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Gallant F, Jagsi R. Deep Inspiration Breath Hold for Cardiac Sparing: No Deep Pockets Required. JACC CardioOncol 2024; 6:526-528. [PMID: 39239336 PMCID: PMC11372024 DOI: 10.1016/j.jaccao.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2024] Open
Affiliation(s)
- Fleure Gallant
- Department of Radiation Oncology, Maimonides Medical Center, Brooklyn, New York, USA
- Department of Radiation Oncology, State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Reshma Jagsi
- Department of Radiation Oncology, Emory University, Atlanta, Georgia, USA
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2
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Washington I, Palm RF, White J, Rosenberg SA, Ataya D. The Role of MRI in Breast Cancer and Breast Conservation Therapy. Cancers (Basel) 2024; 16:2122. [PMID: 38893241 PMCID: PMC11171236 DOI: 10.3390/cancers16112122] [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: 04/22/2024] [Revised: 05/19/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Contrast-enhanced breast MRI has an established role in aiding in the detection, evaluation, and management of breast cancer. This article discusses MRI sequences, the clinical utility of MRI, and how MRI has been evaluated for use in breast radiotherapy treatment planning. We highlight the contribution of MRI in the decision-making regarding selecting appropriate candidates for breast conservation therapy and review the emerging role of MRI-guided breast radiotherapy.
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Affiliation(s)
- Iman Washington
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Russell F. Palm
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Julia White
- Department of Radiation Oncology, The University of Kansas Medical Center, 4001 Rainbow Blvd, Kansas City, KS 66160, USA;
| | - Stephen A. Rosenberg
- Department of Radiation Therapy, H. Lee Moffitt Cancer Center & Research Institute, 12902 USF Magnolia Drive, Tampa, FL 33612, USA;
| | - Dana Ataya
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, 10920 N. McKinley Drive, Tampa, FL 33612, USA;
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3
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Berlin E, Yegya-Raman N, Hollawell C, Haertter A, Fosnot J, Rhodes S, Seol SW, Gentile M, Li T, Freedman GM, Taunk NK. Breast Reconstruction Complications After Postmastectomy Proton Radiation Therapy for Breast Cancer. Adv Radiat Oncol 2024; 9:101385. [PMID: 38495035 PMCID: PMC10943514 DOI: 10.1016/j.adro.2023.101385] [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: 05/08/2023] [Accepted: 10/03/2023] [Indexed: 03/19/2024] Open
Abstract
Purpose Our purpose was to report complications requiring surgical intervention among patients treated with postmastectomy proton radiation therapy (PMPRT) for breast cancer in the setting of breast reconstruction (BR). Methods and Materials Patients enrolled on a prospective proton registry who underwent BR with immediate autologous flap, tissue expander (TE), or implant in place during PMPRT (50/50.4 Gy +/- chest wall boost) were eligible. Major reconstruction complication (MRC) was defined as a complication requiring surgical intervention. Absolute reconstruction failure was an MRC requiring surgical removal of BR. A routine revision (RR) was a plastic surgery refining cosmesis of the BR. Kaplan-Meier method was used to assess disease outcomes and MRC. Cox regression was used to assess predictors of MRC. Results Seventy-three courses of PMPRT were delivered to 68 women with BR between 2013 and 2021. Median follow-up was 42.1 months. Median age was 47 years. Fifty-six (76.7%) courses used pencil beam scanning PMPRT. Of 73 BR, 29 were flaps (39.7%), 30 implants (41.1%), and 14 TE (19.2%) at time of irradiation. There were 20 (27.4%) RR. There were 9 (12.3%) MRC among 5 implants, 2 flaps, and 2 TE, occurring a median of 29 months from PMPRT start. Three-year freedom from MRC was 86.9%. Three (4.1%) of the MRC were absolute reconstruction failure. Complications leading to MRC included capsular contracture in 5, fat necrosis in 2, and infection in 2. On univariable analysis, BR type, boost, proton technique, age, and smoking status were not associated with MRC, whereas higher body mass index trended toward significance (hazard ratio, 1.07; 95% CI, 0.99-1.16; P = .10). Conclusions Patients undergoing PMPRT to BR had a 12.3% incidence of major complications leading to surgical intervention, and total loss of BR was rare. MRC rates were similar among reconstruction types. Minor surgery for RR is common in our practice.
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Affiliation(s)
| | | | | | | | - Joshua Fosnot
- Division of Plastic Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Herr DJ, Moncion A, Griffith KA, Marsh R, Grubb M, Bhatt A, Dominello M, Walker EM, Narayana V, Abu-Isa E, Vicini FA, Hayman JA, Pierce LJ. Factors Associated With Cardiac Radiation Dose Reduction After Hypofractionated Radiation Therapy for Localized, Left-Sided Breast Cancer in a Large Statewide Quality Consortium. Int J Radiat Oncol Biol Phys 2024; 118:632-638. [PMID: 37797748 DOI: 10.1016/j.ijrobp.2023.09.013] [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: 05/16/2023] [Revised: 08/31/2023] [Accepted: 09/09/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE Limiting cardiac radiation dose is important for minimizing long-term cardiac toxicity in patients with left-sided early-stage breast cancer. METHODS AND MATERIALS Prospectively collected dosimetric data were analyzed for patients undergoing moderately hypofractionated radiation therapy to the left breast within the Michigan Radiation Oncology Quality Consortium from 2016 to 2022. The mean heart dose (MHD) goal was progressively tightened from ≤2 Gy in 2016 to MHD ≤ 1.2 Gy in 2018. In 2021, a planning target volume (PTV) coverage goal was added, and the goal MHD was reduced to ≤1 Gy. Multivariate logistic regression models were developed to assess for covariates associated with meeting the MHD goals in 2016 to 2020 and the combined MHD/PTV coverage goal in 2021 to 2022. RESULTS In total, 4165 patients were analyzed with a median age of 64 years. Overall average cardiac metric compliance was 91.7%. Utilization of motion management increased from 41.8% in 2016 to 2020 to 46.5% in 2021 to 2022. Similarly, use of prone positioning increased from 12.2% to 22.2% in these periods. On multivariate analysis in the 2016 to 2020 cohort, treatment with motion management (odds ratio [OR], 5.20; 95% CI, 3.59-7.54; P < .0001) or prone positioning (OR, 3.21; 95% CI, 1.85-5.57; P < .0001) was associated with meeting the MHD goal, while receipt of boost (OR, 0.25; 95% CI, 0.17-0.39; P < .0001) and omission of hormone therapy (OR, 0.65; 95% CI, 0.49-0.88; P = .0047) were associated with not meeting the MHD goal. From 2021 to 2022, treatment with motion management (OR, 1.89; 95% CI, 1.12-3.21; P = .018) or prone positioning (OR, 3.71; 95% CI, 1.73-7.95; P = .0008) was associated with meeting the combined MHD/PTV goal, while larger breast volume (≥1440 cc; OR, 0.34; 95% CI, 0.13-0.91; P = .031) was associated with not meeting the combined goal. CONCLUSIONS In our statewide consortium, high rates of compliance with aggressive targets for limiting cardiac dose were achievable without sacrificing target coverage.
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Affiliation(s)
| | | | - Kent A Griffith
- School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | | | - Amit Bhatt
- Department of Radiation Oncology, Karmanos Cancer Institute at McLaren Greater Lansing, Lansing, Michigan
| | - Michael Dominello
- Department of Radiation Oncology, Karmanos Cancer Institute, Detroit, Michigan
| | - Eleanor M Walker
- Department of Radiation Oncology, Henry Ford Cancer Institute, Detroit, Michigan
| | - Vrinda Narayana
- Department of Radiation Oncology, Ascension Providence Hospital, Southfield, Michigan
| | - Eyad Abu-Isa
- Department of Radiation Oncology, Ascension Providence Hospital, Southfield, Michigan
| | - Frank A Vicini
- MHP Radiation Oncology Institute/GenesisCare USA, Farmington Hills, Michigan
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5
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Alaimo R, Ippolito E, Falconi R, Perrone Congedi F, Sciommari C, Silipigni S, Pellegrini R, Carnevale A, Greco C, Fiore M, D’Angelillo RM, Ramella S. Breast Volume Is a Predictor of Higher Heart Dose in Whole-Breast Supine Free-Breathing Volumetric-Modulated Arc Therapy Planning. Curr Oncol 2023; 30:10530-10538. [PMID: 38132402 PMCID: PMC10742666 DOI: 10.3390/curroncol30120768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 11/23/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
In breast cancer volumetric-modulated arc therapy (VMAT) planning, the rotation of the gantry around the target implies a greater dose spreading to the whole heart, compared to tangential-field standard treatment. A consecutive cohort of 121 breast cancer patients treated with the VMAT technique was investigated. The correlation of breast volume, heart volume and lung volume with mean heart dose (mHD) and mean and maximum LAD dose (mLAD dose, MLAD dose) was tested, and a subsequent a linear regression analysis was carried out. VMAT treatment plans from 56 left breast cancer and 65 right breast cancer patients were analyzed. For right-sided patients, breast volume was significantly correlated with mHD, mLAD and MLAD dose, while for left-sided patients, breast volume was significantly correlated with mHD and mLAD, while heart volume and lung volume were correlated with mHD, mLAD and MLAD dose. Breast volume was the only predictor of increased heart and LAD dose (p ≤ 0.001) for right-sided patients. In left-sided patients, heart and lung were also predictors of increased mHD (p = 0.005, p ≤ 0.001) and mean LAD dose (p = 0.009, p ≤ 0.001). In this study, we observed an increase in heart and LAD doses in larger-breasted patients treated with VMAT planning. In right-sided patients, breast volume was shown to be the only predictor of increased heart dose and LAD dose.
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Affiliation(s)
- Rita Alaimo
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
| | - Edy Ippolito
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
- Department of Radiation Oncology (Medicine and Surgery), Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rita Falconi
- Medical Physics Unit, S. Filippo Neri Hospital, ASL Roma 1, 00135 Rome, Italy;
| | - Francesca Perrone Congedi
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
| | - Cecilia Sciommari
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
| | - Sonia Silipigni
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
| | | | - Alessia Carnevale
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
| | - Carlo Greco
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
- Department of Radiation Oncology (Medicine and Surgery), Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Michele Fiore
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
- Department of Radiation Oncology (Medicine and Surgery), Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | | | - Sara Ramella
- Radiation Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Rome, Italy; (R.A.); (F.P.C.); (C.S.); (S.S.); (A.C.); (C.G.); (M.F.); (S.R.)
- Department of Radiation Oncology (Medicine and Surgery), Università Campus Bio-Medico di Roma, 00128 Rome, Italy
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6
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Watt GP, Smith SA, Howell RM, Pérez-Andújar A, Reiner AS, Cerviño L, McCormick B, Hess D, Knight JA, Malone KE, John EM, Bernstein L, Lynch CF, Mellemkjær L, Shore RE, Liang X, Woods M, Boice JD, Dauer LT, Bernstein JL. Trends in Radiation Dose to the Contralateral Breast During Breast Cancer Radiation Therapy. Radiat Res 2023; 200:331-339. [PMID: 37590492 PMCID: PMC10684055 DOI: 10.1667/rade-23-00014.1] [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: 01/27/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023]
Abstract
Over 4 million survivors of breast cancer live in the United States, 35% of whom were treated before 2009. Approximately half of patients with breast cancer receive radiation therapy, which exposes the untreated contralateral breast to radiation and increases the risk of a subsequent contralateral breast cancer (CBC). Radiation oncology has strived to reduce unwanted radiation dose, but it is unknown whether a corresponding decline in actual dose received to the untreated contralateral breast has occurred. The purpose of this study was to evaluate trends in unwanted contralateral breast radiation dose to inform risk assessment of second primary cancer in the contralateral breast for long-term survivors of breast cancer. Individually estimated radiation absorbed doses to the four quadrants and areola central area of the contralateral breast were estimated for 2,132 women treated with radiation therapy for local/regional breast cancers at age <55 years diagnosed between 1985 and 2008. The two inner quadrant doses and two outer quadrant doses were averaged. Trends in dose to each of the three areas of the contralateral breast were evaluated in multivariable models. The population impact of reducing contralateral breast dose on the incidence of radiation-associated CBC was assessed by estimating population attributable risk fraction (PAR) in a multivariable model. The median dose to the inner quadrants of the contralateral breast was 1.70 Gy; to the areola, 1.20 Gy; and to the outer quadrants, 0.72 Gy. Ninety-two percent of patients received ≥1 Gy to the inner quadrants. For each calendar year of diagnosis, dose declined significantly for each location, most rapidly for the inner quadrants (0.04 Gy/year). Declines in dose were similar across subgroups defined by age at diagnosis and body mass index. The PAR for CBC due to radiation exposure >1 Gy for women <40 years of age was 17%. Radiation dose-reduction measures have reduced dose to the contralateral breast during breast radiation therapy. Reducing the dose to the contralateral breast to <1 Gy could prevent an estimated 17% of subsequent radiation-associated CBCs for women treated under 40 years of age. These dose estimates inform CBC surveillance for the growing number of breast cancer survivors who received radiation therapy as young women in recent decades. Continued reductions in dose to the contralateral breast could further reduce the incidence of radiation-associated CBC.
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Affiliation(s)
- Gordon P. Watt
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Julia A. Knight
- Lunenfeld-Tanenbaum Research Institute, Sinai Health, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Kathleen E. Malone
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Esther M. John
- Departments of Epidemiology & Population Health and of Medicine, Stanford University School of Medicine, Stanford, California
- Stanford Cancer Institute, Stanford University School of Medicine, Stanford, California
| | - Leslie Bernstein
- Beckman Research Institute, City of Hope Comprehensive Cancer Center, Duarte, California
| | | | | | - Roy E. Shore
- Department of Population Health, New York University Grossman School of Medicine, New York, New York
| | - Xiaolin Liang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Meghan Woods
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John D. Boice
- National Council on Radiation Protection and Measurements, Bethesda, Maryland
- Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | | | - Jonine L. Bernstein
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
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7
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Jagsi R, Barlow WE, Woodward WA, Connolly E, Mahtani R, Shumway D, Speers C, Stecklein SR, Zeidan Y, Zhang H, Sharma P, Pusztai L, Hortobagyi GN, Kalinsky K. Radiotherapy Use and Incidence of Locoregional Recurrence in Patients With Favorable-Risk, Node-Positive Breast Cancer Enrolled in the SWOG S1007 Trial. JAMA Oncol 2023; 9:1083-1089. [PMID: 37410451 PMCID: PMC10326730 DOI: 10.1001/jamaoncol.2023.1984] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/18/2023] [Indexed: 07/07/2023]
Abstract
Importance Little is known about regional nodal irradiation (RNI) practice patterns or rates of locoregional recurrence (LRR) with and without RNI in patients with limited nodal disease and favorable biology treated with modern surgical and systemic therapy, including approaches that de-escalate those latter treatments. Objective To investigate how often patients with low-recurrence score breast cancer with 1 to 3 nodes involved receive RNI, incidence and predictors of LRR, and associations between locoregional therapy and disease-free survival. Design, Setting, and Participants In this secondary analysis of the SWOG S1007 trial, patients with hormone receptor-positive, ERBB2-negative breast cancer, and a Oncotype DX 21-gene Breast Recurrence Score assay result of no more than 25, were randomized to endocrine therapy alone vs chemotherapy then endocrine therapy. Prospectively collected radiotherapy information was collected from 4871 patients treated in diverse settings. Data were analyzed June 2022 to April 2023. Exposure Receipt of RNI (targeting at least the supraclavicular region). Main Outcome(s) and Measure(s) Cumulative incidence of LRR was calculated by locoregional treatment received. Analyses were assessed for associations between invasive disease-free survival (IDFS) and locoregional therapy, adjusted for menopausal status, treatment group, recurrence score, tumor size, nodes involved, and axillary surgery. Radiotherapy information was recorded in the first year after randomization, so survival analyses were landmarked as starting at 1 year among those still at risk. Results Of 4871 female patients (median [range] age, 57 [18-87] years) with radiotherapy forms, 3947 (81.0%) reported radiotherapy receipt. Of 3852 patients who received radiotherapy and had complete information on targets, 2274 (59.0%) received RNI. With a median follow-up of 6.1 years, the cumulative incidence of LRR by 5 years was 0.85% among patients who received breast-conserving surgery and radiotherapy with RNI; 0.55% after breast-conserving surgery with radiotherapy without RNI; 0.11% after mastectomy with postmastectomy radiotherapy; and 1.7% after mastectomy without radiotherapy. Similarly low LRR was observed within the group assigned to endocrine therapy without chemotherapy. The rate of IDFS did not differ by RNI receipt (premenopausal: hazard ratio [HR], 1.03; 95% CI, 0.74-1.43; P = .87; postmenopausal: HR, 0.85; 95% CI, 0.68-1.07; P = .16). Conclusions and Relevance In this secondary analysis of a clinical trial, RNI use was divided in the setting of biologically favorable N1 disease, and rates of LRR were low even in patients who did not receive RNI. Disease-free survival was not associated with RNI receipt; omission of chemotherapy among patients similar to those enrolled in the S1007 trial is not an independent indication for use of RNI.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | | | | | | | | | - Corey Speers
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Hong Zhang
- University of Rochester, Rochester, New York
| | | | | | | | - Kevin Kalinsky
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Akhtaruzzaman M, Islam MJ, Mannan MA, Sumon MA, Ebert M. Delivery of a VMAT technique with flattening filter (FF) and flattening filter free (FFF) mode for whole breast irradiation with five fractions (FAST-Forward trial). Med Dosim 2023; 48:211-215. [PMID: 37188547 DOI: 10.1016/j.meddos.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023]
Abstract
To investigate the feasibility of volumetric modulated arc therapy (VMAT) delivery for whole breast irradiation with a 5-fraction regimen according to the FAST-Forward trial. Recently, we treated 10 patients with carcinoma of the left breast after breast conserving surgery. The dose prescription to the PTV was 26 Gy in 5 fractions. Treatment plans were produced using a VMAT technique with the Eclipse treatment planning system for 6 MV flattening filter (FF) and FF free (FFF) beams. Dose volume histograms (DVHs) for the PTV and the organs at risk (OARs), the ipsilateral lung and heart, were compared with the dose constraints specified in the FAST-Forward trial (PTV, D95 > 95%, D5 < 105%, D2 < 107% and Dmax < 110%; ipsilateral lung, D15 < 8Gy; Heart, D30 < 1.5Gy and D5 < 7Gy). Furthermore, conformity index (CI), homogeneity index (HI) and dose to the heart, contralateral lung, contralateral breast, and left anterior descending artery (LAD), were also assessed. Mean ± SD D95(%), D5(%), D2(%), and Dmax (%) for PTV were 97.75 ± 1.12, 105.2 ± 0.82, 105.90 ± 0.89, 109.36 ± 1.00 (FF) and 96.46 ± 0.75, 103.97 ± 0.97, 104.70 ± 1.09, 108.58 ± 1.33 (FFF) respectively. The mean ± SD CI was 1.07 ± 0.05 (FF), 1.048 ± 0.06 (FFF) and HI was 0.11 ± 0.02 (FF), 0.10 ± 0.02 (FFF). Dose constraints for OARs were met for both treatment techniques. However, D15 (Gy) for ipsilateral lung was 3.0% lower with FFF beams. In contrast, D5 (Gy) for heart was 9.0% higher with FFF beams. The dose difference between FF and FFF beams for other OARs such as contralateral lung-D10 (Gy) contralateral breast-D5 (Gy) and LAD was up to 6.0%. Both FF and FFF methods met the acceptable criteria. However, the treatment plans with FFF mode were more conformal and provided greater target homogeneity.
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Affiliation(s)
| | | | - Md Abdul Mannan
- Labaid Cancer Hospital and Superspecialty Centre, Dhaka, Bangladesh
| | - Mostafa Aziz Sumon
- Labaid Cancer Hospital and Superspecialty Centre, Dhaka, Bangladesh; Kurmitola General Hospital, Dhaka, Bangladesh
| | - Martin Ebert
- The University of Western Australia, Perth, Australia; Sir Charles Gairdner Hospital, Perth, Australia
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9
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Duggar WN, Roberts PR, Thomas TV, Dulaney C. Building Better Patient Care in Mississippi Radiation Oncology: Why Mississippi Needs a Collaborative Quality Initiative. South Med J 2023; 116:415-418. [PMID: 37137476 DOI: 10.14423/smj.0000000000001549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
OBJECTIVES Cancer is an insidious and devastating disease that affects many people. Progress in mortality rate has not been realized universally across the United States, and challenges remain in how to best make up the ground that has been lost in these areas, one of which is Mississippi. Radiation therapy is a significant contributor to cancer control rates and certain challenges exist specifically regarding this treatment modality. METHODS The challenges of radiation oncology in Mississippi have been reviewed and discussed, with the proposal of a potential collaboration between clinical practitioners and payors to provide optimal and cost-effective radiation therapy to patients in Mississippi. RESULTS A similar model to that proposed has been reviewed and evaluated. This model is discussed based on its potential validity and usefulness in Mississippi. CONCLUSIONS Significant barriers exist in the state of Mississippi to patients receiving a consistent standard of care, regardless of their location and socioeconomic status. A collaborative quality initiative has been shown to be a boon to this endeavor elsewhere and stands to have a similar impact in Mississippi.
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Affiliation(s)
- William N Duggar
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Paul R Roberts
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Toms V Thomas
- From Radiation Oncology, University of Mississippi Medical Center, Jackson
| | - Caleb Dulaney
- Radiation Oncology, Anderson Regional Medical Center, Meridian, Mississippi
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10
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Prunaretty J, Bourgier C, Gourgou S, Lemanski C, Azria D, Fenoglietto P. Different meaning of the mean heart dose between 3D-CRT and IMRT for breast cancer radiotherapy. Front Oncol 2023; 12:1066915. [PMID: 36727074 PMCID: PMC9886087 DOI: 10.3389/fonc.2022.1066915] [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: 10/11/2022] [Accepted: 12/22/2022] [Indexed: 01/17/2023] Open
Abstract
Background Previous studies in 2D and in 3D conformal radiotherapy concludes that the maximal heart distance and the mean heart dose (MHD) are considered predictive of late cardiac toxicities. As the use of inverse-planned intensity modulated radiation therapy (IMRT) is increasing worldwide, we hypothesized that this 3D MHD might not be representative of heart exposure after IMRT for breast cancer (BC). Methods Patients with left-sided BC and unfavorable cardiac anatomy received IMRT. Their treatment plan was compared to a virtual treatment plan for 3D conformal radiotherapy with similar target volume coverage (study A). Then, a second 3D conformal treatment plan was generated to achieve equivalent individual MHD obtained by IMRT. Then the heart and left anterior descending (LAD) coronary artery exposures were analyzed (study B). Last, the relationship between MHD and the heart volume or LAD coronary artery volume receiving at least 30Gy, 40Gy and 45Gy in function of each additional 1Gy to the MHD was assessed (study C). Results A significant decrease of heart and LAD coronary artery exposure to high dose was observed with the IMRT compared with the 3D conformal radiotherapy plans that both ensured adequate target coverage (study A). The results of study B and C showed that 3D MHD was not representative of similar heart substructure exposure with IMRT, especially in the case of high dose exposure. Conclusions The mean heart dose is not a representative dosimetric parameter to assess heart exposure following IMRT. Equivalent MHD values following IMRT and 3DRT BC treatment do not represent the same dose distribution leading to extreme caution when using this parameter for IMRT plan validation.
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Affiliation(s)
- Jessica Prunaretty
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France,Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France,*Correspondence: Jessica Prunaretty, ; Sophie Gourgou,
| | - Celine Bourgier
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France,Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France,Université Montpellier, Montpellier, France
| | - Sophie Gourgou
- Biostatistics Department, Institut du Cancer de Montpellier, Montpellier, France,*Correspondence: Jessica Prunaretty, ; Sophie Gourgou,
| | - Claire Lemanski
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France,Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France
| | - David Azria
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France,Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France,Université Montpellier, Montpellier, France
| | - Pascal Fenoglietto
- Institut de Recherche en Cancérologie de Montpellier (IRCM), INSERM U1194, Montpellier, France,Fédération Universitaire d’Oncologie Radiothérapie d’Occitanie Méditerranée, Institut régional du Cancer Montpellier (ICM), Montpellier, France
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11
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Dilworth JT, Zureick AH, Grzywacz VP, Almahariq MF. In Reply to Fodor et al. Int J Radiat Oncol Biol Phys 2022; 114:555-556. [PMID: 36152646 DOI: 10.1016/j.ijrobp.2022.06.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/09/2022] [Indexed: 10/31/2022]
Affiliation(s)
- Joshua T Dilworth
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Andrew H Zureick
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Vincent P Grzywacz
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan
| | - Muayad F Almahariq
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, Michigan; Department of Radiation Oncology, Beaumont Hospital Dearborn, Dearborn, Michigan
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12
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Chapman CH, Jagsi R, Griffith KA, Moran JM, Vicini F, Walker E, Dominello M, Abu-Isa E, Hayman J, Laucis AM, Mietzel M, Pierce L. Mediators of Racial Disparities in Heart Dose Among Whole Breast Radiotherapy Patients. J Natl Cancer Inst 2022; 114:1646-1655. [PMID: 35916737 PMCID: PMC9949587 DOI: 10.1093/jnci/djac120] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/22/2022] [Accepted: 06/09/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Racial disparities in survival of patients with cancer motivate research to quantify treatment disparities and evaluate multilevel determinants. Previous research has not evaluated cardiac radiation dose in large cohorts of breast cancer patients by race nor examined potential causes or implications of dose disparities. METHODS We used a statewide consortium database to consecutively sample 8750 women who received whole breast radiotherapy between 2012 and 2018. We generated laterality- and fractionation-specific models of mean heart dose. We generated patient- and facility-level models to estimate race-specific cardiac doses. We incorporated our data into models to estimate disparities in ischemic cardiac event development and death. All statistical tests were 2-sided. RESULTS Black and Asian race independently predicted higher mean heart dose for most laterality-fractionation groups, with disparities of up to 0.42 Gy for Black women and 0.32 Gy for Asian women (left-sided disease and conventional fractionation: 2.13 Gy for Black women vs 1.71 Gy for White women, P < .001, 2-sided; left-sided disease and accelerated fractionation: 1.59 Gy for Asian women vs 1.27 Gy for White women, P = .002). Patient clustering within facilities explained 22%-30% of the variability in heart dose. The cardiac dose disparities translated to estimated excesses of up to 2.6 cardiac events and 1.3 deaths per 1000 Black women and 0.7 cardiac events and 0.3 deaths per 1000 Asian women vs White women. CONCLUSIONS Depending on laterality and fractionation, Asian women and Black women experience higher cardiac doses than White women. This may translate into excess radiation-associated ischemic cardiac events and deaths. Solutions include addressing inequities in baseline cardiac risk factors and facility-level availability and use of radiation technologies.
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Affiliation(s)
- Christina Hunter Chapman
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Reshma Jagsi
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Kent A Griffith
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Jean M Moran
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | | | | | | | - Eyad Abu-Isa
- Ascension Providence Hospital, Southfield, MI, USA
| | - James Hayman
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Anna M Laucis
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Melissa Mietzel
- Rogel Comprehensive Cancer Center at the University of Michigan, Ann Arbor, MI, USA
| | - Lori Pierce
- Correspondence to: Lori J. Pierce, MD, University of Michigan Rogel Comprehensive Cancer Center, Rm 4308, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA (e-mail: )
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13
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Punglia RS, Hassett MJ. Variation in Cardiac Dose Explains a "Fraction" of the Disparities Among Breast Cancer Patients. J Natl Cancer Inst 2022; 114:1570-1571. [PMID: 35916721 PMCID: PMC9745427 DOI: 10.1093/jnci/djac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/13/2022] [Indexed: 01/11/2023] Open
Affiliation(s)
- Rinaa S Punglia
- Correspondence to: Rinaa S. Punglia, MD, MPH, Department of Radiation Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA (e-mail: )
| | - Michael J Hassett
- Harvard Medical School, Boston, MA, USA,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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14
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Lin H, Dong L, Jimenez RB. Emerging Technologies in Mitigating the Risks of Cardiac Toxicity From Breast Radiotherapy. Semin Radiat Oncol 2022; 32:270-281. [DOI: 10.1016/j.semradonc.2022.01.002] [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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15
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Jagsi R, Schipper M, Mietzel M, Pandya R, Moran JM, Matuszak M, Vicini F, Jolly S, Paximadis P, Mancini B, Griffith K, Hayman J, Pierce L, On Behalf Of The Michigan Radiation Oncology Quality Consortium Mroqc. The Michigan Radiation Oncology Quality Consortium: A Novel Initiative to Improve the Quality of Radiation Oncology Care. Int J Radiat Oncol Biol Phys 2022; 113:257-265. [PMID: 35124133 DOI: 10.1016/j.ijrobp.2022.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Numerous quality measures have been proposed in radiation oncology, and initiatives to improve access to high-complexity care, quality, and equity are needed. We describe the design and evaluate impact of a voluntary statewide collaboration for quality improvement in radiation oncology initiated a decade ago. METHODS AND MATERIALS We evaluate compliance before and since implementation of annual metrics for quality improvement, using an observational dataset with information from over 20,000 patients treated in the 28 participating radiation oncology practices. At thrice-yearly meetings, experts have spoken regarding trends within the field and inspired discussions regarding potential targets for quality improvement. Blinded data on practices at various sites have been provided. Following Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines, we describe the approach and measures the program has implemented. To evaluate impact, we compare compliance at baseline and now with active measures using mixed effects regression models with site-level random effects. RESULTS Compliance has increased, including use of guideline-concordant hypofractionated radiotherapy, doses to targets/normal tissues, motion management, and consistency in delineating and naming contoured structures (a precondition for quality evaluation). For example, use of guideline-concordant hypofractionation for breast cancer increased from 47% to 97%, adherence to target coverage goals and heart dose limits for dose increased from 46% to 86%, motion assessment in patients with lung cancer increased from 52% to 94%, and use of standard nomenclature increased from 53% to 82% for lung patients and from 80% to 94% for breast patients (all p<0.001). CONCLUSIONS Although observational analysis cannot fully exclude secular trends, contextual data revealing slow uptake of best practices elsewhere in the US and qualitative feedback from participants suggests that this initiative has improved the consistency, efficiency, and quality of radiation oncology care in its member practices and may be a model for oncology quality improvement more generally.
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16
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Fargier-Bochaton O, Wang X, Dipasquale G, Laouiti M, Kountouri M, Gorobets O, Nguyen NP, Miralbell R, Vinh-Hung V. Prone versus supine free-breathing for right-sided whole breast radiotherapy. Sci Rep 2022; 12:525. [PMID: 35017568 PMCID: PMC8752750 DOI: 10.1038/s41598-021-04385-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/24/2021] [Indexed: 01/29/2023] Open
Abstract
Prone setup has been advocated to improve organ sparing in whole breast radiotherapy without impairing breast coverage. We evaluate the dosimetric advantage of prone setup for the right breast and look for predictors of the gain. Right breast cancer patients treated in 2010-2013 who had a dual supine and prone planning were retrospectively identified. A penalty score was computed from the mean absolute dose deviation to heart, lungs, breasts, and tumor bed for each patient's supine and prone plan. Dosimetric advantage of prone was assessed by the reduction of penalty score from supine to prone. The effect of patients' characteristics on the reduction of penalty was analyzed using robust linear regression. A total of 146 patients with right breast dual plans were identified. Prone compared to supine reduced the penalty score in 119 patients (81.5%). Lung doses were reduced by 70.8%, from 4.8 Gy supine to 1.4 Gy prone. Among patient's characteristics, the only significant predictors were the breast volumes, but no cutoff could identify when prone would be less advantageous than supine. Prone was associated with a dosimetric advantage in most patients. It sets a benchmark of achievable lung dose reduction.Trial registration: ClinicalTrials.gov NCT02237469, HUGProne, September 11, 2014, retrospectively registered.
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Affiliation(s)
| | - Xinzhuo Wang
- Radiation Oncology Department, Geneva University Hospitals, Geneva, Switzerland
- Radiation Oncology, Tianjin Union Medical Center, Tianjin, 300121, China
| | - Giovanna Dipasquale
- Radiation Oncology Department, Geneva University Hospitals, Geneva, Switzerland
| | - Mohamed Laouiti
- Radiation Oncology Department, Geneva University Hospitals, Geneva, Switzerland
- Service de Radio-Oncologie, Hôpital Riviera-Chablais, Rennaz, Switzerland
| | - Melpomeni Kountouri
- Radiation Oncology Department, Geneva University Hospitals, Geneva, Switzerland
| | | | - Nam P Nguyen
- Radiation Oncology, Howard University, Washington, DC, USA
| | - Raymond Miralbell
- Radiation Oncology Department, Geneva University Hospitals, Geneva, Switzerland.
- Université de Genève, Geneva, Switzerland.
- Centro de Protonterapia Quirónsalud, Pozuelo de Alarcón, 28223, Madrid, Spain.
- Servei de Radiooncologia, Institut Oncològic Teknon, Quironsalud, Vilana 12, 08022, Barcelona, Spain.
| | - Vincent Vinh-Hung
- Radiation Oncology Department, Geneva University Hospitals, Geneva, Switzerland
- CHU de Martinique, Fort-de-France, Martinique, France
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17
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McKenzie E, Razvi Y, Bosnic S, Wronski M, Zhang L, Karam I, Donovan E, Milton L, Behroozian T, Drost L, Yee C, Wong G, Lam E, Chow E. Dosimetry and outcomes in patients receiving radiotherapy for synchronous bilateral breast cancers. J Med Imaging Radiat Sci 2021; 52:527-543. [PMID: 34580051 DOI: 10.1016/j.jmir.2021.08.013] [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: 07/05/2021] [Revised: 08/16/2021] [Accepted: 08/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Synchronous bilateral breast cancer (SBBC) is rare and there is little evidence describing organs at risk (OAR) and limits to the heart and lungs caused by radiotherapy (RT). Quantifying mean heart dose (MHD) and mean lung dose (MLD) from RT in this patient cohort may lead to better understanding of doses to OAR and resultant effects on clinical outcomes. The primary objective was to assess median MHD and MLD in SBBC, while secondary aims included analyses of 1) factors associated with MHD and MLD, 2) V5 and V20 values and 3) factors associated with clinical outcomes. METHODS Patients planned for adjuvant bilateral whole breast/chest wall (WB) RT from a single institution treated in 2011-2018 were included. Median MHD and MLD (Gy) were stratified by hypofractionated (42.56 Gy/16 fractions, HFRT) and conventional fractionation (50 Gy/ 25 fractions, CFRT) and summarized separately based on the following treatments: 1) locoregional RT, WB tangential RT either 2) no boost 3) sequential boost or 4) simultaneous integrated boost. MHD, MLD, lung V5 and V20 values, and demographics were collected. Linear regression analyses identified factors associated with MHD and MLD and factors associated with clinical outcomes. RESULTS A total of 88 patients were included. The median MHD for HFRT and CFRT was 1.99 Gy and 2.94 Gy, respectively. The median MLD for HFRT and CFRT was 6.00 Gy and 10.08 Gy, respectively. MHD and MLD were significantly associated with the occurrence of a cardiac or pulmonary event post-radiation. Patients who had a mastectomy or tumoral muscle involvement were more likely to develop a local recurrence, metastasis or new primary while patients who had a lumpectomy or tumor with a positive estrogen receptor status were less likely to experience these events. CONCLUSIONS Further investigation should be conducted to identify SBBC RT techniques that mitigate dose to OARs to improve clinical outcomes in bilateral breast patients.
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Affiliation(s)
- Erin McKenzie
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Yasmeen Razvi
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Sandi Bosnic
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Matt Wronski
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Irene Karam
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Elysia Donovan
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Lauren Milton
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Tara Behroozian
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Leah Drost
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Caitlin Yee
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Gina Wong
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Emily Lam
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Edward Chow
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
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18
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Harris EER. Breast Radiation and the Heart: Cardiac Toxicity and Cardiac Avoidance. Clin Breast Cancer 2021; 21:492-496. [PMID: 34474986 DOI: 10.1016/j.clbc.2021.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 07/12/2021] [Accepted: 07/24/2021] [Indexed: 10/20/2022]
Abstract
The purpose of this invited review is to discuss the most recent and relevant outcome studies assessing the risk of late cardiac toxicity in women treated with radiotherapy for breast cancer and to describe the evidence-based technical factors associated with late cardiac toxicity. This review will also discuss the common radiation techniques for reducing radiation dose to the heart, which will lead to better outcomes and lower rates of late toxicity that can cause morbidity and mortality in women who have been cured of their breast cancer.
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Affiliation(s)
- Eleanor E R Harris
- Department of Radiation Oncology, Seidman Cancer Center University Hospitals, Case Western Reserve University Medical School, Cleveland, OH.
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19
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Meattini I, Poortmans PM, Aznar MC, Becherini C, Bonzano E, Cardinale D, Lenihan DJ, Marrazzo L, Curigliano G, Livi L. Association of Breast Cancer Irradiation With Cardiac Toxic Effects: A Narrative Review. JAMA Oncol 2021; 7:924-932. [PMID: 33662107 DOI: 10.1001/jamaoncol.2020.7468] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE To promptly recognize and manage cardiovascular (CV) risk factors before, during, and after cancer treatment, decreasing the risk of cancer therapy-related cardiac dysfunction is crucial. After recent advances in breast cancer treatment, mortality rates from cancer have decreased, and the prevalence of survivors with a potentially higher CV disease risk has increased. Cardiovascular risks might be associated with the multimodal approach, including systemic therapies and breast radiotherapy (RT). OBSERVATIONS The heart disease risk seems to be higher in patients with tumors in the left breast, when other classic CV risk factors are present, and when adjunctive anthracycline-based chemotherapy is administered, suggesting a synergistic association. Respiratory control as well as modern RT techniques and their possible further refinement may decrease the prevalence and severity of radiation-induced heart disease. Several pharmacological cardioprevention strategies for decreasing cardiac toxic effects have been identified in several guidelines. However, further research is needed to ascertain the feasibility of these strategies in routine practice. CONCLUSIONS AND RELEVANCE This review found that evidence-based recommendations are lacking on the modalities for and intensity of heart disease screening, surveillance of patients after RT, and treatment of these patients. A multidisciplinary and multimodal approach is crucial to guide optimal management.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Philip M Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - Marianne Camille Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Elisabetta Bonzano
- Department of Radiation Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Matteo Polyclinic Foundation, Pavia, Italy
- PhD School in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, IRCCS, Milan, Italy
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
| | - Livia Marrazzo
- Medical Physics Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development, European Institute of Oncology, IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences Mario Serio, University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
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20
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Abstract
Radiation therapy plays an integral role in the treatment of all stages of non-small cell lung cancer. Survival outcomes are improving, but radiation therapy remains associated with long-term toxicity. Recently, it has become evident that the heart is an important organ at risk for treatment-related morbidity. In this review, we discuss the hypothesis that particle radiation therapy offers superior dosimetry compared with photon-based treatment, and that this comparative advantage translates into clinically meaningful cardiac toxicity reduction with similar local tumor control. We discuss the evidence in non-small cell lung cancer to date, the ongoing prospective trials that may provide additional insight, and the opportunities to optimally integrate particle therapy into future prospective investigation.
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21
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Altınok P, Korkmaz L, Altınok A, Beşe N. Were We Able to Reduce Cardiac Doses in Breast Cancer Radiotherapy Over Time? Eur J Breast Health 2021; 17:145-149. [PMID: 33870114 DOI: 10.4274/ejbh.galenos.2021.6148] [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: 10/13/2020] [Accepted: 01/22/2021] [Indexed: 12/01/2022]
Abstract
Objective In this study, we aimed to review the heart and left coronary artery doses over the years in patients who received breast cancer radiotherapy (RT). Materials and Methods A total of 436 breast cancer patients of 2 RT centers treated between the years 2010 and 2018 were included. The mean heart doses (HeartDmean-HDM) and left coronary artery mean doses (LDM) were analyzed using nonparametric tests. The conventional RT (CRT) was 50 Gy/2 Gy in 5 weeks, and the hypofractionated RT (HRT) was 40.05 Gy/2.67 Gy in 3 weeks. Boost was applied as 10-16 Gy/2 Gy for CRT and 10 Gy/2.5 Gy for HRT. An equivalent conventional total dose of 2 Gy/fraction (EQD2) was taken into account for HRT. Results HDM was 107±104 cGy, and LDM was 288±209 cGy for the entire group. HDM was significantly lower in patients with breast-conserving surgery (99±94 cGy) than that in those with mastectomy (128±124 cGy) (p<0.001). Field-in-field intensity-modulated RT technique significantly reduced the doses compared to volumetric applications (104±95 cGy vs 141±38 cGy; p = 0.002). HDM was significantly increased with lymphatic RT (132±58 cGy vs 112±115 cGy; p<0.001). The addition of internal mammary volumes significantly increased HDM (p<0.001). No significant effect of boost was observed (p = 0.96). For both CRT and HRT regimens, HDM values were significantly lower after the year 2014 (right side p<0.001, left side p = 0.01). In the left side CRT, HDM was 1.74 Gy before 2014 and 1.3 Gy after 2014 and 1.0 and 1.19 Gy, respectively, for the right side. Conclusion All efforts to reduce the cardiac doses will likely reduce long-term side effects.
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Affiliation(s)
- Pelin Altınok
- Department of Radiation Oncology, University of Health Sciences Turkey, Ümraniye Training and Research Hospital, İstanbul, Turkey
| | - Latif Korkmaz
- Research Institute of Senology, Acıbadem Maslak Hospital, İstanbul, Turkey
| | - Ayse Altınok
- Research Institute of Senology, Acıbadem Maslak Hospital, İstanbul, Turkey
| | - Nuran Beşe
- Research Institute of Senology, Acıbadem Maslak Hospital, İstanbul, Turkey
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22
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Trivedi SJ, Tang S, Byth K, Stefani L, Lo Q, Otton J, Jameson M, Tran D, Batumalai V, Holloway L, Delaney GP, Koh ES, Thomas L. Segmental Cardiac Radiation Dose Determines Magnitude of Regional Cardiac Dysfunction. J Am Heart Assoc 2021; 10:e019476. [PMID: 33749308 PMCID: PMC8174310 DOI: 10.1161/jaha.120.019476] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Subclinical left ventricular dysfunction detected by 2‐dimensional global longitudinal strain post breast radiotherapy has been described in patients with breast cancer. We hypothesized that left ventricular dysfunction postradiotherapy may be site specific, based on differential segmental radiotherapy dose received. Methods and Results Transthoracic echocardiograms were performed at baseline, 6 weeks, and 12 months postradiotherapy on 61 chemotherapy‐naïve women with left‐sided breast cancer undergoing tangential breast radiotherapy. Radiation received within basal, mid, and apical regions for the 6 left ventricular walls was quantified from the radiotherapy treatment planning system. Anterior, anteroseptal, and anterolateral walls received the highest radiation doses, while inferolateral and inferior walls received the lowest. There was a progressive increase in the radiation dose received from basal to apical regions. At 6 weeks, the most significant percentage deterioration in strain was seen in the apical region, with greatest reductions in the anterior wall followed by the anteroseptal and anterolateral walls, with a similar pattern persisting at 12 months. There was a within‐patient dose–response association between the segment‐specific percentage deterioration in strain at 6 weeks and 12 months and the radiation dose received. Conclusions Radiotherapy for left‐sided breast cancer causes differential segmental dysfunction, with myocardial segments that receive the highest radiation dose demonstrating greatest strain impairment. Percentage deterioration in strain observed 6 weeks postradiotherapy persisted at 12 months and demonstrated a dose–response relationship with radiotherapy dose received. Radiotherapy‐induced subclinical cardiac dysfunction is of importance because it could be additive to chemotherapy‐related cardiotoxicity in patients with breast cancer. Long‐term outcomes in patients with asymptomatic strain reduction require further investigation.
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Affiliation(s)
- Siddharth J Trivedi
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,Westmead Clinical School University of Sydney NSW Australia
| | - Simon Tang
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Central Coast Cancer Therapy Centre Gosford NSW Australia
| | - Karen Byth
- Research and Education Network Western Sydney Local Health DistrictWestmead Hospital Sydney NSW Australia.,NHMRC Clinical Trials CentreUniversity of Sydney NSW Australia
| | - Luke Stefani
- Department of Cardiology Westmead Hospital Sydney NSW Australia
| | - Queenie Lo
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Department of Cardiology St George Hospital Sydney NSW Australia
| | - James Otton
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Department of Cardiology Liverpool Hospital Sydney NSW Australia
| | - Michael Jameson
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - David Tran
- Department of Cardiology Liverpool Hospital Sydney NSW Australia
| | - Vikneswary Batumalai
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Lois Holloway
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Geoff P Delaney
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Eng-Siew Koh
- South Western Sydney Clinical School University of New South Wales Sydney NSW Australia.,Ingham Institute of Applied Medical Research Sydney NSW Australia.,Cancer Therapy Centre Liverpool Hospital Sydney NSW Australia
| | - Liza Thomas
- Department of Cardiology Westmead Hospital Sydney NSW Australia.,Westmead Clinical School University of Sydney NSW Australia.,South Western Sydney Clinical School University of New South Wales Sydney NSW Australia
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Deep inspiration breath hold reduces the mean heart dose in left breast cancer radiotherapy. Radiol Oncol 2021; 55:212-220. [PMID: 33600676 PMCID: PMC8042816 DOI: 10.2478/raon-2021-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/18/2020] [Indexed: 12/25/2022] Open
Abstract
Background Patients with left breast cancer who undergo radiotherapy have a non-negligible risk of developing radiation-induced cardiovascular disease (CVD). Cardioprotection can be achieved through better treatment planning protocols and through respiratory gating techniques, including deep inspiration breath hold (DIBH). Several dosimetric studies have shown that DIBH reduces the cardiac dose, but clinical data confirming this effect is limited. The aim of the study was to compare the mean heart dose (MHD) in patients with left breast cancer who underwent radiotherapy at our institution as we transitioned from non-gated free-breathing (FB) radiotherapy to gated radiotherapy (FB-GRT), and finally to DIBH. Patients and methods Retrospective study involving 2022 breast cancer patients who underwent radiotherapy at West Pomeranian Oncology Center in Szczecin from January 1, 2014 through December 31, 2017. We compared the MHD in these patients according to year of treatment and technique. Results Overall, the MHD for patients with left breast cancer in our cohort was 3.37 Gy. MHD values in the patients treated with DIBH were significantly lower than in patients treated with non-gated FB (2.1 vs. 3.48 Gy, p < 0.0001) and gated FB (3.28 Gy, p < 0.0001). The lowest MHD values over the four-year period were observed in 2017, when nearly 85% of left breast cancer patients were treated with DIBH. The proportion of patients exposed to high (> 4 Gy) MHD values decreased every year, from 40% in 2014 to 7.9% in 2017, while the percentage of patients receiving DIBH increased. Conclusions Compared to free-breathing techniques (both gated and non-gated), DIBH reduces the mean radiation dose to the heart in patients with left breast cancer. These findings support the use of DIBH in patients with left breast cancer treated with radiotherapy.
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Iwaki K, Kamaya A, Fuwa N, Tanisada K, Matsueda K, Shibahara T, Fujita Y, Kunieda E, Todaka H, Nomura M, Ii N. Verification of the junctional dose for irradiation of the chest wall and supraclavicular regions under the circumstances of advanced technologies. Med Dosim 2021; 46:e1-e9. [PMID: 33461825 DOI: 10.1016/j.meddos.2020.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 11/29/2020] [Accepted: 12/03/2020] [Indexed: 11/17/2022]
Abstract
A single-isocenter half-beam technique is commonly used when irradiating the chest wall and supraclavicular regions in patients with high-risk breast cancer. However, several studies have reported that underdosage can occur at the junction of the chest wall and supraclavicular regions due to a "tongue-and-groove" effect. This study verified the efficacy of an open leaf technique (OL-tech) that involves placing a multileaf collimator 5 mm outside from the beam central axis to remove the effect of the multileaf collimator in a single-isocenter half-beam technique. We compared the junction doses of the OL-tech with those of a conventional technique (C-tech) in square and clinical plans, using 4 and 10 MV x-rays in the Clinac iX and 6 and 10 MV x-rays in the Trilogy accelerators (Varian Medical Systems, Palo Alto, CA). EBT3 radiochromic films were used for measurements. Measurements were performed at a depth of 3 cm when verifying field matching. The EBT3 films in the square plan indicated junction doses for the C-tech of 78.3% with the Clinac iX accelerator and 73.6% with the Trilogy accelerator. By contrast, the corresponding doses for the OL-tech were 107.2% and 99.8%, respectively. In the clinical plan, the junction doses for the C-tech were 76.5% with the Clinac iX accelerator and 72.6% with the Trilogy accelerator; the corresponding doses for the OL-tech were 108.3% and 101.7%, respectively. As with the square plan, variations in the junction dose were much smaller using the OL-tech than using the C-tech. Our results suggest that the OL-tech can be useful for improving dose homogeneity at the junction of the chest wall and supraclavicular regions.
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Affiliation(s)
- Kengo Iwaki
- Department of Medical Technology, Ise Red Cross Hospital, Ise- shi, Mie, Japan.
| | - Akira Kamaya
- Department of Medical Technology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
| | - Nobukazu Fuwa
- Department of Radiation Oncology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
| | - Kazuaki Tanisada
- Department of Medical Technology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
| | - Kouji Matsueda
- Department of Medical Technology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
| | - Takahiko Shibahara
- Department of Medical Technology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
| | - Yukio Fujita
- Faculty of Health Sciences, Komazawa University, Tokyo, Japan
| | - Etsuo Kunieda
- Department of Radiation Oncology, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Hideharu Todaka
- Department of Radiology, Tokai University Hospital, Isehara-shi, Kanagawa, Japan
| | - Miwako Nomura
- Department of Radiation Oncology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
| | - Noriko Ii
- Department of Radiation Oncology, Ise Red Cross Hospital, Ise- shi, Mie, Japan
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Breast size and dose to cardiac substructures in adjuvant three-dimensional conformal radiotherapy compared to tangential intensity modulated radiotherapy. Radiol Oncol 2020; 54:470-479. [PMID: 32990650 PMCID: PMC7585338 DOI: 10.2478/raon-2020-0050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/10/2020] [Indexed: 02/06/2023] Open
Abstract
Background The aim of the study was to quantify planned doses to the heart and specific cardiac substructures in free-breathing adjuvant three-dimensional radiation therapy (3D-CRT) and tangential intensity modulated radiotherapy (t-IMRT) for left-sided node-negative breast cancer, and to assess the differences in planned doses to organs at risk according to patients’ individual anatomy, including breast volume. Patients and methods In the study, the whole heart and cardiac substructures were delineated for 60 patients using cardiac atlas. For each patient, 3D-CRT and t-IMRT plans were generated. The prescribed dose was 42.72 Gy in 16 fractions. Patients were divided into groups with small, medium, and large clinical target volume (CTV). Calculated dose distributions were compared amongst the two techniques and the three different groups of CTV. Results Mean absorbed dose to the whole heart (MWHD) (1.9 vs. 2.1 Gy, P < 0.005), left anterior descending coronary artery mean dose (8.2 vs. 8.4 Gy, P < 0.005) and left ventricle (LV) mean dose (3.0 vs. 3.2, P < 0.005) were all significantly lower with 3D-CRT technique compared to t-IMRT. Apical (8.5 vs. 9.0, P < 0.005) and anterior LV walls (5.0 vs. 5.4 Gy, P < 0.005) received the highest mean dose (Dmean). MWHD and LV-Dmean increased with increasing CTV size regardless of the technique. Low MWHD values (< 2.5 Gy) were achieved in 44 (73.3%) and 41 (68.3%) patients for 3D-CRT and t-IMRT techniques, correspondingly. Conclusions Our study confirms a considerable range of the planned doses within the heart for adjuvant 3D-CRT or t-IMRT in node-negative breast cancer. We observed differences in heart dosimetric metrics between the three groups of CTV size, regardless of the radiotherapy planning technique.
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Factors Affecting Mean Heart Dose in Patients Receiving Breast Radiotherapy from 2011 to 2018 in a Single Institution. J Med Imaging Radiat Sci 2020; 51:379-393. [DOI: 10.1016/j.jmir.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/17/2020] [Accepted: 03/27/2020] [Indexed: 12/25/2022]
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Tang B, Ma J, Xu J, Li J, Kang S, Wang P, Wu F, Orlandini LC. Feasibility of using calibrated cone-beam computed tomography scans to validate the heart dose in left breast post-mastectomy radiotherapy. J Int Med Res 2020; 48:300060520929168. [PMID: 32567427 PMCID: PMC7309397 DOI: 10.1177/0300060520929168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective In post-mastectomy radiotherapy, high-conformal techniques are a valid method for determining the dose distribution around a target. However, the proximity of critical structures is a reason for concern. This study aims to evaluate the feasibility of using calibrated cone-beam computed tomography (CBCT) scans as a valid tool for a timely heart dose evaluation. Methods A retrospective analysis was conducted on 170 retrospective CBCT scans of 17 patients who underwent high-conformal post-mastectomy irradiation. The delivered doses that were calculated using personalized calibrated CBCT were compared with the doses planned, using the dose–volume histogram dosimetric parameters. Results The heart volume that was evaluated using CBCT presented a mean increase of 6%; this discrepancy impacted the heart dose in 4 of 17 patients, with an absolute increase of V25 Gy (range, 2.5%–7.6%) and an increase in the mean dose (range, 1.1–3.4 Gy). The dose for the target, ipsilateral lung, and contralateral breast remained unchanged. Conclusion Using CBCT to monitor the dose that is delivered to the heart is feasible, allowing for a timely shift to an adaptive plan if clinically necessary.
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Affiliation(s)
- Bin Tang
- Key Laboratory of Radiation Physics, Institute of Nuclear Science and Technology, Sichuan University, No. 24, South Section 1, Yihuar, Chengdu, 610065, China.,Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Jiabao Ma
- Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Jinghui Xu
- Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Jie Li
- Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Shengwei Kang
- Key Laboratory of Radiation Physics, Institute of Nuclear Science and Technology, Sichuan University, No. 24, South Section 1, Yihuar, Chengdu, 610065, China.,Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Pei Wang
- Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Fan Wu
- Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
| | - Lucia Clara Orlandini
- Department of Radiation Oncology, Sichuan Cancer Hospital & Research Institute, No. 55, the 4th Section, Renmin South Road, Chengdu, 610041, China
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Yamauchi R, Mizuno N, Itazawa T, Saitoh H, Kawamori J. Dosimetric evaluation of deep inspiration breath hold for left-sided breast cancer: analysis of patient-specific parameters related to heart dose reduction. JOURNAL OF RADIATION RESEARCH 2020; 61:447-456. [PMID: 32100831 PMCID: PMC7299269 DOI: 10.1093/jrr/rraa006] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/18/2019] [Accepted: 02/06/2020] [Indexed: 06/10/2023]
Abstract
Deep inspiration breath hold (DIBH) is a common method used worldwide for reducing the radiation dose to the heart. However, few studies have reported on the relationship between dose reduction and patient-specific parameters. The aim of this study was to compare the reductions of heart dose and volume using DIBH with the dose/volume of free breathing (FB) for patients with left-sided breast cancer and to analyse patient-specific dose reduction parameters. A total of 85 Asian patients who underwent whole-breast radiotherapy after breast-conserving surgery were recruited. Treatment plans for FB and DIBH were retrospectively generated by using an automated breast planning tool with a two-field tangential intensity-modulated radiation therapy technique. The prescribed dose was 50 Gy in 25 fractions. The dosimetric parameters (e.g., mean dose and maximum dose) in heart and lung were extracted from the dose-volume histogram. The relationships between dose-volume data and patient-specific parameters, such as age, body mass index (BMI), and inspiratory volume, were analyzed. The mean heart doses for the FB and DIBH plans were 1.56 Gy and 0.75 Gy, respectively, a relative reduction of 47%. There were significant differences in all heart dosimetric parameters (p < 0.001). For patients with a high heart dose in the FB plan, a relative reduction of the mean heart dose correlated with inspiratory volume (r = 0.646). There was correlation between the relative reduction of mean heart dose and BMI (r = -0.248). We recommend considering the possible feasibility of DIBH in low BMI patients because the degree of benefit from DIBH varied with BMI.
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Affiliation(s)
- Ryohei Yamauchi
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan
| | - Norifumi Mizuno
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
| | - Tomoko Itazawa
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
| | - Hidetoshi Saitoh
- Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St Luke’s International Hospital, Tokyo, Japan
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Liao X, Wu F, Wu J, Peng Q, Yao X, Kang S, Zhao Y, Orlandini LC. Impact of positioning errors in the dosimetry of VMAT left-sided post mastectomy irradiation. Radiat Oncol 2020; 15:103. [PMID: 32381103 PMCID: PMC7206823 DOI: 10.1186/s13014-020-01556-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/28/2020] [Indexed: 12/25/2022] Open
Abstract
Background Volumetric modulated arc therapy (VMAT) adopted in post-mastectomy radiation therapy (PMRT) has the capacity to achieve highly conformal dose distributions. The research aims to evaluate the impact of positioning errors in the dosimetry of VMAT left-sided PMRT. Methods A total of 18 perturbations where introduced in 11 VMAT treatment plans that shifted the isocenter from its reference position of 3, 5, 10 mm in six directions. The thoracic wall and supraclavicular clinical target volumes (CTVs), the heart and the left lung dose volume histograms (DVHs) of 198 perturbed plans were calculated. The absolute differences (∆) of the mean dose (Dm) and DVH endpoints Vx and Dy (percentage volume receiving x Gy, and dose covering y% of the volume, respectively) were used to compare the dosimetry of the reference vs perturbed plans. Results Isocenter shifts in the anterior and lateral directions lead to maximum disagreement between the CTVs dosimetry of perturbed vs reference plans. Isocenter shifts of 10 mm shown a decrease of D95, D98 and Dm of 12.8, 18.0, and 2.9% respectively, for the CTVs. For 5 mm isocenter shifts, these differences decreased to 3.2, 5.2, and 0.9%, respectively, and for 3 mm shifts to 1.0, 1.7, and 0.6%, respectively. For the organs at risk (OARs), only isocenter shifts in the right, posterior and inferior directions worsen the plan dosimetry, nevertheless not negligible lung ∆ V20 of + 2.6%, and heart ∆ V25 of + 1.6% persist for 3 mm shifts. Conclusions Inaccuracy in isocenter positioning for VMAT left-sided PMRT irradiation may impact the dosimetry of the CTVs and OARs to a different extent, depending on the directions and magnitude of the perturbation. The acquired information could be useful for planning strategies to guarantee the accuracy of the treatment delivered.
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Affiliation(s)
- Xiongfei Liao
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
| | - Fan Wu
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
| | - Junxiang Wu
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
| | - Qian Peng
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China.
| | - Xinghong Yao
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
| | - Shengwei Kang
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
| | - Yanqun Zhao
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
| | - Lucia Clara Orlandini
- Sichuan Cancer Hospital & Research Institute, School of Medicine University of Electronic Science and Technology of China, 55th Renmin South Road, 4th Section, Chengdu, 610041, China
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Prognosis of acute coronary syndromes after radiotherapy for breast cancer. Radiother Oncol 2020; 146:110-117. [PMID: 32146256 DOI: 10.1016/j.radonc.2020.02.007] [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] [Received: 07/16/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Breast cancer patients treated with radiotherapy are at increased risk of subsequent acute coronary syndromes (ACS). We aimed to study if radiotherapy also influences the prognosis of these ACS. MATERIALS AND METHODS We included all 398 patients diagnosed with ACS following radiotherapy from our hospital-based cohort of early breast cancer patients aged <71 years, treated 1970-2009. Cardiovascular disease incidence and cause of death were acquired through questionnaires to general practitioners and cardiologists. Internal mammary chain (IMC) irradiation delivers the highest heart doses in breast cancer radiotherapy. Hence, we compared ACS prognosis between patients treated with/without IMC-irradiation. ACS prognosis was assessed through cardiac death, death due to ACS and cardiovascular disease incidence, using multivariable Cox proportional hazard models and by estimating cumulative incidence. RESULTS In total, 62% of patients with ACS had received IMC-irradiation and 38% did not (median age at ACS diagnosis, 67 years). Median time between breast cancer and ACS was 15 years. After ACS, ten-year cumulative risk of cardiac death was 35% for patients who had IMC-irradiation (95% confidence interval [95%CI] 29-41) compared to 24% (95%CI 17-31) for patients without IMC-irradiation (p = 0.04). After correction for confounders, IMC-irradiation remained associated with a less favourable prognosis of ACS compared to no IMC-irradiation (hazard ratio cardiac death = 1.7, 95%CI 1.1-2.5). CONCLUSION Our results suggest that radiotherapy, in case of substantial heart doses,may worsen ACS prognosis. This is an important, novel finding that may impact upon the risk-based care for breast cancer survivors with ACS.
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Yeh HP, Huang YC, Wang LY, Shueng PW, Tien HJ, Chang CH, Chou SF, Hsieh CH. Helical tomotherapy with a complete-directional-complete block technique effectively reduces cardiac and lung dose for left-sided breast cancer. Br J Radiol 2020; 93:20190792. [PMID: 31939310 PMCID: PMC7362916 DOI: 10.1259/bjr.20190792] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objectives: To evaluate the feasibility and optimal restricted angle of the complete-directional-complete block (CDCB) technique in helical tomotherapy (HT) by including regional nodal irradiation (RNI) with the internal mammary node (IMN) in left-sided breast cancer. Methods: Ten left-sided breast cancer patients treated with 50 Gy in 25 fractions were compared with five-field intensity-modulated radiation therapy (5F-IMRT) and six types of HT plans. In the HT plans, complete block (CB), organ-based directional block (OBDB) and CDCB with different restricted angles were used. Results: The conformity index (CI) between the CDCB0,10,15,20 and 5F-IMRT groups was similar. Compared to CB, OBDB and 5F-IMRT, CDCB20 resulted in a decreased ipsilateral mean lung dose. The low-dose region (V5) of the ipsilateral lung in OBDB (84.0%) was the highest among all techniques (p < 0.001). The mean dose of the heart in CB was significantly reduced (by 11.5–22.4%) compared with other techniques. The V30 of the heart in CDCB20 (1.9%) was significantly lower than that of CB, OBDB and 5F-IMRT. Compared to the mean dose of the left anterior descending (LAD) artery of 5F-IMRT (27.0 Gy), CDCB0, CDCB10, CDCB15, CDCB20 and OBDB reduced the mean dose effectively by 31.7%, 38.3%, 39.6%, 42.0 and 56.2%, respectively. Considering the parameters of the organs-at-risk (OARs), CDCB10,15,20 had higher expectative values than the other techniques (p = 0.01). Conclusions: HT with the CDCB technique is feasible for treating left-sided breast cancer patients. The CDCB10-20 techniques not only achieved similar planning target volume coverage, homogeneity and dose conformity but also allowed better sparing of the heart and bilateral lungs. Advances in knowledge: For left-sided breast cancer patients whose RNI field includes the IMN, heart avoidance is an important issue. The CDCB technique achieved good PTV coverage, homogeneity and dose conformity and allowed better sparing of the mean dose of the lung, the LAD artery, and the heart and reduced the V30 of the heart.
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Affiliation(s)
- Hsin-Pei Yeh
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China
| | - Yu-Chuen Huang
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, Republic of China.,School of Chinese Medicine, China Medical University, Taichung, Taiwan, Republic of China
| | - Li-Ying Wang
- Physical Therapy Center, National Taiwan University Hospital, Taipei, Taiwan, Republic of China.,School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan, Republic of China
| | - Pei-Wei Shueng
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Hui-Ju Tien
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China.,Department of Biomedical Imaging and Radiological Science, National Yang- Ming University, Taipei, Taiwan
| | - Chiu-Han Chang
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China
| | - San-Fang Chou
- Department of Medical Research, Far Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China
| | - Chen-Hsi Hsieh
- Division of Radiation Oncology, Department of Radiology, Far Eastern Memorial Hospital, New Taipei City, Taiwan, Republic of China.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China.,Institute of Traditional Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
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Dutta SW, Aliotta E, Alonso CE, Bliley RC, Romano KD, Libby B, Showalter TN, Showalter SL, Janowski EM. Normal tissue dose and risk estimates from whole and partial breast radiation techniques. Breast J 2019; 26:1308-1315. [PMID: 31876106 DOI: 10.1111/tbj.13735] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare radiation dose to organs at risk in patients with early-stage breast cancer treated with lumpectomy and intraoperative radiation therapy with CT-guided HDR brachytherapy (precision breast IORT; PB-IORT) and those treated with external beam whole breast irradiation (WB-DIBH) or partial breast irradiation (PB-DIBH) with deep inspiratory breath hold. METHODS We retrospectively identified 52 consecutive patients with left-sided breast cancers treated with either PB-IORT (n = 17, 76% outer breast) on a phase I clinical trial, adjuvant PB-DIBH (n = 18, 56% outer breast, 6% cavity boost), or WB-DIBH (n = 17, 76% outer breast, 53% with lumpectomy cavity boost). Conventional (2 Gy/fraction) or moderate hypofractionation (2.66 Gy/fraction) was prescribed for the external beam cohorts and 12.5 Gy in 1 fraction to 1 cm from the balloon surface was prescribed to the HDR brachytherapy cohort. CT-based planning was used for all patients. Organ at risk doses and excess risk ratios (ERR) for secondary lung cancers, contralateral breast cancers, and cardiac toxicity were compared between treatment techniques. RESULTS Compared to WB-DIBH and PB-DIBH, PB-IORT resulted in lower ipsilateral lung V5, V10, V20, mean, and max dose (P < .05). Mean ipsilateral lung BED3Gy was as follows: 1.32 Gy for PB-IORT, 4.33 Gy for WB-DIBH, 3.35 Gy for PB-DIBH. The ERR for lung cancer was lowest for PB-IORT (P < .001). There was significantly higher contralateral breast max dose but lower mean BED3Gy for WB-DIBH compared with PB-IORT (P = .012, P = .011, respectively). Mean contralateral breast BED3Gy was as follows: 0.10 Gy for PB-IORT, 0.06 Gy for WB-DIBH, and 0.08 Gy for PB-DIBH. The ERR for contralateral breast cancer was low for all breast techniques, but WB-DIBH showed lower ERR compared to PB-IORT (P = .019). Mean heart BED2Gy was higher with PB-IORT at 1.26 Gy compared to 0.48 Gy and 0.24 Gy for WB-DIBH and PB-DIBH, respectively (P < .001). CONCLUSIONS Patients with early-stage breast cancer treated with PB-IORT and with tissue-sparing external beam techniques all received low organ at risk doses, but PB-IORT resulted in far lower ipsilateral lung dose compared with external beam techniques. Our data indicate the lowest mean contralateral breast BED in the WB-DIBH group, likely due to the simplicity of the field design in low-risk patients using tangential whole breast radiation. External beam using DIBH results in lowest heart dose, but all techniques were well within recommended heart constraints.
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Affiliation(s)
- Sunil W Dutta
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Eric Aliotta
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Clayton E Alonso
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Roy C Bliley
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Bruce Libby
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | | | - Einsley M Janowski
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
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Soumarová R, Rušinová L. Cardiotoxicity of breast cancer radiotherapy - overview of current results. Rep Pract Oncol Radiother 2019; 25:182-186. [PMID: 32021574 DOI: 10.1016/j.rpor.2019.12.008] [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: 03/01/2019] [Revised: 07/31/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022] Open
Abstract
Adjuvant radiotherapy after breast cancer surgery is an important part of breast cancer treatment improving local control and overall survival. However, a higher risk of cardiac mortality was observed when conventional radiotherapy techniques were used. Cardiac morbidity and mortality after radiation therapy have been studied in many meta-analyses. In those focused on modern radiotherapy techniques, cardiac morbidity and mortality were no longer presented. However, an extremely long follow-up period is required. Importantly, the cardiac morbidity rates vary depending not only on the dose delivered to the heart, but also on the systemic therapies administrated and the pre-existing cardiac disease. Systematic heart dose monitoring is of great importance, as are efforts to constantly decrease doses, using advanced radiotherapy techniques. Nowadays, it is essential to individualize treatment according to tumor characteristics and anatomical predispositions, and to consider the cost and benefits.
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Affiliation(s)
- R Soumarová
- Department of Radiotherapy and Oncology, Third Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague, Czech Republic
| | - L Rušinová
- Department of Radiotherapy and Oncology, Third Faculty of Medicine, Charles University and Královské Vinohrady University Hospital, Prague, Czech Republic
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Karimi AM, Tom MC, Manyam BV, Obi E, Tendulkar RD, Cherian S, Fleming C, Suarez E, Naik M, Shah C. Evaluating improvements in cardiac dosimetry in breast radiotherapy and comparison of cardiac sparing techniques. ACTA ACUST UNITED AC 2019. [DOI: 10.1007/s13566-019-00400-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Testolin A, Ciccarelli S, Vidano G, Avitabile R, Dusi F, Alongi F. Deep inspiration breath-hold intensity modulated radiation therapy in a large clinical series of 239 left-sided breast cancer patients: a dosimetric analysis of organs at risk doses and clinical feasibility from a single center experience. Br J Radiol 2019; 92:20190150. [PMID: 31265316 PMCID: PMC6732919 DOI: 10.1259/bjr.20190150] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/18/2019] [Accepted: 06/25/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To evaluate dose to organs at risk, target coverage and treatment compliance in left-sided breast cancer patients (LSBCP) treated with deep inspiration breath-hold (DIBH) and intensity modulated radiation therapy (IMRT) technique in a contest of daily clinical practice. METHODS A total of 280 consecutive LSBCP referred for adjuvant radiotherapy were systematically screened for suitability of DIBH technique. 239 were able to comply with the requirement for DIBH. Whole breast or chest wall were irradiated in DIBH, monitored by Varian RPM™ Respiratory Gating System, and two tangential inverse-planned beams with dynamic dose delivery. Dose prescription was 42.4 Gy/16 fractions in 205 patients and 50 Gy/25 fractions in 34. 23 patients received local and nodal treatment. Boost to tumor bed, of 10 Gy/5 fractions was used in 135 patients. Relevant dose metrics for heart, left anterior descending (LAD) coronary artery, lungs, contralateral breast and planning target volume were retrospectively analyzed. RESULTS The average mean heart dose (MHD) for all patients was 0.94 Gy and mean maximum LAD dose was 13.82 Gy. MHD and LAD maximum dose were significantly higher in patients treated with conventional fractionation whether expressed in absolute dose (1.44 vs 0.85 Gy, p < 0.0005 and 20.78 vs 12.45 Gy, p < 0.0005 respectively) or in equivalent doses of 2 Gy fractionation (0.88 vs 0.52 Gy, p =< 0.0005 and 17.68 vs 10.63 Gy, p = 0.0002 respectively). In 57 patients (23.8%) the maximum LAD dose was >20 Gy. Mean V20 ipsilateral lung dose was 8.5%. Mean doses of contralateral breast and lung were 0.13 Gy and 0.09 Gy respectively. Mean planning target volume V95% coverage was 96.1%. Compliance rate of DIBH technique was 84.5% (239/280). CONCLUSION DIBH and IMRT in daily clinical practice are feasible in high percentage of unselected patients and allows low levels of irradiation of organs at risk without compromising target coverage. However, despite low MHD a significant proportion of patients receives a maximum LAD dose superior to 20 Gy. ADVANCES IN KNOWLEDGE The value of MHD used exclusively is not able to describe entirely the risk of late heart toxicity, which can be better evaluated with the joint analysis of the maximum dose to LAD region. The vast majority of LSBCP referred to adjuvant radiotherapy in the setting of routine practice are able to comply with the requirement of DIBH.
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Affiliation(s)
- Alessandro Testolin
- Department of Radiation Oncology, Policilinico Abano Terme, Abano Terme, Padua, Italy
| | - Stefano Ciccarelli
- Department of Radiation Oncology, Policilinico Abano Terme, Abano Terme, Padua, Italy
| | - Giulia Vidano
- Department of Radiation Oncology, Policilinico Abano Terme, Abano Terme, Padua, Italy
| | - Rossella Avitabile
- Department of Radiation Oncology, Policilinico Abano Terme, Abano Terme, Padua, Italy
| | - Francesca Dusi
- Department of Radiation Oncology, Policilinico Abano Terme, Abano Terme, Padua, Italy
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Finazzi T, Nguyen VT, Zimmermann F, Papachristofilou A. Impact of patient and treatment characteristics on heart and lung dose in adjuvant radiotherapy for left-sided breast cancer. Radiat Oncol 2019; 14:153. [PMID: 31462267 PMCID: PMC6714299 DOI: 10.1186/s13014-019-1364-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/21/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE The heart and lungs are routinely exposed to incidental irradiation during adjuvant radiotherapy (RT) of breast cancer. We analyzed the impact of patient and treatment characteristics on heart and lung dose in left-sided breast RT. METHODS We analyzed 332 female patients treated with left-sided breast RT between 2013 and 2018. Mean heart dose (MHD), left mean lung dose (MLD) and heart / lung V20Gy were collected from treatment plans. Patients were stratified by RT technique (3D-conformal RT, 3DCRT; intensity-modulated RT, IMRT; volumetric modulated arc therapy, VMAT) and target volumes, including lymph node RT (LN-RT). Patient characteristics (body mass index (BMI), heart and lung volume) were assessed using correlation analyses. RESULTS LN-RT was performed in 111 patients with increased MHD (median 4.6 vs. 3.3 Gy; p < .01), left MLD (14.8 vs. 7.7 Gy; p < .01) and left lung V20Gy (30.0% vs. 14.4%; p < .01) compared to treatment without LN-RT. Internal mammary LN-RT further increased organ doses compared to RT involving only supraclavicular +/- axillary LN (p < .01 for all values; MHD 6.9 vs. 4.2 Gy). In 221 patients treated without LN-RT, IMRT/VMAT was associated with higher left lung doses (MLD 9.1 vs. 7.4 Gy, p < .01; V20Gy 18.8% vs. 14.0%, p < .01) compared to 3DCRT. A negative correlation between total lung volume and both MHD (r = - 0.38; p < .01) and heart V20Gy (r = - 0.37; p < .01), as well as a weak positive correlation of BMI and MHD (r = 0.27; p < .01) were observed. CONCLUSIONS In adjuvant RT for left-sided breast cancer, LN-RT is associated with a marked increase in heart and lung doses, particularly with internal mammary LN-RT. Potential advantages of IMRT/VMAT for breast or chest wall RT need to be weighed against a moderately increased lung dose.
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Affiliation(s)
- Tobias Finazzi
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Van-Trinh Nguyen
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Frank Zimmermann
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Alexandros Papachristofilou
- Clinic of Radiotherapy and Radiation Oncology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
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Dess RT, Sun Y, Muenz DG, Paximadis PA, Dominello MM, Grills IS, Kestin LL, Movsas B, Masi KJ, Matuszak MM, Radawski JD, Moran JM, Pierce LJ, Hayman JA, Schipper MJ, Jolly S. Cardiac Dose in Locally Advanced Lung Cancer: Results From a Statewide Consortium. Pract Radiat Oncol 2019; 10:e27-e36. [PMID: 31382026 DOI: 10.1016/j.prro.2019.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/17/2019] [Accepted: 07/23/2019] [Indexed: 12/25/2022]
Abstract
PURPOSE The heart has been identified as a potential significant organ at risk in patients with locally advanced non-small cell lung cancer treated with radiation. Practice patterns and radiation dose delivered to the heart in routine practice in academic and community settings are unknown. METHODS AND MATERIALS Between 2012 and 2017, 746 patients with stage III non-small cell lung cancer were treated with radiation within the statewide Michigan Radiation Oncology Quality Consortium (MROQC). Cardiac radiation dose was characterized, including mean and those exceeding historical or recently proposed Radiation Therapy Oncology Group and NRG Oncology constraints. Sites were surveyed to determine dose constraints used in practice. Patient-, anatomic-, and treatment-related associations with cardiac dose were analyzed using multivariable regression analysis and inverse probability weighting. RESULTS Thirty-eight percent of patients had a left-sided primary, and 80% had N2 or N3 disease. Median prescription was 60 Gy (interquartile range, 60-66 Gy). Twenty-two percent of patients were prescribed 60 Gy in 2012, which increased to 62% by 2017 (P < .001). Median mean heart dose was 12 Gy (interquartile range, 5-19 Gy). The volume receiving 30 Gy (V30 Gy) exceeded 50% in 5% of patients, and V40 Gy was >35% in 3% of cases. No heart dose constraint was uniformly applied. Intensity modulated radiation therapy (IMRT) usage increased from 33% in 2012 to 86% in 2017 (P < .001) and was significantly associated with more complex cases (larger planning target volume, higher stage, and preexisting cardiac disease). In multivariable regression analysis, IMRT was associated with a lower percent of the heart receiving V30 Gy (absolute reduction = 3.0%; 95% confidence interval, 0.5%-5.4%) and V50 Gy (absolute reduction = 3.6%; 95% confidence interval, 2.4%-4.8%) but not mean dose. In inverse probability weighting analysis, IMRT was associated with 29% to 48% relative reduction in percent of the heart receiving V40-V60 Gy without increasing lung or esophageal dose or compromising planning target volume coverage. CONCLUSIONS Within MROQC, historical cardiac constraints were met in most cases, yet 1 in 4 patients received a mean heart dose exceeding 20 Gy. Future work is required to standardize heart dose constraints and to develop treatment approaches that allow for constraints to be met without compromising other planning goals.
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Affiliation(s)
- Robert T Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Yilun Sun
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Daniel G Muenz
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Larry L Kestin
- MHP Radiation Oncology Institute, Farmington Hills, Michigan
| | | | | | - Martha M Matuszak
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | | | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - James A Hayman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Matthew J Schipper
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
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Mizuno N, Yamauchi R, Kawamori J, Itazawa T, Shimbo M, Nishimura K, Yamano T, Hatanaka S, Hariu M, Takahashi T. Evaluation of a new commercial automated planning software for tangential breast intensity-modulated radiation therapy. Radiol Phys Technol 2019; 12:249-259. [PMID: 31115835 DOI: 10.1007/s12194-019-00515-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/25/2022]
Abstract
Automated treatment planning may decrease the effort required in planning and promote increased routine clinical use of intensity-modulated radiation therapy (IMRT) for many breast cancer patients. The aim of this study was to evaluate a new commercial automated planning software for tangential breast IMRT by comparing it with clinical plans from whole-breast irradiation. We prospectively enrolled 150 patients with Stage 0-1 breast cancer who underwent breast-conserving surgery at our institution between September 2016 and August 2017. Total doses of 42.56 Gy in 16 fractions (n = 98) or 50 Gy in 25 fractions (n = 44) were used. All treatment plans were retrospectively re-planned using the automated breast planning (ABP) software. All automated plans generated clinically deliverable beam parameters with no patient body collision and no contralateral breast pass through. The mean homogeneity index of the automatically generated clinical target volume, percentage volume of lungs receiving dose more than 20 Gy, mean heart dose, and dose to the highest irradiated 2-cc volumes of the irradiated volume were 0.077 ± 0.019, 4.2% ± 1.2%, 142 ± 69 cGy, and 105.8% ± 1.7% (prescribed dose: 100%), respectively. The mean planning time was 4.8 ± 1.4 min. The ABP software demonstrated high clinical acceptability and treatment planning cost efficiency for tangential breast IMRT. The ABP software may be useful for delivering high-quality treatment to a majority of patients with early-stage breast cancer.
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Affiliation(s)
- Norifumi Mizuno
- Department of Radiation Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan. .,Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan.
| | - Ryouhei Yamauchi
- Department of Radiation Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Tomoko Itazawa
- Department of Radiation Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Munefumi Shimbo
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan
| | - Keiichiro Nishimura
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan
| | - Takafumi Yamano
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan
| | - Shogo Hatanaka
- Department of Radiation Oncology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-8560, Japan.,Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan
| | - Masatsugu Hariu
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan
| | - Takeo Takahashi
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe City, Saitama, 350-8550, Japan
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Haffty BG. Supine or Prone Breast Radiation: Upsides and Downsides. Int J Radiat Oncol Biol Phys 2019; 101:510-512. [PMID: 29893266 DOI: 10.1016/j.ijrobp.2018.03.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/11/2018] [Accepted: 03/22/2018] [Indexed: 01/12/2023]
Affiliation(s)
- Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson and New Jersey Medical School, New Brunswick, New Jersey.
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Desai N, Currey A, Kelly T, Bergom C. Nationwide Trends in Heart-Sparing Techniques Utilized in Radiation Therapy for Breast Cancer. Adv Radiat Oncol 2019; 4:246-252. [PMID: 31011669 PMCID: PMC6460327 DOI: 10.1016/j.adro.2019.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/03/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose Radiation dose to the heart correlates with cardiac-related deaths and may partially diminish the benefit of radiation for breast cancer. This study assessed the current nationwide trends in heart-sparing techniques for breast cancer radiation. Methods and Materials In November 2017, an institutional review board–approved survey was sent to radiation oncologists in the United States. Questions assessed demographics and the type and frequency of heart-sparing techniques. Data were analyzed using descriptive statistics and χ2 tests. Results In total, 530 responses (13%) were obtained. Most physicians had practiced >15 years (46%), with most in a private setting (59%). Eighty-three percent of physicians offered prone positioning and/or deep inspiration breath hold (DIBH). This was more common in academic practice (P < .01). Seventy-three percent of physicians used heart-sparing techniques for more than three-fourths of left-sided patients. The most commonly used technique was DIBH, and 43% of physicians used the technique more than three-fourths of the time. Commonly used DIBH systems were Varian RPM (54%) and Vision RT/Align RT (31%). No increase in DIBH use was observed with regional nodal irradiation, and coverage of internal mammary chain nodes varied. Patient tolerance (78%) and cardiac-to-chest wall distance (72%) were the most common determinants of DIBH in left-sided patients. Twenty-three percent of physicians used DIBH for right-sided patients, with lung (64%) and heart sparing (46%) as the most common reasons for use. Lack of facilities was the most common reason not to use DIBH (61%). Conclusions Most respondents offer heart-sparing techniques for breast cancer radiation; this is more common in academic centers. DIBH is the most common technique across all practice settings. DIBH is much less commonly used in right-sided patients but is still used by >20% of practitioners, with lung and heart sparing cited as reasons for use. More data are needed to determine if and when this technique should be used in right-sided cases.
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Affiliation(s)
- Nina Desai
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
| | - Adam Currey
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
| | - Tracy Kelly
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
| | - Carmen Bergom
- Medical College of Wisconsin, Department of Radiation Oncology, Milwaukee, Wisconsin
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Delineation of a Cardiac Planning Organ-At-Risk Volume Using Real-Time Magnetic Resonance Imaging for Cardiac Protection in Thoracic and Breast Radiation Therapy. Pract Radiat Oncol 2018; 9:e298-e306. [PMID: 30576844 DOI: 10.1016/j.prro.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/15/2018] [Accepted: 12/08/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Cardiac radiation is associated with cardiotoxicity in patients with thoracic and breast malignancies. We conducted a prospective study using cine magnetic resonance imaging (MRI) scans to evaluate heart motion. We hypothesized that cine MRI could be used to define population-based cardiac planning organ-at-risk volumes (PRV). METHODS AND MATERIALS A total of 16 real-time acquisitions were obtained per subject on a 1.5 Tesla MRI (Philips Ingenia). Planar cine MRI was performed in 4 sequential sagittal and coronal planes at free-breathing (FB) and deep-inspiratory breath hold (DIBH). In-plane cardiac motion was assessed using a scale-invariant feature transformation-based algorithm. Subject-specific pixel motion ranges were defined in anteroposterior (AP), left-right (LR), and superoinferior (SI) planes. Averages of the 98% and 67% of the maximum ranges of pixel displacement were defined by subject, then averaged across the cohort to calculate PRV expansions at FB and DIBH. RESULTS Data from 20 subjects with a total of 3120 image frames collected per subject in coronal and sagittal planes at DIBH and FB, and 62,400 total frames were analyzed. Cohort averages of 98% of the maximum cardiac motion ranges comprised margin expansions of 12.5 ± 1.1 mm SI, 5.8 ± 1.2 mm AP, and 6.6 ± 1.0 mm LR at FB and 6.7 ± 1.5 mm SI, 4.7 ± 1.3 mm AP, and 5.3 ± 1.3 mm LR at DIBH. Margins for 67% of the maximum range comprised 7.7 ± 0.7 mm SI, 3.2 ± 0.6 mm AP, and 3.7 ± 0.6 mm LR at FB and 4.1 ± 0.9 mm SI, 2.7 ± 0.8 mm AP, and 3.2 ± 0.8 mm LR at DIBH. Subsequently, these margins were simplified to form PRVs for treatment planning. CONCLUSIONS We implemented scale-invariant feature transformation-based motion tracking for analysis of the cardiac cine MRI scans to quantify motion and create cohort-based cardiac PRVs to improve cardioprotection in breast and thoracic radiation.
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Xu H, Lee SW, Guerrero M, Yi BY, Chen S, Becker SJ, Chung H, Cheston SB. Dosimetric effects of the kV based image-guided radiation therapy of prone breast external beam radiation: Towards the optimized imaging frequency. J Appl Clin Med Phys 2018; 20:212-219. [PMID: 30550644 PMCID: PMC6333126 DOI: 10.1002/acm2.12511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/10/2018] [Accepted: 11/20/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE For prone breast treatment, daily image-guided radiation therapy (IGRT) allows couch shifting to correct breast position relative to the treatment field. This work investigates the dosimetric effect of reducing kV imaging frequencies and the feasibility of optimizing the frequency using patient anatomy or their first 3-day shifts. METHOD Thirty-seven prone breast patients who had been treated with skin marker alignment followed by daily kV were retrospectively analyzed. Three IGRT schemes (daily-kV, weekly-kV, no-kV) were simulated, assuming that fractions with kV imaging deliver a dose distribution equivalent to that in computed tomography (CT) planning, whereas other fractions yield a dose distribution as recreated by shifting the CT plan isocenter back to its position before the couch shift was applied. Treatment dose to targets (breast and lumpectomy cavity [LPC]) and organs at risks (OAR)s (heart, ipsilateral lung) in different schemes were calculated. Patient anatomy information on CT plans and first 3-day couch shift data were analyzed to investigate whether these factors could guide imaging scheme optimization. RESULTS When kV imaging frequency was reduced, the percentage dose changes (δD) for breast and LPC objectives (average <1%) were smaller than those for heart and lung (average 28%-31% for Dmean ). In general, the δD of no-kV imaging was approximately that of weekly kV imaging × a factor of 1.2-1.4. Although most dose objectives were not affected, the potential higher heart dose may be of concern. No strong correlation was found between δD for different kV frequencies and patient anatomy size/distance or the first 3-day couch shift data. CONCLUSIONS Despite resulting in lower imaging dose, time, cost, and similar target coverage, a reduction in kV imaging frequency may introduce higher heart complication risk. Daily kVs are needed more in left-sided breast patients. A less frequent imaging schedule, if considered, cannot be individually optimized using CT anatomic features or early shift data.
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Affiliation(s)
- Huijun Xu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Sung-Woo Lee
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Mariana Guerrero
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Byong Yong Yi
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
| | | | - Sally B Cheston
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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Demissei BG, Freedman G, Feigenberg SJ, Plastaras JP, Maity A, Smith AM, McDonald C, Sheline K, Simone CB, Lin LL, Carver JR, Liu P, Zhang L, Bekelman JE, Ky B. Early Changes in Cardiovascular Biomarkers with Contemporary Thoracic Radiation Therapy for Breast Cancer, Lung Cancer, and Lymphoma. Int J Radiat Oncol Biol Phys 2018; 103:851-860. [PMID: 30445173 DOI: 10.1016/j.ijrobp.2018.11.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/11/2018] [Accepted: 11/06/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE We characterized the early changes in cardiovascular biomarkers with contemporary thoracic radiation therapy (RT) and evaluated their associations with radiation dose-volume metrics including mean heart dose (MHD), V5, and V30. METHODS AND MATERIALS In a prospective longitudinal study of 87 patients with breast cancer, lung cancer, or mediastinal lymphoma treated with photon or proton thoracic RT, blood samples were obtained pre-RT and after completion of RT (median, 20 days; interquartile range [IQR], 1-35). High-sensitivity cardiac troponin T, N-terminal pro-B-type natriuretic peptide, placental growth factor (PIGF), and growth differentiation factor 15 (GDF-15) were measured. Associations between MHD, V5 and V30, and biomarker levels and associations between echocardiography-derived measures of cardiac function and biomarker levels were assessed in multivariable linear regression models. Analyses were performed according to the following subgroups: (1) breast cancer alone and (2) lung cancer and lymphoma combined. RESULTS The median (IQR) estimates of MHD ranged from 1.3 Gy (0.9-2.4) in breast cancer (n = 60) to 6.8 Gy (5.4-10.2) in mediastinal lymphoma (n = 14) and 8.4 Gy (6.7-16.1) in lung cancer (n = 13) patients (P < .001). There were no significant increases in biomarker levels from pre-RT to post-RT in breast cancer. In lung cancer/lymphoma, PIGF increased from a median (IQR) of 20 ng/L (16-26) to 22 ng/L (16-30) (P = .005), and GDF-15 increased from 1171 ng/L (755-2493) to 1887 ng/L (903-3763) (P = .006). MHD, V5, and V30 were significantly associated with post-RT PIGF and GDF-15 levels in multivariable models. Changes in biomarkers were not significantly associated with changes in echocardiography-derived measures of cardiac function. CONCLUSION Contemporary thoracic RT induces acute abnormalities in vascular and inflammatory biomarkers that are associated with radiation dose-volume metrics, particularly in lung cancer and mediastinal lymphoma. Long-term follow-up studies are needed to determine the impact of these changes on the development of overt cardiac disease.
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Affiliation(s)
- Biniyam G Demissei
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gary Freedman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Plastaras
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Maity
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda M Smith
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin McDonald
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karyn Sheline
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles B Simone
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, Maryland
| | - Lilie L Lin
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph R Carver
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter Liu
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Liyong Zhang
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Justin E Bekelman
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Medicine, Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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Dean MK, Amestoy W, Takita C, Samuels SE. Radiographic predictors of IMRT for treating regional lymph nodes in breast cancer. Med Dosim 2018; 44:274-278. [PMID: 30396725 DOI: 10.1016/j.meddos.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/05/2018] [Accepted: 10/11/2018] [Indexed: 10/27/2022]
Abstract
Regional nodal irradiation (RNI) is an essential part of the treatment of high risk early stage (Stage IIb) and locally advanced (Stage III) breast cancer. Acceptable radiation plans can usually be achieved using 3-dimensional conformal radiation therapy with deep-inspiration breath hold to limit dose to the heart, although in some cases intensity-modulated radiation therapy produces superior results. The goal of this study is to identify radiographic parameters that predict the need for IMRT when delivering RNI. We retrospectively examined breast cancer patients treated with comprehensive RNI including internal mammary lymph nodes, supraclavicular lymph nodes, and undissected axillary lymph nodes at our institution from January 2016 to February 2018. Radiographic parameters including lung volume, internal mammary lymph nodes depth, modified central lung distance (mCLD), tangent length, and target height were recorded. Univariate and multivariate logistic regression was performed using IMRT as a binary endpoint (yes/no). A total of 46 patients were evaluated, of which 9 (20%) required IMRT. Five of the 9 (56%) IMRT patients were postmastectomy with a tissue expander in place. There was an increased likelihood of IMRT per 0.5 cm increase in mCLD (odds ratios [OR]: 3.27; 95% confidence interval [CI]: 1.39 to 9.63; p = 0.01) and per 1 cm increase in target height (OR: 1.77; 95% CI: 1.08 to 3.40; p = 0.04). A threshold value of 3.38 cm was identified for mCLD (OR 10.3; 95% CI: 2.14 to 61.4; p value = 0.005), and 25.2 cm for target height (OR 10.9; 95% CI: 2.19 to 82.7; p value = 0.007). When delivering RNI, larger values of mCLD and target height corresponded to the use of IMRT. Further investigations are warranted to confirm these findings, which may improve the efficiency of the treatment planning process and in turn patient care.
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Affiliation(s)
- Mary K Dean
- Department of Radiation Oncology, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - William Amestoy
- Department of Radiation Oncology, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Cristiane Takita
- Department of Radiation Oncology, University of Miami/Jackson Memorial Hospital, Miami, FL, USA
| | - Stuart E Samuels
- Department of Radiation Oncology, University of Miami/Jackson Memorial Hospital, Miami, FL, USA.
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Drost L, Yee C, Lam H, Zhang L, Wronski M, McCann C, Lee J, Vesprini D, Leung E, Chow E. A Systematic Review of Heart Dose in Breast Radiotherapy. Clin Breast Cancer 2018; 18:e819-e824. [DOI: 10.1016/j.clbc.2018.05.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/27/2018] [Accepted: 05/30/2018] [Indexed: 11/26/2022]
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Ratosa I, Jenko A, Oblak I. Breast size impact on adjuvant radiotherapy adverse effects and dose parameters in treatment planning. Radiol Oncol 2018; 52:233-244. [PMID: 30210048 PMCID: PMC6137355 DOI: 10.2478/raon-2018-0026] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/12/2018] [Indexed: 02/08/2023] Open
Abstract
Background Breast radiotherapy is an established adjuvant treatment after breast conserving surgery. One of the important individual factors affecting the final cosmetic outcome after radiation is breast size. The purpose of this review is to summarise the clinical toxicity profile of adjuvant radiotherapy in women with breasts of various sizes, and to evaluate the treatment planning studies comparing target coverage and dose to thoracic organs at risk in relation to breast size. Conclusions Inhomogeneity and excessive radiation dose (hot spots) in the planning of target volume as well as large volume of the breast per se, all contribute to a higher rate of acute adverse events and suboptimal final cosmetic outcome in adjuvant breast cancer radiotherapy, regardless of the fractionation schedule. Improved homogeneity leads to a lower rate of ≥ grade 2 toxicity and can be achieved with three-dimensional conformal or modulated radiotherapy techniques. There may be an association between body habitus (higher body mass index, bigger breast size, pendulous breast, and large chest wall separation) and a higher mean dose to the ipsilateral lung and whole heart. A combination of the technical innovations (i.e. the breath-hold technique, prone position with or without holding breath, lateral decubitus position, and thermoplastic bra), dose prescription (i.e. moderate hypofractionation), and irradiated volume (i.e. partial breast irradiation) should be tailored to every single patient in clinical practice to mitigate the risk of radiation adverse effects.
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Affiliation(s)
- Ivica Ratosa
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Aljasa Jenko
- Division of Radiotherapy, Department of Medical Physics, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Irena Oblak
- Division of Radiotherapy, Institute of Oncology Ljubljana, Ljubljana, Slovenia
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Boekel NB, Jacobse JN, Schaapveld M, Hooning MJ, Gietema JA, Duane FK, Taylor CW, Darby SC, Hauptmann M, Seynaeve CM, Baaijens MHA, Sonke GS, Rutgers EJT, Russell NS, Aleman BMP, van Leeuwen FE. Cardiovascular disease incidence after internal mammary chain irradiation and anthracycline-based chemotherapy for breast cancer. Br J Cancer 2018; 119:408-418. [PMID: 30065254 PMCID: PMC6133926 DOI: 10.1038/s41416-018-0159-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 04/14/2018] [Accepted: 06/07/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Improved breast cancer (BC) survival and evidence showing beneficial effects of internal mammary chain (IMC) irradiation underscore the importance of studying late cardiovascular effects of BC treatment. METHODS We assessed cardiovascular disease (CVD) incidence in 14,645 Dutch BC patients aged <62 years, treated during 1970-2009. Analyses included proportional hazards models and general population comparisons. RESULTS CVD rate-ratio for left-versus-right breast irradiation without IMC was 1.11 (95% CI 0.93-1.32). Compared to right-sided breast irradiation only, IMC irradiation (interquartile range mean heart doses 9-17 Gy) was associated with increases in CVD rate overall, ischaemic heart disease (IHD), heart failure (HF) and valvular heart disease (hazard ratios (HRs): 1.6-2.4). IHD risk remained increased until at least 20 years after treatment. Anthracycline-based chemotherapy was associated with an increased HF rate (HR = 4.18, 95% CI 3.07-5.69), emerging <5 years and remaining increased at least 10-15 years after treatment. IMC irradiation combined with anthracycline-based chemotherapy was associated with substantially increased HF rate (HR = 9.23 95% CI 6.01-14.18), compared to neither IMC irradiation nor anthracycline-based chemotherapy. CONCLUSIONS Women treated with anthracycline-based chemotherapy and IMC irradiation (in an older era) with considerable mean heart dose exposure have substantially increased incidence of several CVDs. Screening may be appropriate for some BC patient groups.
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Affiliation(s)
- Naomi B Boekel
- Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Judy N Jacobse
- Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Michael Schaapveld
- Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Maartje J Hooning
- Department of Medical Oncology, Erasmus MC - Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Jourik A Gietema
- Medical Oncology, University Medical Center Groningen, Hanzeplein 1, 9213 GZ, Groningen, The Netherlands
| | - Frances K Duane
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Carolyn W Taylor
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Sarah C Darby
- Nuffield Department of Population Health, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Michael Hauptmann
- Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Caroline M Seynaeve
- Department of Medical Oncology, Erasmus MC - Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Margreet H A Baaijens
- Radiation Oncology, Erasmus MC - Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Gabe S Sonke
- Medical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Emiel J T Rutgers
- Surgery, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Nicola S Russell
- Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Berthe M P Aleman
- Radiation Oncology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Flora E van Leeuwen
- Epidemiology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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Piroth MD. Abschätzung von Langzeitrisiken der modernen Strahlentherapie bei Patientinnen mit Mammakarzinom: Evidenz zu Strahlendosen an Lunge und Herz. Strahlenther Onkol 2018; 194:693-694. [DOI: 10.1007/s00066-018-1310-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Chang JS, Kim YB, Shin J. In Regard to Cahlon et al. Int J Radiat Oncol Biol Phys 2018; 100:1298-1299. [DOI: 10.1016/j.ijrobp.2018.01.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 01/16/2018] [Indexed: 11/29/2022]
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