity-Modulated Radiation Therapy (IMRT) and Volumetric-Modulated Arc Therapy (VMAT). Cureus 2023; 15:e38045. [PMID: 37228558 PMCID: PMC10206676 DOI: 10.7759/cureus.38045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Breast cancer treated with adjuvant hypofractionation radiotherapy with two different techniques, i.e., volumetric-modulated arc therapy (VMAT) and intensity-modulated radiation therapy (IMRT) and their effects in terms of loco-regional control and adverse effects in terms of cutaneous, pulmonary, and cardiac outcomes are compared. MATERIALS AND METHODS This is a prospective non-randomized observational study. VMAT and IMRT plan for 30 breast cancer patients who were supposed to receive adjuvant radiotherapy were prepared using a hypofractionation schedule. The plans were dosimetrically evaluated. OBJECTIVE Dosimetric comparative analysis of IMRT and VMAT in hypofractionated radiotherapy in breast cancer is done and tested whether VMAT has a dosimetric advantage over IMRT. These patients were recruited for a clinical assessment of toxicities. They were followed up for at least three months. RESULT On dosimetric analysis, planning target volume (PTV) coverage (PTV_ V95) of both VMAT (96.41 ± 1.31) and IMRT (96.63 ± 1.56) were similar with significantly lower monitor units required with VMAT plans (1,084.36 ± 270.82 vs 1,181.55 ± 244.50, p = 0.043). Clinically, all patients tolerated hypofractionation through VMAT (n = 8) and IMRT (n = 8) satisfactorily in the short term. No cardiotoxicity or appreciable falls in pulmonary function test parameters were observed. Acute radiation dermatitis poses challenges similar to standard fractionation or any other delivery technique. CONCLUSION PVT dose, homogeneity, and conformity indices were similar in both VMAT and IMRT groups. In VMAT, there was high-dose sparing of some critical organs like the heart and lungs at the cost of the low-dose baths to these organs. Increased risk of secondary cancer will require a decade-long follow-up study to indict the VMAT technique. As we move toward precision in oncology, "one-size-fits-all" can never be an acceptable dictum. Each patient is unique and therefore we must offer, and the patient must "choose wisely."
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Affiliation(s)
- Pallav Prasun
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Vipin Kharade
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Vikas Pal
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Manish Gupta
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Saikat Das
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Rajesh Pasricha
- Radiation Oncology, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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Tang R, Li A, Li Y, Deng G, Wang Y, Xiao Q, Zhang L, Luo Y. Dosimetric comparison of two dose expansion methods in intensity modulated radiotherapy for breast cancer. Radiat Oncol 2023; 18:23. [PMID: 36737788 PMCID: PMC9898932 DOI: 10.1186/s13014-023-02217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To explore the dosimetric difference between IMRT-VB plan based on the establishment of external expansion structure and virtual bolus (VB) and IMRT-SF based on the skin flash (SF) tool of the Eclipse treatment planning system in postoperative chest wall target intensity modulation radiotherapy plan of breast cancer. METHODS Twenty patients with breast cancer were randomly selected as subjects to develop IMRT-VB plan based on virtual bolus and IMRT-SF plan based on skin flash tool of Eclipse treatment planning system. The planning target volume, monitor unit (MU) of every single treatment and the dosimetric parameters of organ at risk (OARs) were recorded. Paired t-test was used for normal distribution data while nonparametric paired Wilcoxon rank sum test was used for non-normal distribution data. RESULTS Both IMRT-VB and IMRT-SF plan can expand outward to the chest wall skin and meet the dose requirements of clinical prescription. The conformal index, the homogeneity index, D2%, D98% and D50% were significantly better in IMRT-SF plan than those in IMRT-VB plan (P < 0.05). The average MU of the IMRT-SF plan was much higher than that of the IMRT-VB plan (866.0 ± 68.1 MU vs. 760.9 ± 50.4 MU, P < 0.05). In terms of organ at risk protection, IMRT-SF plan had more advantages in the protection of ipsilateral lung and spinal cord than IMRT-VB plan (P < 0.05). CONCLUSION Our study indicated that IMRT-SF plan displayed clinical application superiority compared to IMRT-VB plan, and the operation steps of which are simpler and faster. Besides, IMRT-SF plan took advantages in achieve effective external expansion of skin dose intensity and OARs protection.
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Affiliation(s)
- Ran Tang
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Aimin Li
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Yingjing Li
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Guanhua Deng
- grid.490151.8Guangdong 999 Brain Hospital, Guangzhou, 510510 China
| | - Yufeng Wang
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Qing Xiao
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Luosheng Zhang
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Yue Luo
- Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315, Guangdong, China. .,Cancer Center, Southern Medical University, Guangzhou, 510315, China.
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Bazan JG, Khan AJ. Target Volume Delineation and Patterns of Recurrence in the Modern Era. Semin Radiat Oncol 2022; 32:254-269. [DOI: 10.1016/j.semradonc.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Joo JH, Yang JD, Park HY, Park J, Wu ZY, Ko B, Jongmoo P, Kim SS. The patterns and spatial locations of local recurrence in breast cancer with implant-based reconstruction after mastectomy. Radiother Oncol 2022; 170:111-117. [PMID: 35245569 DOI: 10.1016/j.radonc.2022.02.028] [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: 12/02/2021] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE The European Society for Radiotherapy and Oncology (ESTRO) recently defined delineation guidelines for the clinical target volume for postmastectomy radiation therapy (PMRT) after immediate implant-based reconstruction for early-stage breast cancer. We analyzed the three-dimensional location and pattern of local recurrence in accordance with the reconstruction type and ESTRO-target volume. MATERIALS AND METHODS This retrospective study involved patients who had undergone mastectomy with implant reconstruction between 2010 and 2019 and who had local recurrence as the first event. For mapping analysis, one subpectoral and one prepectoral implant patient were selected. All recurrence lesions were contoured and mapped in a representative case. RESULTS A total of 1,327 patients with breast cancer who underwent mastectomy and implant-based breast reconstruction were identified; 51 were enrolled with a total of 65 lesions. In subpectoral implant patients, 93% of recurrences were located in the ESTRO-target volume. No recurrence occurred in the implant pocket, but 7% of the recurrent tumors developed in the pectoralis major and deep thoracic muscle. In prepectoral implant patients, all recurrent tumors occurred within the ESTRO-target volume. CONCLUSION The ESTRO-target volume in PMRT after reconstruction encompassed most local recurrences in patients who underwent mastectomy with immediate implant reconstruction. Our results support the application of the ESTRO Advisory Committee for Radiation Oncology Practice consensus guideline for target volume of PMRT after immediate implant-based reconstruction for early-stage breast cancer.
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Affiliation(s)
- Ji Hyeon Joo
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jung Dug Yang
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ho Yong Park
- Department of Surgery, School of Medicine, Kyungpook National University School of Medicine, Daegu, Republic of Korea
| | - Jaehyeon Park
- Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Zhen-Yu Wu
- Department of Breast Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China; Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - BeomSeok Ko
- Division of Breast Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Park Jongmoo
- Department of Radiation Oncology, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea.
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Lee SM, Lee JW, Kim WC, Min CK, Kim ES, Jo IY. Effects of Tumor-Rib Distance and Dose-Dependent Rib Volume on Radiation-Induced Rib Fractures in Patients with Breast Cancer. J Pers Med 2022; 12:jpm12020240. [PMID: 35207728 PMCID: PMC8876362 DOI: 10.3390/jpm12020240] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 01/29/2022] [Accepted: 02/02/2022] [Indexed: 12/10/2022] Open
Abstract
This study aimed to investigate the effects of tumor-rib distance and dose-dependent rib volume on radiation-induced rib fractures (RIRFs) in patients with breast cancer. We retrospectively included 510 women with breast cancer who underwent surgical resection with adjuvant radiotherapy. The tumor-rib distance was measured using preoperative computed tomography (CT) images. Postoperative chest wall thickness and dose-dependent rib volumes, which are absolute rib volumes receiving >20 Gy (V20), 30 Gy (V30), 40 Gy (V40), 45 Gy (V45), and 50 Gy (V50), were measured from the stimulation CT images for radiation treatment planning. We assessed the relationship of RIRF with tumor-rib distance, postoperative chest wall thickness, and dose-dependent rib volumes. Patients with high values of tumor-rib distance and postoperative chest wall thickness had significantly lower risks of RIRF than those with low values. Patients with high values of V20, V30, V40, V45, and V50 had significantly higher risks of RIRF than those with low values. In a multivariate analysis, tumor-rib distance and all five dose-dependent rib volumes, as well as osteoporosis and radiation field, were independent risk factors for RIRF. Tumor-rib distance and dose-dependent rib volume were independent risk factors for RIRF in patients with breast cancer.
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Affiliation(s)
- Sang Mi Lee
- Department of Nuclear Medicine, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea;
| | - Jeong Won Lee
- Department of Nuclear Medicine, International St. Mary’s Hospital, College of Medicine, Catholic Kwandong University, Simgok-ro 100-gil 25, Seo-gu, Incheon 22711, Korea;
| | - Woo Chul Kim
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea; (W.C.K.); (C.K.M.); (E.S.K.)
| | - Chul Kee Min
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea; (W.C.K.); (C.K.M.); (E.S.K.)
| | - Eun Seog Kim
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea; (W.C.K.); (C.K.M.); (E.S.K.)
| | - In Young Jo
- Department of Radiation Oncology, Soonchunhyang University Cheonan Hospital, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea; (W.C.K.); (C.K.M.); (E.S.K.)
- Correspondence: ; Tel.: +82-41-570-3557
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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11
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Joo JH, Ki Y, Kim W, Nam J, Kim D, Park J, Kim HY, Jung YJ, Choo KS, Nam KJ, Nam SB. Pattern of local recurrence after mastectomy and reconstruction in breast cancer patients: a systematic review. Gland Surg 2021; 10:2037-2046. [PMID: 34268088 DOI: 10.21037/gs-21-15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 05/14/2021] [Indexed: 12/24/2022]
Abstract
Background This study aimed to describe the locations of local recurrences based on the mastectomy and reconstruction type in breast cancer patients. Methods In November 2020, a systematic literature review was performed through MEDLINE/PubMed and the Cochrane Centre Register of Controlled Trials. Publications that included skin-sparing or nipple-sparing mastectomy followed by breast reconstruction and described the location of local recurrences were analyzed. Exclusion criteria included salvage or prophylactic mastectomy, unclear distinction between local and regional recurrences, rare tumor types. Results From 19 publications, 272 local recurrences lesions were reported in a total of 4,787 patients. After autologous reconstruction (n=2,465), local recurrences were located in the skin in 45 (1.8%) patients, in the chest wall in 18 (0.7%), and in the nipple-areolar complex in 9 (0.4%). After implant reconstruction (n=1,917), local recurrences sites included the skin in 91 (4.7%) patients, chest wall in 8 (0.4%), and nipple-areolar complex in 8 (0.4%). Of the 70 lesions with reported in-breast location, 57 (81.4%) relapsed in the original tumor location. Discussion Although meta-analysis was not conducted, present analysis demonstrated that most local recurrences after skin-sparing or nipple-sparing mastectomy occurred within the skin or subcutaneous tissues. It was found that the original tumor location was the most frequent site of relapse. Therefore, special attention should be paid to the original tumor overlying the skin while planning postmastectomy radiation therapy.
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Affiliation(s)
- Ji Hyeon Joo
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yongkan Ki
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, Korea
| | - Wontaek Kim
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, Korea
| | - Jiho Nam
- Department of Radiation Oncology, Pusan National University Hospital, Busan, Korea
| | - Donghyun Kim
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, Korea
| | - Jongmoo Park
- Department of Radiation Oncology, Kyungbook National University Chilgok Hospital, Daegu, Korea
| | - Hyun Yul Kim
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Youn Joo Jung
- Department of Surgery, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Ki Seok Choo
- Department of Radiology, Pusan National University School of Medicine, Yangsan, Korea
| | - Kyung Jin Nam
- Department of Radiology, Pusan National University School of Medicine, Yangsan, Korea
| | - Su Bong Nam
- Department of Plastic and Reconstructive Surgery, Pusan National University School of Medicine, Yangsan, Korea
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12
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Lao N, Brackstone M, Formenti SC, Doherty C, Perera F, Chow R, DeLyzer T, Grant A, Boldt G, Lock M. Redefining postmastectomy radiation contouring in the era of immediate breast reconstruction: An accurate assessment of local recurrence risk. Clin Transl Radiat Oncol 2021; 29:33-39. [PMID: 34113723 PMCID: PMC8170417 DOI: 10.1016/j.ctro.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 04/12/2021] [Accepted: 05/01/2021] [Indexed: 11/28/2022] Open
Abstract
Breast cancer recurrences deep to pectoralis are very rare after mastectomy. Post-mastectomy chest wall radiation should exclude deep chest wall structures. Radiation after immediate implant reconstruction increases complications. Post-mastectomy radiation should target subcutaneous tissues and pectoralis major.
Introduction Most studies report post-mastectomy local recurrences as chest wall recurrences without clarifying whether the recurrence is in the subcutaneous tissue, muscle or underlying rib. Post-mastectomy chest wall radiation is recommended in patients at increased risk of locoregional recurrence. Chest wall radiation-related fibrosis has become an important clinical consideration in the era of immediate implant-based breast reconstruction. In patients with commonly performed subpectoral implant-based reconstruction, the pectoralis major becomes relocated anterior to the implant and just deep to skin, therefore raising the question of value in radiating deep chest wall structures. This study assessed the rate of recurrence in each anatomical region of chest wall in post-mastectomy patients. Methods A comprehensive breast cancer database of 4287 patients at a single regional cancer center from 2006 to 2018 was retrospectively analyzed to identify 1571 mastectomy patients. Recurrences were classified as local skin/subcutaneous, pectoralis muscle (pectoralis major), deep chest wall (pectoralis minor, intercostal muscle or rib) or regional axillary recurrence. Results A total of 26 patients with locoregional recurrence were identified. Most recurrences were in the skin/subcutaneous level. Of 1571 mastectomy patients, only one patient developed a local recurrence posterior to pectoralis major. Our literature search and meta-analysis revealed that local recurrences post-mastectomy are much more likely to be in subcutaneous tissues/pectoralis major versus deeper chest wall. Conclusion A reduced clinical target volume which encompasses skin/subcutaneous and pectoralis muscle layers without treating deep chest wall may be more appropriate to reduce radiation-associated toxicity since avoiding circumferential radiation of an implant may prevent capsular contracture without compromising treatment benefit.
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Affiliation(s)
- Nicholas Lao
- Dept. Oncology, London Regional Cancer Program, London, ON, Canada
| | - Muriel Brackstone
- Dept. Oncology, London Regional Cancer Program, London, ON, Canada.,Div General Surgery, London Health Sciences Centre, London, ON, Canada
| | | | - Christopher Doherty
- Div Plastic & Reconstructive Surgery, Vancouver General Hospital, Vancouver, BC, Canada
| | - Francisco Perera
- Dept. Oncology, London Regional Cancer Program, London, ON, Canada
| | - Ronald Chow
- Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Tanya DeLyzer
- Div Plastic & Reconstructive Surgery, London Health Sciences Centre, London, ON, Canada
| | - Aaron Grant
- Div Plastic & Reconstructive Surgery, London Health Sciences Centre, London, ON, Canada
| | - Gabriel Boldt
- Dept. Oncology, London Regional Cancer Program, London, ON, Canada
| | - Michael Lock
- Dept. Oncology, London Regional Cancer Program, London, ON, Canada
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13
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Should we worry about residual disease after mastectomy? Lancet Oncol 2020; 21:1011-1013. [DOI: 10.1016/s1470-2045(20)30331-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/01/2020] [Indexed: 01/03/2023]
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14
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Wang LW, Li L, Zhang HY, Chen YY, Zhong YH. Patterns of Chest Wall Recurrence and Suggestions on the Clinical Target Volume of Breast Cancer: A Retrospective Analysis of 121 Postmastectomy Patients. Cancer Manag Res 2020; 12:5909-5918. [PMID: 32765092 PMCID: PMC7381817 DOI: 10.2147/cmar.s250789] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/05/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose Radiotherapy is a powerful strategy to prevent chest wall recurrence (CWR) of postmastectomy breast cancer (BC). This retrospective study aims at analyzing patterns of CWR to explore the delineation of clinical target volume. Patients and Methods Detailed clinicopathological information of postmastectomy BC patients with CWR was collected from our single cancer center based on clear criteria. To describe recurrent positions more accurately, the chest wall was divided into three layers: skin layer (skin and subcutaneous tissues), pectoralis layer (pectoralis major and minor), and rib layer (rib and intercostal muscle). The frequency distribution of recurrence location and its association with clinical pathological factors were analyzed. Results A total of 121 postmastectomy BC with CWR were included in this study. The percentages of breast tumor located in the upper outer quadrant, upper inner quadrant, lower inner quadrant, lower outer quadrant, overlapping quadrant, and areola area were 31.0% (35/113), 26.5% (30/113), 12.4% (14/113), 5.3% (6/113), 21.1% (25/113), and 2.7% (3/113), respectively. HER2-positive BC (51/113, 45.1%) is the most common BC subtype. Analysis on the patterns of CWR showed that recurrences locating in the skin layer, pectoralis layer, rib layer, mixed layers, and incision periphery accounted for 58.6% (68/116), 9.5% (11/116), 1.7% (2/116), 30.2% (35/116), and 60.5% (46/76), respectively. Rates of recurrences located in the skin and/or pectoralis layers for all BC patients, patients with concomitant distance metastasis, and patients without concomitant distance metastasis were 82.8% (96/116), 85.9% (49/57), and 81.0% (47/58), respectively. Conclusion For BC patients receiving mastectomy, skin, subcutaneous tissues, pectoralis, and area around incision have a high risk of recurrence, which should be paid more attention in chest wall radiotherapy.
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Affiliation(s)
- Lin-Wei Wang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, People's Republic of China
| | - Li Li
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, People's Republic of China
| | - Hong-Yan Zhang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, People's Republic of China
| | - Yuan-Yuan Chen
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, People's Republic of China
| | - Ya-Hua Zhong
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Wuhan, People's Republic of China
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15
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Spatial location of local recurrences after mastectomy: a systematic review. Breast Cancer Res Treat 2020; 183:263-273. [PMID: 32661665 DOI: 10.1007/s10549-020-05774-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/25/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE We performed a systematic review to document the spatial location of local recurrences (LR) after mastectomy. METHODS A PubMed search was conducted in August 2019 for the following terms: breast [Title/Abstract] AND cancer [Title/Abstract] AND recurrence [Title/Abstract] AND mastectomy [Title/Abstract]. The search was filtered for English language. Exclusion criteria included studies that did not specify the LR location or studies reporting LR associated with inflammatory breast cancer, or other breast cancers such as phyllodes tumours, lymphoma or associated with sarcoma/angiosarcoma. RESULTS A total of 3922 titles were identified, of which 21 publications were eligible for inclusion in the final analysis. A total of 6901 mastectomy patients were included (range 25-1694). The mean LR proportion was 3.5%. Among the total of 351 LR lesions, 81.8% were in the subcutaneous tissue and the skin, while 16% were pectoral muscle recurrences. CONCLUSION Local recurrences are mostly located within the subcutaneous tissue and the skin, assumed to result from unrecognized/subclinical tumour foci left behind after mastectomy, surgical implantation of tumour cells in the wound/scar and/or tumour emboli within the subcutaneous lymphatics. Pectoral muscle recurrences are less frequent and may be attributed to residual disease along the posterior surgical margin and/or lymphatic involvement.
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16
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Poortmans PMP, Takanen S, Marta GN, Meattini I, Kaidar-Person O. Winter is over: The use of Artificial Intelligence to individualise radiation therapy for breast cancer. Breast 2020; 49:194-200. [PMID: 31931265 PMCID: PMC7375562 DOI: 10.1016/j.breast.2019.11.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 11/16/2019] [Accepted: 11/20/2019] [Indexed: 01/08/2023] Open
Abstract
Artificial intelligence demonstrated its value for automated contouring of organs at risk and target volumes as well as for auto-planning of radiation dose distributions in terms of saving time, increasing consistency, and improving dose-volumes parameters. Future developments include incorporating dose/outcome data to optimise dose distributions with optimal coverage of the high-risk areas, while at the same time limiting doses to low-risk areas. An infinite gradient of volumes and doses to deliver spatially-adjusted radiation can be generated, allowing to avoid unnecessary radiation to organs at risk. Therefore, data about patient-, tumour-, and treatment-related factors have to be combined with dose distributions and outcome-containing databases.
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Affiliation(s)
| | - Silvia Takanen
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Gustavo Nader Marta
- Department of Radiation Oncology - Hospital Sírio-Libanês, Brazil; Department of Radiology and Oncology - Radiation Oncology, Instituto Do Câncer Do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Orit Kaidar-Person
- Radiation Oncology Unit, Breast Radiation Unit, Sheba Tel Ha'shomer, Ramat Gan, Israel
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17
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Mutter RW, Jethwa KR, Wan Chan Tseung HS, Wick SM, Kahila MMH, Viehman JK, Shumway DA, Corbin KS, Park SS, Remmes NB, Whitaker TJ, Beltran CJ. Incorporation of Biologic Response Variance Modeling Into the Clinic: Limiting Risk of Brachial Plexopathy and Other Late Effects of Breast Cancer Proton Beam Therapy. Pract Radiat Oncol 2019; 10:e71-e81. [PMID: 31494289 PMCID: PMC7734652 DOI: 10.1016/j.prro.2019.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/30/2019] [Accepted: 08/29/2019] [Indexed: 12/25/2022]
Abstract
Purpose: The relative biologic effectiveness (RBE) rises with increasing linear energy transfer toward the end of proton tracks. Presently, there is no consensus on how RBE heterogeneity should be accounted for in breast cancer proton therapy treatment planning. Our purpose was to determine the dosimetric consequences of incorporating a brachial plexus (BP) biologic dose constraint and to describe other clinical implications of biologic planning. Methods and Materials: We instituted a biologic dose constraint for the BP in the context of MC1631, a randomized trial of conventional versus hypofractionated postmastectomy intensity modulated proton therapy (IMPT). IMPT plans of 13 patients treated before the implementation of the biologic dose constraint (cohort A) were compared with IMPT plans of 38 patients treated on MC1631 after its implementation (cohort B) using (1) a commercially available Eclipse treatment planning system (RBE = 1.1); (2) an in-house graphic processor unit-based Monte Carlo physical dose simulation (RBE = 1.1); and (3) an in-house Monte Carlo biologic dose (MCBD) simulation that assumes a linear relationship between RBE and dose-averaged linear energy transfer (product of RBE and physical dose = biologic dose). Results: Before implementation of a BP biologic dose constraint, the Eclipse mean BP D0.01 cm3 was 107%, and the MCBD estimate was 128% (ie, 64 Gy [RBE = biologic dose] in 25 fractions for a 50-Gy [RBE = 1.1] prescription), compared with 100.0% and 116.0%, respectively, after the implementation of the constraint. Implementation of the BP biologic dose constraint did not significantly affect clinical target volume coverage. MCBD plans predicted greater internal mammary node coverage and higher heart dose than Eclipse plans. Conclusions: Institution of a BP biologic dose constraint may reduce brachial plexopathy risk without compromising target coverage. MCBD plan evaluation provides valuable information to physicians that may assist in making clinical judgments regarding relative priority of target coverage versus normal tissue sparing.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Stephanie M Wick
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Jason K Viehman
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - Chris J Beltran
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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18
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Radiotherapy after skin-sparing mastectomy with immediate breast reconstruction in intermediate-risk breast cancer. Strahlenther Onkol 2019; 195:949-963. [DOI: 10.1007/s00066-019-01507-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
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19
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Mutter RW. ESTRO ACROP consensus guideline for target volume delineation in the setting of postmastectomy radiation therapy after implant-based immediate reconstruction for early stage breast cancer. Radiother Oncol 2019; 141:329-330. [PMID: 31451284 DOI: 10.1016/j.radonc.2019.07.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/01/2019] [Accepted: 07/12/2019] [Indexed: 11/25/2022]
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20
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Kaidar-Person O, Vrou Offersen B, Hol S, Arenas M, Aristei C, Bourgier C, Cardoso MJ, Chua B, Coles CE, Engberg Damsgaard T, Gabrys D, Jagsi R, Jimenez R, Kirby AM, Kirkove C, Kirova Y, Kouloulias V, Marinko T, Meattini I, Mjaaland I, Nader Marta G, Witt Nystrom P, Senkus E, Skyttä T, Tvedskov TF, Verhoeven K, Poortmans P. ESTRO ACROP consensus guideline for target volume delineation in the setting of postmastectomy radiation therapy after implant-based immediate reconstruction for early stage breast cancer. Radiother Oncol 2019; 137:159-166. [PMID: 31108277 DOI: 10.1016/j.radonc.2019.04.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/04/2019] [Indexed: 02/07/2023]
Abstract
Immediate breast reconstruction (IBR) rates after mastectomy are increasing. Postmastectomy radiation therapy (PMRT) contouring guidelines for target volumes in the setting of IBR are lacking. Therefore, many patients who have had IBR receive PMRT to target volumes similar to conventional simulator-based whole breast irradiation. The aim of this paper is to describe delineation guidelines for PMRT after implant-based IBR based on a thorough understanding of the surgical procedures, disease stage, patterns of recurrence and radiation techniques. They are based on a consensus endorsed by a global multidisciplinary group of breast cancer experts.
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Affiliation(s)
- Orit Kaidar-Person
- Oncology Institute, Radiation Oncology Unit, Rambam Medical Center, Haifa, Israel.
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Department of Oncology, Aarhus University Hospital, Denmark
| | - Sandra Hol
- Department of Radiation Oncology, Institute Verbeeten, Tilburg, the Netherlands
| | - Meritxell Arenas
- Department of Radiation Oncology, Hospital Universitari Sant Joan de Reus, University Rovira i Virgili, Spain
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Science, University of Perugia and Perugia General Hospital, Italy
| | - Celine Bourgier
- Department of Radiation Oncology, ICM - Val d'Aurelle, INSERM U1194, IRCM; Montpellier University, Montpellier, France
| | - Maria Joao Cardoso
- Breast Unit, Champalimaud Foundation, and Nova Medical School, Lisbon, Portugal
| | - Boon Chua
- Faculty of Medicine, The University of New South Wales, UNSW Sydney, NSW, Australia
| | | | | | - Dorota Gabrys
- Department of Radiation Oncology, Maria Sklodowska Curie Memorial Cancer Centre, Gliwice, Poland
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, USA
| | - Rachel Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, USA
| | - Anna M Kirby
- Department of Radiotherapy, Royal Marsden NHS Foundation Trust and Institute of Cancer Research, Sutton, UK
| | - Carine Kirkove
- Department of Radiation Oncology, University Hospital St-Luc, Brussels, Belgium
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Vassilis Kouloulias
- National and Kapodistrian University of Athens, Medical School, 2nd Dpt of Radiology, Radiotherapy Unit, Athens, Greece
| | - Tanja Marinko
- Department of Radiation Oncology, Institute of Oncology Ljubljana, Slovenia
| | - Icro Meattini
- Department of Biomedical, Experimental, and Clinical Sciences, University of Florence, Italy, Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ingvil Mjaaland
- Department of Oncology & Radiotherapy, Stavanger University Hospital, Norway
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, São Paulo, Brazil; Department of Radiology and Oncology, Division of Radiation Oncology, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo, Brazil
| | - Petra Witt Nystrom
- The Skandion Clinic, Uppsala, Sweden and Danish Center for Particle Therapy, Aarhus, Denmark
| | - Elzbieta Senkus
- Department of Oncology & Radiotherapy, Medical University of Gdańsk, Poland
| | - Tanja Skyttä
- Department of Oncology, Tampere University Hospital, Finland
| | - Tove F Tvedskov
- Dept. of Breast Surgery, Herlev Hospital, Copenhagen, Denmark
| | - Karolien Verhoeven
- GROW School for Oncology and Developmental Biology, Department of Radiation Oncology, Maastricht University Medical Centre, Netherlands
| | - Philip Poortmans
- Department of Radiation Oncology, Institut Curie, and Paris Sciences & Lettres University, Paris, France
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21
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Smith NL, Jethwa KR, Viehman JK, Harmsen WS, Gonuguntla K, Elswick SM, Grauberger JN, Amundson AC, Whitaker TJ, Remmes NB, Harless CA, Boughey JC, Nguyen MDT, Park SS, Corbin KS, Mutter RW. Post-mastectomy intensity modulated proton therapy after immediate breast reconstruction: Initial report of reconstruction outcomes and predictors of complications. Radiother Oncol 2019; 140:76-83. [PMID: 31185327 DOI: 10.1016/j.radonc.2019.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE To report reconstructive outcomes of patients treated with post-mastectomy intensity modulated proton therapy (IMPT) following immediate breast reconstruction (IBR). MATERIALS AND METHODS Consecutive women with breast cancer who underwent implant-based IBR and post-mastectomy IMPT were included. Clinical characteristics, dosimetry, and acute toxicity were collected prospectively and reconstruction complications retrospectively. RESULTS Fifty-one women were treated between 2015 and 2017. Forty-two had bilateral reconstruction with unilateral IMPT. The non-irradiated contralateral breasts served as controls. Conventional fractionation (median 50 Gy/25 fractions) was administered in 37 (73%) and hypofractionation (median 40.5 Gy/15 fractions) in 14 (27%) patients. Median mean heart, ipsilateral lung V20Gy, and CTV-IMN V95% were 0.6 Gy, 13.9%, and 97.4%. Maximal acute dermatitis grade was 1 in 32 (63%), 2 in 17 (33%), and 3 in 2 (4%) patients. Surgical site infection (hazard ratio [HR] 13.19, 95% confidence interval [CI] 1.67-104.03, p = 0.0012), and unplanned surgical intervention (HR 9.86, 95% CI 1.24-78.67, p = 0.0068) were more common in irradiated breasts. Eight of 51 irradiated breasts and 2 of 42 non-irradiated breasts had reconstruction failure (HR 3.59, 95% CI 0.78-16.41, p = 0.084). Among irradiated breasts, hypofractionation was significantly associated with reconstruction failure (HR 4.99, 95% CI 1.24-20.05, p = 0.024), as was older patient age (HR 1.14, 95% CI 1.05-1.24, p = 0.002). CONCLUSIONS IMPT following IBR spared underlying organs and had low rates of acute toxicity. Reconstruction complications are more common in irradiated breasts, and reconstructive outcomes appear comparable with photon literature. Hypofractionation was associated with higher reconstruction failure rates. Further investigation of optimal dose-fractionation after IBR is needed.
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Affiliation(s)
- Na L Smith
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Jason K Viehman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | | | | | | | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | | | | | | | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
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22
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HALFMOON TomoTherapy (Helical ALtered Fractionation for iMplant partial OmissiON): implant-sparing post-mastectomy radiotherapy reshaping the clinical target volume in the reconstructed breast. J Cancer Res Clin Oncol 2019; 145:1887-1896. [PMID: 31144158 DOI: 10.1007/s00432-019-02938-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To report the dosimetric feasibility of the radiation technique HALFMOON (Helical ALtered Fractionation for iMplant partial OmissiON) for post-mastectomy radiation therapy (PMRT) in intermediate-high-risk breast cancer patients with implant-based immediate breast reconstruction, where the clinical target volume (CTV) does not include the whole implant (implant-sparing approach). METHODS In the HALFMOON technique, the CTV consisted of skin, subcutaneous tissues, and pectoralis major muscle, excluding the implant, chest wall muscles, and rib plane. The HALFMOON plans were compared with conventionally contoured CTV plans, in which the whole implant, chest wall muscles, and ribs plane were included in the CTV, in a ratio 1:3. All patients underwent hypofractionated treatment of 40.05 Gy/15 fractions, using helical Tomotherapy®. RESULTS Eighteen patients undergoing HALFMOON technique were compared to 54 subjects treated with conventionally contoured CTV plans. No difference was found in the planning target volume coverage between the two groups. Conversely, a statistically relevant dose reduction in HALFMOON patients was observed for ipsilateral lung (D15%, p < 0.0001; D20%, p < 0.0001; D35%, p = 0.003), contralateral lung (D20%, p = 0.048), contralateral breast (D15%, p = 0.031; D20%, p = 0.047), and stomach (Dmean, p = 0.011). Regarding the implant, V90% and D50% decreased by 46% and 8%, respectively, in the HALFMOON plans (p < 0.0001). CONCLUSION The HALFMOON approach is technically feasible and resulted in high-dose conformity of the target with a significant reduction of radiation dose delivered to implant and other organs. A clinical study is needed to assess the impact on reconstruction cosmetic outcome and local control.
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23
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Gee HE, Moses L, Stuart K, Nahar N, Tiver K, Wang T, Ward R, Ahern V. Contouring consensus guidelines in breast cancer radiotherapy: Comparison and systematic review of patterns of failure. J Med Imaging Radiat Oncol 2018; 63:102-115. [PMID: 30267561 DOI: 10.1111/1754-9485.12804] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 08/16/2018] [Indexed: 11/28/2022]
Abstract
Adequate coverage of sites harbouring potential microscopic disease is paramount, where the clinical decision has been made to include regional lymph node radiotherapy for patients with breast cancer. This must be achieved in balance with minimising dose to normal tissues. Several international consensus guidelines detailing clinical target volumes (CTVs) are available, but there is currently no agreement as to which is most appropriate for a given clinical situation. Contouring guidelines are beneficial for routine practice and essential for clinical trial quality assurance. The aims of this study were as follows: to provide a single point of comparison of four commonly used contouring guidelines, including one used in a current Trans-Tasman Radiation Oncology Group trial; and to undertake a systematic review of existing studies which map sites of breast cancer recurrence against contouring guidelines. Two international consensus guidelines (European Society for Radiotherapy and Oncology, and Radiation Therapy Oncology Group) were compared with two clinical trial guidelines (TROG 12.02 PET LABRADOR and the Proton/Photon trial NCT02603341 RADCOMP). Comprehensive literature search for patterns of failure studies was undertaken using Embase and Pubmed. We detail the small but significant differences between the breast consensus guidelines, particularly the supraclavicular (SCF) and internal mammary chain CTVs. Seven series were found mapping recurrence patterns. These results are discussed in the context of the contouring guidelines. Several studies found the SCF CTV is the area at greatest risk of geographical 'miss'. This review will facilitate further discussion about guideline selection and modification, particularly for future clinical trials in Australia and New Zealand.
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Affiliation(s)
- Harriet E Gee
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, C24 - Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Lauren Moses
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Kirsty Stuart
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, C24 - Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Najmun Nahar
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ken Tiver
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Nepean Cancer Care Centre, Nepean Hospital, New South Wales, Australia
| | - Tim Wang
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, C24 - Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rachel Ward
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Verity Ahern
- Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, C24 - Westmead Hospital, The University of Sydney, Sydney, New South Wales, Australia.,Westmead Breast Cancer Institute, Westmead Hospital, Sydney, New South Wales, Australia
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24
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The Lack of Consensus of International Contouring Guidelines for the Dorsal Border of the Chest Wall Clinical Target Volume: What is the Impact on Organs at Risk and Relationships to Patterns of Recurrence in the Modern Era? Adv Radiat Oncol 2018; 4:35-42. [PMID: 30706008 PMCID: PMC6349659 DOI: 10.1016/j.adro.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/02/2018] [Accepted: 09/19/2018] [Indexed: 01/08/2023] Open
Abstract
Purpose Variation exists in cooperative group recommendations for the dorsal border for the chest wall clinical target volume (CTV). We aimed to quantify the impact of this variation on doses to critical organs and examine patterns of chest wall recurrence relative to the pectoralis muscle. Methods and Materials We retrospectively assessed patterns of chest wall recurrence quantified to the recommended CTV borders for women treated between 2005 and 2017. We compared treatment plans for 5 women who were treated with left postmastectomy radiation therapy, with the chest wall contoured using varying dorsal borders for CTV: (1) Anterior pleural surface (Radiation Therapy Oncology Group), (2) anterior surface of pectoralis major (European Society for Radiotherapy and Oncology), and (3) anterior rib surface (institutional practice). Treatment plans were generated for 50 Gy in 25 fractions. Doses to organs-at-risk were compared using paired-sample t tests. Results Institutional patterns of chest wall recurrence were 64.7% skin and subcutaneous tissue, 23.5% both anterior to and between the pectoralis muscles, and 11.8% isolated to the tissue between the pectoralis major and minor. No chest wall recurrences were noted deep to pectoralis minor. When comparing the plans generated per the Radiation Therapy Oncology Group versus European Society for Radiotherapy and Oncology contouring guidelines, the mean lung V20Gy, heart mean dose, and left anterior descending artery mean dose were 33.5% versus 29.4% (P < .01), 5.2 Gy versus 3.2Gy (P = .02), and 27.3Gy versus 17.8Gy (P = .04), respectively. Conclusions The recommended variations in the dorsal chest wall CTV border have significant impact on doses to the heart and lungs. Although our study was limited by small numbers, our institutional patterns of recurrence would support a more anterior dorsal border for the chest wall CTV consistent with older literature.
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25
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Chhabra A, Schneider C, Chowdhary M, Diwanji TP, Mohindra P, Mishra MV. How Histopathologic Tumor Extent and Patterns of Recurrence Data Inform the Development of Radiation Therapy Treatment Volumes in Solid Malignancies. Semin Radiat Oncol 2018; 28:218-237. [PMID: 29933882 DOI: 10.1016/j.semradonc.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The ability to deliver highly conformal radiation therapy using intensity-modulated radiation therapy and particle therapy provides for new opportunities to improve patient outcomes by reducing treatment-related morbidities following radiation therapy. By reducing the volume of normal tissue exposed to radiation therapy (RT), while also allowing for the opportunity to escalate the dose of RT delivered to the tumor, use of conformal RT delivery should also provide the possibility of expanding the therapeutic index of radiotherapy. However, the ability to safely and confidently deliver conformal RT is largely dependent on our ability to clearly define the clinical target volume for radiation therapy, which requires an in-depth knowledge of histopathologic extent of different tumor types, as well as patterns of recurrence data. In this article, we provide a comprehensive review of the histopathologic and radiographic data that provide the basis for evidence-based guidelines for clinical tumor volume delineation.
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Affiliation(s)
- Arpit Chhabra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Craig Schneider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, IL
| | - Tejan P Diwanji
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD.
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26
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Orecchia R, Rojas DP, Cattani F, Ricotti R, Santoro L, Morra A, Cambria R, Luraschi R, Dicuonzo S, Ronchi S, Surgo A, Dell' Acqua V, Veronesi P, De Lorenzi F, Fodor C, Leonardi MC, Jereczek-Fossa BA. Hypofractionated postmastectomy radiotherapy with helical tomotherapy in patients with immediate breast reconstruction: dosimetric results and acute/intermediate toxicity evaluation. Med Oncol 2018; 35:39. [PMID: 29442173 DOI: 10.1007/s12032-018-1095-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/05/2018] [Indexed: 10/18/2022]
Abstract
The aim of this study was to evaluate the dosimetry and toxicity of hypofractionation in postmastectomy radiotherapy (PMRT) with intensity-modulated radiotherapy (IMRT) in breast cancer (BC) patients. Stage II-III BC patients with implant-based immediate breast reconstruction received PMRT to the chest wall (CW) and to the infra/supraclavicular nodal region (NR) using a 15-fraction schedule (2.67 Gy/fraction) and helical IMRT (Tomotherapy® System, Accuray Incorporated, Sunnyvale, CA). A score was assigned to each treatment plan in terms of planning target volume (PTV) coverage of CW and NR and the sparing of the organs at risk (OARs). The total score for each plan was calculated. Toxicity was prospectively assessed according to validated scales. Data from 120 consecutive patients treated in the period 2012-2015 were analysed with a median follow-up from the end of radiotherapy of 13.2 months (range 0.0-35 months). 70.8% (85/120) of the plans had high total scores as a result of an optimal coverage of both CW and RN and optimal sparing of all OARs. The maximum acute toxicity was of grade 2 in 36.7% of the cases. Early late toxicity was mild in the majority of cases. In the study population, helical tomotherapy-based IMRT produced optimal treatment plans in most cases. Acute and late toxicity was mild/moderate. Hypofractionated helical IMRT appears to be safe and feasible in the moderate term for PMRT.
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Affiliation(s)
- Roberto Orecchia
- Department of Medical Imaging and Radiation Sciences, European Institute of Oncology, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Damaris Patricia Rojas
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy.,Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Rosalinda Ricotti
- Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Luigi Santoro
- Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Raffaella Cambria
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Rosa Luraschi
- Unit of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Samantha Dicuonzo
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy.,Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Sara Ronchi
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy.,Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Alessia Surgo
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy.,Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Veronica Dell' Acqua
- Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
| | - Maria Cristina Leonardi
- Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy.
| | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy.,Division of Radiation Oncology, European Institute of Oncology, Via Ripamonti 435, 20141, Milan, Italy
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27
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Electron postmastectomy chest wall plus comprehensive nodal irradiation technique using Electron Monte Carlo dose algorithm. Med Dosim 2018; 43:230-236. [DOI: 10.1016/j.meddos.2017.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/25/2017] [Accepted: 08/28/2017] [Indexed: 11/22/2022]
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28
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Chang JS, Lee J, Chun M, Shin KH, Park W, Lee JH, Kim JH, Yoon WS, Lee IJ, Kim J, Park HL, Kim YB. Mapping patterns of locoregional recurrence following contemporary treatment with radiation therapy for breast cancer: A multi-institutional validation study of the ESTRO consensus guideline on clinical target volume. Radiother Oncol 2017; 126:139-147. [PMID: 29050960 DOI: 10.1016/j.radonc.2017.09.031] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/13/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE To validate the ESTRO guideline on clinical target volume (CTV) delineation for breast cancer using a multi-centre dataset. MATERIALS AND METHODS Patients with axial imaging of gross locoregional recurrence (LRR) were identified from 10 participating institutions. All patients received RT, albeit not to all regional node. The location of LRR was transferred to the corresponding area on representative axial computed tomography images and compared with ESTRO-CTV. RESULTS The locations of LRRs in 234 patients with 337 recurrence lesions were mapped. The ESTRO-CTV encompassed 97.6% of all LRRs, except in lymph node level 4 and the pectoralis muscle. Although 8.8% of level 4 failures occurred outside the ESTRO-CTV, cranial to the subclavian artery, all nodes were located within 6 mm cranially. Another 20% occurred posterolateral to anterior scalene muscles; however, 11/16 cases had simultaneous multiple lymph node recurrences, and 8/16 initially had N2-3 tumours. Local recurrence at the pectoralis muscle was prominent in patients undergoing mastectomy but not breast-conservation surgery (28% vs. 2.9%, P = .001). CONCLUSIONS Our mapping data demonstrated that the ESTRO-CTV, with some considerations, successfully encompassed most LRRs in patients undergoing contemporary management, thus validating ESTRO-CTV to be valuable for highly conformal radiation therapy techniques.
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Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jeongshim Lee
- Department of Radiation Oncology, Inha University Hospital, Incheon, Republic of Korea
| | - Mison Chun
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong Hoon Lee
- Department of Radiation Oncology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Won Sup Yoon
- Department of Radiation Oncology, Ansan Hospital, Korea University Medical Center, Ansan, Republic of Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Juree Kim
- Department of Radiation Oncology, Cheil General Hospital, Dankook University College of Medicine, Seoul, Republic of Korea
| | - Hye Li Park
- Department of Radiation Oncology, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
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29
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Chang JS, Byun HK, Kim YB. Reply to the Letter to the Editor by Vargo et al. Radiother Oncol 2017; 123:485. [PMID: 28554499 DOI: 10.1016/j.radonc.2017.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/04/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
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30
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Vargo JA, Beriwal S. In reply to Chang et al.: Contouring guidelines for post-mastectomy radiotherapy a cry for international consensus. Radiother Oncol 2017; 123:483-484. [PMID: 28528018 DOI: 10.1016/j.radonc.2017.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 05/01/2017] [Indexed: 10/19/2022]
Affiliation(s)
- John A Vargo
- West Virginia University, Department of Radiation Oncology, Morgantown, USA.
| | - Sushil Beriwal
- Unversity of Pittsburgh, Department of Radiation Oncology, USA
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Chang JS, Byun HK, Kim JW, Kim KH, Lee J, Cho Y, Lee IJ, Keum KC, Suh CO, Kim YB. Three-dimensional analysis of patterns of locoregional recurrence after treatment in breast cancer patients: Validation of the ESTRO consensus guideline on target volume. Radiother Oncol 2017; 122:24-29. [DOI: 10.1016/j.radonc.2016.10.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/04/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
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32
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Loveland-Jones C, Lin H, Shen Y, Bedrosian I, Shaitelman S, Kuerer H, Woodward W, Ueno N, Valero V, Babiera G. Disparities in the Use of Postmastectomy Radiation Therapy for Inflammatory Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 95:1218-25. [PMID: 27209502 DOI: 10.1016/j.ijrobp.2016.02.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/22/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Although radiation therapy improves locoregional control and survival for inflammatory breast cancer (IBC), it is underused in this population. The purpose of this study was to identify variables associated with the underuse of postmastectomy radiation therapy (PMRT) for IBC. METHODS AND MATERIALS Using the 1998 to 2011 National Cancer Data Base, we identified 8273 women who underwent mastectomy for nonmetastatic IBC. We used logistic regression modeling to determine the demographic, tumor, and treatment variables associated with the underuse of PMRT. RESULTS Although the use of PMRT increased over time, a total of 30.3% of our cohort did not receive PMRT. On multivariate analysis, variables associated with the underuse of PMRT for IBC included the following (all P<.05): Medicare insurance (odds ratio [OR] = 0.70), annual income <$34,999 (<$30,000: OR=0.79; $30,000-$34,999: OR=0.82), cN2 and cN0 disease (cN2: OR=0.71; cN0: OR=0.63), failure to receive chemotherapy and hormone therapy (chemotherapy: OR=0.15; hormone therapy: OR=0.35), treatment at lower-volume centers (OR=0.83), and treatment in the South and West (South: OR=0.73; West: OR=0.80). Greater distance between patient's residence and radiation facility was also associated with the underuse of PMRT (P=.0001). CONCLUSIONS Although the use of PMRT for IBC has increased over time, it continues to be underused. Disparities related to a variety of variables impact which IBC patients receive PMRT. A concerted effort must be made to address these disparities in order to optimize the outcomes for IBC.
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Affiliation(s)
| | - Heather Lin
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Yu Shen
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | | | | | - Henry Kuerer
- University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Wendy Woodward
- University of Texas, MD Anderson Cancer Center, Houston, Texas; MD Anderson Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, Texas
| | - Naoto Ueno
- University of Texas, MD Anderson Cancer Center, Houston, Texas; MD Anderson Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, Texas
| | - Vicente Valero
- University of Texas, MD Anderson Cancer Center, Houston, Texas; MD Anderson Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, Texas
| | - Gildy Babiera
- University of Texas, MD Anderson Cancer Center, Houston, Texas; MD Anderson Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, Houston, Texas.
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33
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White J. Defining Target Volumes in Breast Cancer Radiation Therapy for the Future: Back to Basics. Int J Radiat Oncol Biol Phys 2015; 93:277-80. [DOI: 10.1016/j.ijrobp.2015.06.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 06/16/2015] [Indexed: 11/25/2022]
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