1
|
Chen ZJ, Li XA, Brenner DJ, Hellebust TP, Hoskin P, Joiner MC, Kirisits C, Nath R, Rivard MJ, Thomadsen BR, Zaider M. AAPM Task Group Report 267: A joint AAPM GEC-ESTRO report on biophysical models and tools for the planning and evaluation of brachytherapy. Med Phys 2024; 51:3850-3923. [PMID: 38721942 DOI: 10.1002/mp.17062] [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: 12/05/2023] [Revised: 02/28/2024] [Accepted: 03/08/2024] [Indexed: 06/05/2024] Open
Abstract
Brachytherapy utilizes a multitude of radioactive sources and treatment techniques that often exhibit widely different spatial and temporal dose delivery patterns. Biophysical models, capable of modeling the key interacting effects of dose delivery patterns with the underlying cellular processes of the irradiated tissues, can be a potentially useful tool for elucidating the radiobiological effects of complex brachytherapy dose delivery patterns and for comparing their relative clinical effectiveness. While the biophysical models have been used largely in research settings by experts, it has also been used increasingly by clinical medical physicists over the last two decades. A good understanding of the potentials and limitations of the biophysical models and their intended use is critically important in the widespread use of these models. To facilitate meaningful and consistent use of biophysical models in brachytherapy, Task Group 267 (TG-267) was formed jointly with the American Association of Physics in Medicine (AAPM) and The Groupe Européen de Curiethérapie and the European Society for Radiotherapy & Oncology (GEC-ESTRO) to review the existing biophysical models, model parameters, and their use in selected brachytherapy modalities and to develop practice guidelines for clinical medical physicists regarding the selection, use, and interpretation of biophysical models. The report provides an overview of the clinical background and the rationale for the development of biophysical models in radiation oncology and, particularly, in brachytherapy; a summary of the results of literature review of the existing biophysical models that have been used in brachytherapy; a focused discussion of the applications of relevant biophysical models for five selected brachytherapy modalities; and the task group recommendations on the use, reporting, and implementation of biophysical models for brachytherapy treatment planning and evaluation. The report concludes with discussions on the challenges and opportunities in using biophysical models for brachytherapy and with an outlook for future developments.
Collapse
Affiliation(s)
- Zhe Jay Chen
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - X Allen Li
- Department of Radiation Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David J Brenner
- Center for Radiological Research, Columbia University Medical Center, New York, New York, USA
| | - Taran P Hellebust
- Department of Oncology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - Peter Hoskin
- Mount Vernon Cancer Center, Mount Vernon Hospital, Northwood, UK
- University of Manchester, Manchester, UK
| | - Michael C Joiner
- Department of Radiation Oncology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Christian Kirisits
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Ravinder Nath
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mark J Rivard
- Department of Radiation Oncology, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
| | - Marco Zaider
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
2
|
Sato K, Fuchikami H, Takeda N, Natsume N, Kato M. Preliminary report on ultrashort perioperative partial-breast irradiation with multicatheter interstitial brachytherapy for early-stage breast cancer. Breast Cancer 2024; 31:382-390. [PMID: 38363473 DOI: 10.1007/s12282-024-01546-w] [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: 09/21/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE Perioperative partial-breast irradiation (PBI) with multicatheter interstitial brachytherapy (MIB) is less invasive and more convenient than postoperative one. This study aimed to compare ultrashort perioperative MIB-PBI (uPBI) and conventional perioperative MIB-PBI (cPBI) performed during the same period of time. METHODS Inclusion criteria of the study were patients aged ≥ 40 years and those with T0-2 (≤ 3 cm), N0-mi, and negative margins on mammography. The locoregional recurrence (LRR) and toxicity rates were compared between uPBI at a dose of 25.2 Gy in four fractions and cPBI at a dose of 32 Gy in eight fractions. RESULTS In total, 198 patients (151 with uPBI and 47 with cPBI) were evaluated. At a median follow-up of 20.1 months, one (0.66%) patient in the uPBI group had LRR. The 2-year ipsilateral breast tumor recurrence-free survival rates of the uPBI and cPBI groups were 98.7% and 100%, respectively. The highest toxicity grades were grade 1 in 23 (15.2%) and grade 2 in 2 (1.3%) patients in the uPBI group, and grade 1 in 8 (17.0%) and grade 2 in 1 (2.1%) patient in the cPBI group. None of the patients in the two groups presented with grade 3 and higher toxicities. The toxicity rates between the two groups did not significantly differ. Further, 22 (14.6%) patients in the uPBI group and 8 (17.0%) in the cPBI group, and 3 (2.0%) patients in the uPBI group and 1 (2.1%) in the cPBI had acute and late toxicities, respectively. The timing of toxicity development between the two groups did not significantly differ. CONCLUSIONS Although this preliminary report included a small sample size and had a short follow-up period, the local control and toxicity rates were similar between the uPBI and cPBI groups. Further research is warranted to investigate the ideal dose schedule of MIB-PBI.
Collapse
Affiliation(s)
- Kazuhiko Sato
- Department of Breast Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan.
| | - Hiromi Fuchikami
- Department of Breast Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| | - Naoko Takeda
- Department of Breast Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| | - Nana Natsume
- Department of Radiation Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| | - Masahiro Kato
- Department of Radiation Oncology, Tokyo-West Tokushukai Hospital, Tokyo, Japan
| |
Collapse
|
3
|
Hannoun-Levi JM, Gimeno Morales M, Gal J, Anchuelo J, Guinot JL, Gaztañaga M, Meszaros N, Polgar C, Strnad V, Schiappa R, Gutierrez C. Very accelerated partial breast irradiation in 1 or 2 days: Late toxicity and early oncological outcome of the GEC-ESTRO VAPBI cohort. Radiother Oncol 2024; 194:110217. [PMID: 38460552 DOI: 10.1016/j.radonc.2024.110217] [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: 01/06/2024] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE To analyze late toxicity after very accelerated partial breast irradiation (VAPBI) for low-risk breast cancer. MATERIALS Methods: In this retrospective, observational, international multicenter study (HDH F20220713143949), patients with low-risk breast cancer underwent lumpectomy + vAPBI (high-dose rate multicatheter interstitial brachytherapy-MIBT). VAPBI was performed with 4(4x6.2 Gy/2d), 3(3x7.45 Gy/2d) or 1 fraction (1x16Gy or 1x18Gy/1d). Primary endpoint was late toxicity. Secondary endpoints were cumulative incidence of breast cancer local relapse (LR) and distant metastatic relapse (DMR) and specific (SS) and overall (OS) survivals. Prognostic factors for late toxicity were analyzed. RESULTS From 01/2012 to 06/2022, 516 pts with early breast cancer were enrolled. Median follow-up was 44 months [95 %CI 39-46]. Median age was 71 years [40-100]. Median tumor size was 12 mm [1-35]. VAPBI delivered 1, 3 and 4 fractions for 205pts (39.7 %), 167pts (32.4 %) and 144pts (28 %) respectively. 221 late toxicity events were observed in 168pts (32.6 %) (Fibrosis, dyschromia, pain and telangiectasia). Grade 2 and 3 late toxicities were observed in 7.2 and 0.6 % respectively (no G4) with no difference between 1 and ≥ 2 treatment days. CTV > 50 cc (p = 0.007) and V150 > 40 % (p = 0.027) were prognostic factors for G ≥ 2 late toxicity. Four-year cumulative incidence rates of LR and DMR were 2 % [95 %CI 0-3] and 1 % [95 %CI 0-2] respectively. CONCLUSIONS VAPBI based on 1 or ≥ 2 days of MIBT represents an attractive de-escalation of irradiation approach for low-risk breast cancer. Late toxicity profile appears acceptable while early oncological outcome shows encouraging local control. Longer follow-up is warranted in order to confirm these preliminary results.
Collapse
Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University Côte d'Azur, 33 avenue Valombrose, 06189 Nice Cedex 2, Nice, France.
| | - Marta Gimeno Morales
- Department of Radiation Oncology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Jocelyn Gal
- Department of Statistics, Antoine Lacassagne Cancer Center - University of Côte d'Azur, Nice, France
| | - Javier Anchuelo
- Department of Radiation Oncology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Jose-Luis Guinot
- Department of Radiation Oncology, Instituto Valenciano de Oncologia, Valencia, Spain
| | - Miren Gaztañaga
- Department of Radiation Oncology, Hospital Clínico San Carlos, Madrid, Spain
| | - Norbert Meszaros
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Csaba Polgar
- National Institute of Oncology and National Tumor Biology Laboratory, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
| | - Renaud Schiappa
- Department of Statistics, Antoine Lacassagne Cancer Center - University of Côte d'Azur, Nice, France
| | - Cristina Gutierrez
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| |
Collapse
|
4
|
Kim H, Hieken TJ, Abraha F, Jakub JW, Corbin KS, Furutani KM, Boughey JC, Stish BJ, Deufel CL, Degnim AC, Shumway DA, Ahmed SK, Piltin MA, Sandhu NP, Conners AL, Ruddy KJ, Mutter RW, Park SS. Long-term outcomes of intraoperatively-placed applicator brachytherapy for rapid completion of breast conserving treatment: An analysis of a prospective registry data. Clin Transl Radiat Oncol 2023; 41:100639. [PMID: 37251618 PMCID: PMC10212787 DOI: 10.1016/j.ctro.2023.100639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 02/09/2023] [Accepted: 05/07/2023] [Indexed: 05/31/2023] Open
Abstract
Background and purpose To evaluate the long-term outcome of accelerated partial breast irradiation utilizing intraoperatively placed applicator-based brachytherapy (ABB) in early-stage breast cancer. Materials and methods From our prospective registry, 223 patients with pTis-T2, pN0/pN1mic breast cancer were treated with ABB. The median treatment duration including surgery and ABB was 7 days. The prescribed doses were 32 Gy/8 fx BID (n = 25), 34 Gy/10 fx BID (n = 99), and 21 Gy/3 fx QD (n = 99). Endocrine therapy (ET) adherence was defined as completion of planned ET or ≥ 80% of the follow-up (FU) period. Cumulative incidence of ipsilateral breast tumor recurrence (IBTR) was estimated and influencing factors for IBTR-free survival rate (IBTRFS) were analyzed. Results 218/223 patients had hormone receptor-positive tumors, including 38 (17.0%) with Tis and 185 (83.0%) with invasive cancer. After a median FU of 63 months, 19 (8.5%) patients had recurrence [17 (7.6%) with an IBTR]. Rates of 5-year IBTRFS and DFS were 92.2% and 91.1%, respectively. The 5-year IBTRFS rates were significantly higher for post-menopausal women (93.6% vs. 66.4%, p = 0.04), BMI < 30 kg/m2 (97.4% vs. 88.1%, p = 0.02), and ET-adherence (97.5% vs. 88.6%, p = 0.02). IBTRFS did not differ with dose regimens. Conclusions Postmenopausal status, BMI < 30 kg/m2, and ET- adherence predicted favorable IBTRFS. Our results highlight the importance of careful patient selection for ABB and encouragement of ET compliance.
Collapse
Affiliation(s)
- Haeyoung Kim
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University of School of Medicine, Seoul, South Korea
| | | | - Feven Abraha
- Department of Biostatistics and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - James W. Jakub
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | | | - Bradley J. Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Amy C. Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Dean A. Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mara A. Piltin
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nicole P. Sandhu
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amy L. Conners
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Robert W. Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
5
|
Yashar C, Khan AJ, Chen P, Einck J, Poppe M, Li L, Yehia ZA, Vicini FA, Moore D, Arthur D, Quinn TJ, Kowzun M, Simon L, Scanderbeg D, Shah C, Haffty BG, Kuske R. Three-Fraction Accelerated Partial Breast Irradiation (APBI) Delivered With Interstitial Brachytherapy Is Safe: First Results From the Tri-fraction Radiation Therapy Used to Minimize Patient Hospital Trips (TRIUMPH-T) Trial. Pract Radiat Oncol 2023:S1879-8500(23)00062-0. [PMID: 37140504 DOI: 10.1016/j.prro.2023.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/07/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Shorter courses of breast radiotherapy are offered as an alternative to 4 weeks of whole-breast irradiation after lumpectomy, including brachytherapy. A prospective phase 2multi-institution clinical trial to study 3-fraction accelerated partial breast irradiation delivered by brachytherapy was conducted. METHODS AND MATERIALS The trial treated selected breast cancers after breast-conserving surgery with brachytherapy applicators that delivered 22.5 Gy in 3 fractions of 7.5 Gy. The planning treatment volume was 1 to 2 cm beyond the surgical cavity. Eligible women were age ≥45 years with unicentric invasive or in situ tumors ≤3 cm excised with negative margins and with positive estrogen or progesterone receptors and no metastases to axillary nodes. Strict dosimetric parameters were required to be met and follow up information was collected from the participating sites. RESULTS Two hundred patients were prospectively enrolled; however, a total of 185 patients who were enrolled were followed for a median of 3.63 years. Three-fraction brachytherapy was associated with low chronic toxicity. There was excellent or good cosmesis in 94% of patients. There were no grade 4 toxicities. Grade 3 fibrosis at the treatment site was present in 1.7% and 32% percent had grades 1 or 2 fibrosis at the treatment site. There was 1 rib fracture. Other late toxicities included 7.4% grade 1 hyperpigmentation, 2% grade 1 telangiectasias, 1.7% symptomatic seromas, 1.7% abscessed cavities, and 1.1% symptomatic fat necrosis. There were 2 (1.1%) ipsilateral local recurrences, 2 (1.1%) nodal recurrences and no distant recurrences. Other incidents included one contralateral breast cancer and 2 second malignancies (lung). CONCLUSIONS Ultra-short breast brachytherapy is feasible and has excellent toxicity and could be an alternative to standard 5-day, 10 fraction accelerated partial breast irradiation in eligible patients. Patients from this prospective trial will continue to be followed to evaluate long-term outcomes.
Collapse
Affiliation(s)
- Catheryn Yashar
- UC San Diego/Moores Cancer Center, La Jolla, California; Bryn Mawr Hospital, Bryn Mawr, Pennsylvania.
| | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Chen
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | - John Einck
- Kansas University Medical Center, Kansas City, Kansas
| | - Matthew Poppe
- Hunstman Cancer Center, University of Utah, Salt Lake City, Utah
| | - Linna Li
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | | | - Frank A Vicini
- Michigan Health care Professional, 21st Century Oncology, Farmington Hills, Michigan
| | - Dirk Moore
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Doug Arthur
- Virginia Commonwealth University, Massey Cancer Center, Richmond, Virginia
| | - T J Quinn
- William Beaumont Hospital/Rose Cancer Treatment Center, Royal Oak, Michigan
| | - Maria Kowzun
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Laurie Simon
- UC San Diego/Moores Cancer Center, La Jolla, California
| | | | - Chirag Shah
- Cleveland Clinic Cancer Center, Cleveland, Ohio
| | - Bruce G Haffty
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, Arizona
| |
Collapse
|
6
|
Chung EM, Nguyen AT, Mirhadi A, Steers JM, Phillips T, Atkins KM, Burnison M, Shiao SL, Kamrava M. A Single-Institution Retrospective Study of Three-Fraction HDR Accelerated Partial Breast Irradiation. Brachytherapy 2023; 22:361-367. [PMID: 36997449 DOI: 10.1016/j.brachy.2023.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 03/30/2023]
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) delivered with high-dose-rate brachytherapy is a standard of care treatment typically delivered over 10 fractions. The TRIUMPH-T multi-institutional study recently demonstrated promising results using a shorter three fraction regimen, however there are limited additional published series using this regimen. Here, we report our experience and outcomes for patients treated as per the TRIUMPH-T regimen. METHODS AND MATERIALS This study was a retrospective single-institution analysis of patients who underwent lumpectomy followed by APBI (22.5 Gy in 3 fractions delivered over 2-3 days) using a Strut Adjusted Volume Implant (SAVI) applicator between November 2016 and January 2021. Dose-volume metrics were obtained from the clinically treated plan. Chart review was performed to determine locoregional recurrence and toxicities according to CTCAE v5.0. RESULTS Between 2016 and 2021, 31 patients were treated per the TRIUMPH-T protocol. Median followup was 31 months from completion of brachytherapy. There were no acute/late Grade 3 or higher toxicities. Cumulative late Grade 1 and 2 toxicities were seen in 58.1% and 9.7% of patients, respectively. Of note, four patients experienced locoregional recurrence: three ipsilateral breast tumor recurrences and one nodal recurrence. All three ipsilateral breast tumor recurrences occurred in patients who would be classified as "cautionary" based on ASTRO consensus guidelines due to age ≤50, lobular histology, or high grade. CONCLUSIONS Three-fraction HDR brachytherapy APBI was well-tolerated with no grade 3 or higher toxicities and an acceptably small percentage of grade 2 toxicities. Given the small sample size, the number of recurrences suggests that attention to appropriate patient selection is necessary until more long-term followup data is available.
Collapse
|
7
|
Anderson B, Vicini F, Wazer D, Arthur D. Breast brachytherapy: Building a bright future on the foundation of a rich history of advancement in technology, technique, and patient-centered care. Brachytherapy 2023; 22:368-380. [PMID: 36740541 DOI: 10.1016/j.brachy.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 02/05/2023]
Abstract
For over 20 years, the concept of accelerated partial breast irradiation (APBI) has received considerable attention. Initially concentrating on the appropriateness of APBI as an alternative treatment to whole breast radiotherapy, investigation and innovation evolved towards dose delivery and technique appropriateness. The purpose of this article is to review the pertinent literature that supports the role brachytherapy serves in delivering APBI and the recognized brachytherapy techniques for dose delivery. Publications establishing techniques utilizing multicatheter brachytherapy, single-entry brachytherapy applicators, permanent breast seed implantation brachytherapy, noninvasive breast brachytherapy and electronic brachytherapy are described. The use of brachytherapy for repeat breast conservation therapy is additionally reviewed. A historical perspective and potential direction of future investigation and innovation are presented.
Collapse
Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
| |
Collapse
|
8
|
Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
Collapse
Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| |
Collapse
|
9
|
Four-fraction ultra-accelerated minimal breast irradiation in early breast cancer: The initial feasibility results of an institutional experience. Brachytherapy 2022; 21:475-486. [PMID: 35396137 DOI: 10.1016/j.brachy.2022.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the feasibility, early toxicity, and clinical outcomes of early-breast cancer patients in a single-arm, phase I/II study of an ultra-accelerated, four-fraction schedule of minimal breast irradiation (4f-AMBI) using a multicatheter, minimally-invasive, intraoperative tumor bed implant (MITBI) during breast-conserving surgery (BCS). METHODS AND MATERIALS Eligible women aged >40 years with clinically and radiologically confirmed, unifocal invasive or in situ ≤3 cm tumors were considered as potential candidates for MITBI during BCS. After the pathology report, patients who met APBI criteria received ultra-accelerated four-fractions irradiation (6.2 Gy BID x 4fx over 2 days) with perioperative HDR-brachytherapy (PHDRBT). Early complications, toxicity, clinical outcomes, and cosmetic results were analyzed. RESULTS Of 89 patients initially implanted, 60(67.4%) were definitively included in the 4f-AMBI-protocol. The median age was 64.4 years; the median CTV was 32.1 cc (6.9-75.4 cc), and the external-V100 was 43.1 cc (12.87-107 cc), representing 5% of the breast tissue irradiated with a median CTV D90 of 6.2 Gy (5.6-6.28 Gy). The entire local treatment (BCS&MITBI-4f-AMBI) was completed at a median of 8 days (4-10 days). The rate of early complications was 11%. There were no major complications. Acute skin-subcutaneous G1 toxicity was reported in 11.7%, and late G1 toxicity on 36.7%. After a median follow-up of 27 months (11-51 months), the local, elsewhere, locoregional and distant-control rates were 100%, 98.3%, 100%, and 100% respectively. The early-cosmetic evaluation was excellent-good in 94.5% of patients evaluated. CONCLUSIONS Ultra-accelerated, four-fraction, minimal breast irradiation (4f-AMBI) using a minimally-invasive tumor bed implant procedure is safe, dosimetrically feasible, and shows small irradiated volumes. This program provides low toxicity rates and excellent short-term clinical and cosmesis outcomes.
Collapse
|
10
|
Vicini F, Broughman J, Halima A, Mayo Z, Obi E, Al-Hilli Z, Arthur D, Wazer D, Shah C. Delivery of Adjuvant Radiation in 5 Days or Less After Lumpectomy for Breast Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2021; 112:1090-1104. [PMID: 34921906 DOI: 10.1016/j.ijrobp.2021.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent data have been published supporting the application of ultra-short radiation therapy (RT) regimens for women with early stage breast cancer following breast conserving surgery (BCS). What has remained controversial is whether and how to apply accelerated whole breast irradiation (AWBI) or accelerated partial breast irradiation (APBI) approaches in these patients, as well as the consideration of intraoperative RT (IORT) for this population. METHODS We performed a systematic review of the literature searching for randomized and prospective data published evaluating ultra-short RT delivered in 5-days or less with APBI, AWBI, or IORT. RESULTS We identified two randomized studies applying AWBI (n=5,011 patients) with 5 to 10 year follow up, which supported the use of ultra-short course AWBI (5 fractions in one week) as compared to hypofractionated WBI. We identified six randomized trials evaluating APBI (as compared to WBI) in 5 days or less (n= 8,415) with numerous (n=55) prospective studies as well, with the data supporting short course APBI as compared to WBI. Finally, we identified two randomized trials evaluating IORT; however, both trials demonstrated elevated rates of recurrence with IORT as compared to WBI. CONCLUSIONS The current body of data available for ultra-short adjuvant RT regimens delivered in 5-days or less after BCS overwhelming support their utilization. While data for both exists, APBI regimens have, by far, greater numbers of patients and longer follow-up as compared to AWBI. Also, given increased rates of recurrence seen with IORT with long-term follow-up, this should not be considered a standard approach at this time.
Collapse
Affiliation(s)
| | - James Broughman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Halima
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zachary Mayo
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Obi
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - David Wazer
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Chirag Shah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
11
|
Shah C, Vicini F, Beriwal S, Thaker N, Frank SJ, Rossi P, Orio P, Chang AJ, Joshi N, Campbell SR, Naghavi A, Chao S, Kamrava M, Deufel CL, Mourtada F, Suh JH. American brachytherapy society radiation oncology alternative payment model task force: Quality measures and metrics for brachytherapy. Brachytherapy 2021; 21:63-74. [PMID: 34732290 DOI: 10.1016/j.brachy.2021.10.003] [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: 07/17/2021] [Revised: 09/26/2021] [Accepted: 10/05/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Brachytherapy is an essential technique to deliver radiation therapy and is involved in the treatment of multiple disease sites as monotherapy or as an adjunct to external beam radiation therapy. With a growing focus on the cost and value of cancer treatments as well new payment models, it is essential that standardized quality measures and metrics exist to allow for straightforward assessment of brachytherapy quality and for the development of clinically significant and relevant clinical data elements. We present the American Brachytherapy Society consensus statement on quality measures and metrics for brachytherapy as well as suggested clinical data elements. METHODS AND MATERIALS Members of the American Brachytherapy Society with expertise in disease site specific brachytherapy created a consensus statement based on a literature review and clinical experience. RESULTS Key quality measures (ex. workup, clinical indications), dosimetric metrics, and clinical data elements for brachytherapy were evaluated for each modality including breast cancer, cervical cancer, endometrial cancer, prostate cancer, keratinocyte carcinoma, soft tissue sarcoma, and uveal melanoma. CONCLUSIONS This consensus statement provides standardized quality measures and dosimetric quality metrics as well as clinical data elements for each disease site to allow for standardized assessments of brachytherapy quality. Moving forward, a similar paradigm can be considered for external beam radiation therapy as well, providing comprehensive radiation therapy quality measures, metrics, and clinical data elements that can be incorporated into new payment models.
Collapse
Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH.
| | | | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman cancer Center, Pittsburgh, PA
| | - Nikhil Thaker
- Division of Radiation Oncology, Arizona Oncology, Tucson, AZ
| | - Steven J Frank
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX
| | | | - Peter Orio
- Department of Radiation Oncology, Dana Farber Cancer Institute, Boston, MA
| | - Albert J Chang
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, CA
| | - Nikhil Joshi
- Department of Radiation Oncology, Rush University, Chicago, IL
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Arash Naghavi
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, FL
| | - Samuel Chao
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Firas Mourtada
- Department of Radiation Oncology, Helen F. Graham Cancer Center, ChristianaCare, Newark, DE
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| |
Collapse
|
12
|
Brachytherapy: An emblematic example of extreme hypofractionated regimen. Cancer Radiother 2021; 26:611-615. [PMID: 34728114 DOI: 10.1016/j.canrad.2021.09.008] [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: 08/30/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022]
Abstract
In order to provide more convenient irradiation regimens for patient comfort, radiation facility organization and health expenses, new hypofractionated protocols have been evaluated. Moderately (dose/fraction: 2.3 to 3Gy), then ultra (dose/fraction: 5.2 to 6.1Gy) hypofractionated irradiations were first validated. The current question is: is it possible to go forward using extreme hypofractionated regimens (EHR) based on 1 to 3 fractions. Different irradiation techniques are under investigation. However, brachytherapy remains the smartest way to deliver a high dose in a small volume. We report prospective and retrospective study results which evaluated EHR for breast and prostate brachytherapy. While oncological outcome and toxicity profile appear extremely encouraging for low-risk breast cancer after a 1 to 4 fractions (6.25 to 20Gy/fraction), the use of a single fraction of 19 to 23Gy appears debatable for prostate cancer. Brachytherapy represents an emblematic example of EHR but longer follow-up and more mature results are awaited in order to specify the right indications and refine the EQD2 calculation method including new biological and technical factors.
Collapse
|
13
|
Hannoun-Levi JM, Chamorey E, Boulahssass R, Polgar C, Strnad V. Endocrine therapy with accelerated Partial breast irradiati On or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early-stage breast cancer (EPOPE): The rationale for a GEC-ESTRO randomized phase III-controlled trial. Clin Transl Radiat Oncol 2021; 29:1-8. [PMID: 33997321 PMCID: PMC8102143 DOI: 10.1016/j.ctro.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/20/2022] Open
Abstract
Epidemiologic data confirm the increase of breast cancer incidence in the elderly. The risk of recurrence of breast cancer is basically low. De-escalation breast cancer adjuvant therapy is justified in selected elderly patients. Ultra-accelerated breast irradiation with endocrine therapy omission is under debate. Prospective randomized trial is warranted.
Purpose Breast cancer in the elderly has become a public health concern; there is a need to re-design its treatment with a view to de-escalation. Our paper sets out the rationale for a phase 3 randomized trial to evaluate less burdensome adjuvant procedures that remain effective and efficient. Materials and methods For low-risk breast cancer in the elderly, adjuvant treatment has been adjusted in order to make it more suitable and efficient. Hypofractionated radiation therapy based on accelerated or non-accelerated regimens as well as accelerated and ultra-accelerated partial breast irradiation (APBI) protocols were reviewed. Withdrawal of radiation (RT) or endocrine therapies (ET) from the adjuvant procedure were also investigated. Based on molecular and APBI classifications, inclusion criteria were discussed. Results Phase 3 randomized trials which compared standard vs. accelerated/non-accelerated hypofractionated regimens confirmed that the latter were non-inferior in terms of local control. Similarly, except for intraoperative-based techniques, APBI achieved non-inferior local control rates compared to whole breast irradiation for low-risk breast cancer. In phase 2 prospective trials using ultra APBI, encouraging results were observed regarding oncological outcome and toxicity profile. In phase 3 trials, adjuvant ET without RT significantly increased the rate of local relapse with no impact on overall survival while RT alone proved effective. Elderly patients aged 60 or more with low-risk, luminal A breast cancer were chosen as the target population in a phase 3 randomized trial comparing APBI + 5-year ET vs. uAPBI (16 Gy 1f) alone. Conclusion To investigate de-escalation adjuvant treatment for elderly breast cancer patients, we have defined a road map for testing more convenient strategies. This EPOPE phase 3 randomized trial is supported by the GEC-ESTRO breast cancer working group.
Collapse
Key Words
- ABS, American Brachytherapy Society
- APBI, Accelerated and partial breast irradiation
- ASTRO, American Society of Radiation Oncology
- BCS, Breast cancer surgery
- BCWG, Breast Cancer Working Group
- Brachytherapy
- Breast cancer in the elderly
- DCIS, Ductal carcinoma in situ
- DFS, Disease-free survival
- EPOPE, Endocrine therapy with accelerated Partial breast irradiatiOn or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early stage breast cancer
- EQD2, Equivalent Dose in 2Gy fractions
- ET, Endocrine therapy
- Endocrine therapy
- GEC-ESTRO, Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology
- HDB, High-dose rate Brachytherapy
- LCIS, Lobular carcinoma in situ
- MAPBI, Molecular and APBI GEC-ESTRO
- MIB, Multicatheter Interstitial Brachytherapy
- Oncogeriatric assessment
- QoL, Quality of Life
- RT, Radiotherapy
- Radiation therapy
- WBI, Whole breast irradiation
- uAPBI, ultra-Accelerated Partial Breast Irradiation
Collapse
Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University of Côte d'Azur, Nice, France
| | - Emmanuel Chamorey
- Department of Epidemiology and Biostatistics, Antoine Lacassagne Cancer Centre, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Unit. CHU de NICE, FHU ONCOAGE, University of Cote d'Azur, Nice, France
| | - Csaba Polgar
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
| | | |
Collapse
|
14
|
Hannoun-Lévi JM, Montagne L, Sumodhee S, Schiappa R, Boulahssass R, Gautier M, Gal J, Chand ME. APBI Versus Ultra-APBI in the Elderly With Low-Risk Breast Cancer: A Comparative Analysis of Oncological Outcome and Late Toxicity. Int J Radiat Oncol Biol Phys 2021; 111:56-67. [PMID: 33831490 DOI: 10.1016/j.ijrobp.2021.03.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/26/2021] [Accepted: 03/28/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) represents a validated technique for low-risk breast cancer. Recently, ultra-APBI (uAPBI) using fewer than 5 fractions was described in the literature. We compared clinical outcomes and late toxicity after APBI or uAPBI in older patients. METHODS AND MATERIALS Two cohorts of older patients (aged ≥70 years) with low-risk breast cancer treated with APBI (interstitial brachytherapy) were analyzed retrospectively. A total dose of 34 Gy in10 fractions (APBI) or 16 Gy in 1 fraction (uAPBI) was delivered from 2004 to 2012 and from 2013 to 2018, respectively. Oncologic outcome analyzed the cumulative incidence of local relapse, regional relapse, and distant metastases with disease-free survival, cause-specific survival, and overall survival. Late toxicity and cosmetic results were investigated. RESULTS One hundred fifty-seven patients (APBI, n = 109 patients; uAPBI, n = 48 patients) underwent APBI according to the same selection criteria. Apart from the median follow-up (97 vs 72 months for APBI and uAPBI; P < .002), no significant difference was noted between the 2 groups. Regarding 6-year oncologic outcome, no significant difference was observed between APBI and uAPBI for local recurrence (1.3% vs 0%; P = .4), regional recurrence (2.5% vs 2.3%; P = .9), distant metastases (4.3% vs. 2.4%; P = .6), disease-free survival (85.2% vs. 82.2%; P = .8), cause-specific survival (96.7% vs. 96.2%; P = .9), and overall survival (86.7% vs. 82.2%; P = .7). Regarding late toxicity, no significant difference was observed between APBI and uAPBI (total complication number, 45 vs 33%; P = .173) with only grade 1 (88.4% vs. 95%) and grade 2 (11.6% vs. 5%) late toxicities (P = .677). Similarly, no significant difference was observed for excellent/good cosmetic results between the 2 cohorts (P = .98). CONCLUSIONS We report the first study comparing APBI versus uAPBI in a cohort of older patients with low-risk breast cancer. No significant difference was found between the 2 treatment groups regarding oncologic outcome, late toxicity, and cosmetic result. uAPBI based on a single fraction of brachytherapy represents an attractive option for therapeutic de-escalation in older patients with breast cancer.
Collapse
Affiliation(s)
- Jean-Michel Hannoun-Lévi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France.
| | - Lucile Montagne
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Shakeel Sumodhee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Renaud Schiappa
- Biostatistic Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Coordination Unit for Geriatric Oncology (UCOG) PACA Est, CHU de Nice, University of Cote d'Azur, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Jocelyn Gal
- Biostatistic Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Marie-Eve Chand
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| |
Collapse
|
15
|
Williams VM, Kahn JM, Thaker NG, Beriwal S, Nguyen PL, Arthur D, Petereit D, Dyer BA. The Case for Brachytherapy: Why It Deserves a Renaissance. Adv Radiat Oncol 2021; 6:100605. [PMID: 33723523 PMCID: PMC7940781 DOI: 10.1016/j.adro.2020.10.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/16/2020] [Accepted: 10/13/2020] [Indexed: 01/22/2023] Open
Abstract
The recent global events related to the coronavirus disease of 2019 pandemic have significantly changed the medical landscape and led to a shift in oncologic treatment perspectives. There is a renewed focus on preserving treatment outcomes while maintaining medical accessibility and decreasing medical resource utilization. Brachytherapy, which is a vital part of the treatment course of many cancers (particularly prostate and gynecologic cancers), has the ability to deliver hypofractionated radiation and thus shorten treatment time. Studies in the early 2000s demonstrated a decline in brachytherapy usage despite data showing equivalent or even superior treatment outcomes for brachytherapy in disease sites, such as the prostate and cervix. However, newer data suggest that this trend may be reversing. The renewed call for shorter radiation courses based on data showing equivalent outcomes will likely establish hypofractionated radiation as the standard of care across multiple disease sites. With shifting reimbursement, brachytherapy represents the pinnacle in hypofractionated, conformal radiation therapy, and with extensive long-term data in support of the treatment modality brachytherapy is primed for a renaissance.
Collapse
Affiliation(s)
- Vonetta M. Williams
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jenna M. Kahn
- Department of Radiation Oncology, Oregon Health & Science University, Portland, Oregon
| | - Nikhil G. Thaker
- Department of Radiation Oncology, Arizona Oncology, Tucson, Arizona
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Paul L. Nguyen
- Department of Radiation Oncology, Dana-Farber/Harvard Cancer Center, Boston, Massachusetts
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Daniel Petereit
- Department of Radiation Oncology, Monument Health Cancer Care Institute, Rapid City, South Dakota
| | - Brandon A. Dyer
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| |
Collapse
|
16
|
Accelerated Partial Breast Radiation: Information on Dose, Volume, Fractionation, and Efficacy from Randomized Trials. Int J Radiat Oncol Biol Phys 2020; 108:1123-1128. [PMID: 33220220 DOI: 10.1016/j.ijrobp.2020.06.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/10/2023]
|
17
|
Guinot JL, Gonzalez-Perez V, Meszaros N, Major T, Najjari-Jamal D, Gutierrez-Miguelez C, Santos MA, Smanyko V, Laplana M, Polgar C. Very accelerated partial breast irradiation Phase I-II multicenter trial (VAPBI): Feasibility and early results. Brachytherapy 2020; 20:332-338. [PMID: 33223449 DOI: 10.1016/j.brachy.2020.10.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE This is a multicenter Phase I-II trial endorsed by the GEC-ESTRO Breast Working Group, to analyze if very accelerated partial breast irradiation (VAPBI) with multicatheter interstitial brachytherapy is feasible and safe compared with the standard APBI treatment in 4-5 days for early stage breast carcinomas. METHODS AND MATERIALS We have included 81 patients with pT1-2 pN0 invasive carcinomas after breast-conserving surgery. Between August 2017 and July 2019, 33 women received high-dose-rate brachytherapy, four fractions of 6.25 Gy in 2-3 days, and 48 patients received three fractions of 7.45 Gy in 2 days. Thirty-six patients were implanted perioperatively and 45 postoperatively. Mean age was 68 (51-90). Free surgical margins were of 2 mm or greater. RESULTS Acute effects were 11% dermatitis, 18.5% hematoma, 3.7% infection, and 14.8% pain. At a median followup of 20 months (range 8-35), no relapse has occurred. Pigmentation changes in the entrance and exit of tubes were visible in 16%, but 1 year later, few cases remained. Patients developed G1-2 induration or fibrosis in 18.5% and 2.5%, respectively. No patient developed telangiectasia. The cosmetic outcome was good/excellent in 97.5% and fair in 2.5%. CONCLUSIONS VAPBI with multicatheter interstitial brachytherapy using four fractions of 6.25 Gy or three fractions of 7.45 Gy in two or 3 days is feasible. No excess has been observed in acute effects. At a mean followup of 20 months, late side effects seem to be similar to standard fractionation. VAPBI in two to 3 days is beneficial for the patients and reduces the workload of the brachytherapy units.
Collapse
Affiliation(s)
- Jose Luis Guinot
- Department of Radiation Oncology, Foundation Instituto Valenciano de Oncologia (IVO), Valencia, Spain.
| | - Victor Gonzalez-Perez
- Department of Radiation Physics, Foundation Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - Norbert Meszaros
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Tibor Major
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Dina Najjari-Jamal
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | | | - Miguel Angel Santos
- Department of Radiation Oncology, Foundation Instituto Valenciano de Oncologia (IVO), Valencia, Spain
| | - Viktor Smanyko
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Maria Laplana
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | - Csaba Polgar
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | | |
Collapse
|
18
|
Itami J. Modern development of high-dose-rate brachytherapy. Jpn J Clin Oncol 2020; 50:490-501. [PMID: 32134450 DOI: 10.1093/jjco/hyaa029] [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: 12/16/2019] [Revised: 01/09/2020] [Accepted: 02/04/2000] [Indexed: 01/02/2023] Open
Abstract
Brachytherapy is an invasive therapy with placement of radiation source into or near the tumor. The difference between planning target volume and clinical target volume is minimal, and the dose out of the tumor reduces rapidly due to the inverse-square law. High-dose-rate brachytherapy enables three-dimensional image guidance, and currently, tumor dose as well as doses of the surrounding normal structures can be evaluated accurately. High-dose-rate brachytherapy is the utmost precision radiation therapy even surpassing carbon ion therapy. Biological disadvantages of high-dose rate have been overcome by the fractional irradiation. High-dose-rate brachytherapy is indispensable in the definitive radiation therapy of cervical cancer. Also in prostate cancer and breast cancer, high-dose-rate brachytherapy plays a significant role. Brachytherapy requires techniques and skills of radiation oncologists at the time of invasive placement of the radiation source into the tumor area. Education of young radiation oncologists is most urgent and important.
Collapse
Affiliation(s)
- Jun Itami
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
19
|
Desideri I, Salvestrini V, Livi L. Recent advances in de-intensification of radiotherapy in elderly cancer patients. F1000Res 2020; 9. [PMID: 32518630 PMCID: PMC7255897 DOI: 10.12688/f1000research.21151.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/13/2022] Open
Abstract
Cancer in the elderly remains an evolving issue and a health challenge. Several improvements in the radiotherapy field allow the delivery of higher doses/fractions with a safe toxicity profile, permitting the reduction of radiation treatment protocols in the elderly. Regarding breast, prostate, and lung cancer, the under-representation of older patients in clinical trials limits the extension of treatment recommendations to elderly patients in routine clinical practice. Among the feasible alternatives to standard whole breast radiotherapy (WBRT) in older patients are shorter courses using higher hypofractionation (HF) and accelerated partial breast irradiation (APBI). The boost continues to be used in women at high risk of local recurrence but is less widely accepted for women at lower risk and patients over 70 years of age. Regarding prostate cancer, there are no published studies with a focus on the elderly. Current management decisions are based on life expectancy and geriatric assessment. Regimens of HF and ultra-HF protocols are feasible strategies for older patients. Several prospective non-randomized studies have documented the safe delivery of ultra-HF for patients with localized prostate cancer, and multiple phase III trials and meta-analyses have confirmed that the HF regimen should be offered with similar acute toxicity regardless of patient age and comorbidity. A recent pooled analysis from two randomized trials comparing surgery to stereotactic body radiation therapy (SBRT) in older adult patients with early stage non-small cell lung cancer did show comparable outcomes between surgery and SBRT. Elderly cancer patients are significantly under-represented in all clinical trials. Thus, the inclusion of older patients in clinical studies should be strongly encouraged to strengthen the evidence base for this age group. We suggest that the creation of oncogeriatric coordination units may promote individualized care protocols, avoid overtreatment with aggressive and unrecommended therapies, and support de-escalating treatment in elderly cancer patients.
Collapse
Affiliation(s)
- Isacco Desideri
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| | - Viola Salvestrini
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences Biochemistry, Radiotherapy Unit, University of Florence, Florence, Italy
| |
Collapse
|
20
|
Mohindra P, Beriwal S, Kamrava M. Proposed brachytherapy recommendations (practical implementation, indications, and dose fractionation) during COVID-19 pandemic. Brachytherapy 2020; 19:390-400. [PMID: 32423787 PMCID: PMC7252026 DOI: 10.1016/j.brachy.2020.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Sushil Beriwal
- Department of Radiation Oncology, UPMC Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars Sinai Medical Center, Los Angeles, CA.
| |
Collapse
|
21
|
Kinj R, Chand ME, Gal J, Gautier M, Lam Cham Kee D, Hannoun-Lévi JM. Five-year oncological outcome after a single fraction of accelerated partial breast irradiation in the elderly. Radiat Oncol 2019; 14:234. [PMID: 31864391 PMCID: PMC6925849 DOI: 10.1186/s13014-019-1448-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/17/2019] [Indexed: 01/09/2023] Open
Abstract
Background To update the clinical outcome of an elderly women cohort with early breast cancer who underwent accelerated partial breast irradiation (APBI) based on a post-operative single fraction of multicatheter interstitial high dose–rate brachytherapy (MIB). Material and methods A single institution retrospective cohort study was performed focusing on elderly patients (≥ 65 years old) presenting a low-risk breast carcinoma treated by lumpectomy plus axillary evaluation followed by MIB APBI. A single fraction of 16 Gy was prescribed on the 100% isodose. Clinical outcome at 5 years was reported based on local relapse free survival (LRFS), specific survival (SS) and overall survival (OS). Late toxicity was evaluated. Cosmetic results were evaluated clinically by the physician. Results Between January 2012 and August 2015, 48 women (51 lesions) were treated. Median age was 77.7 years (range: 65–92) with a median tumor size of 12 mm (range: 3–32). Five patients (pts) presented an axillary lymph node involvement (4 Nmic, 1 N1). Invasive ductal carcinoma was the most frequent histology type (86.3%). With a median follow–up of 64 months (range: 56–71), no local relapse occurred while 1 pt. developed an axillary relapse (2.1%). No Grade 3 or higher late toxicity was observed while 16 late toxicities occurred (G1: 14 events [87.5%) mainly G1 breast fibrosis). The rate of excellent cosmetic outcome was 76.4%. Conclusion We confirmed the safety of the process and remained encouraging clinical outcome of a post-operative single fraction of MIB ABPI in the elderly. This approach leads to consider a very APBI as an attractive alternative to intra-operative radiation therapy while all the patients will be good candidates for APBI in regards to the post-operative pathological report.
Collapse
Affiliation(s)
- Rémy Kinj
- Department of Radiation Oncology, University of Côte d'Azur, Fédération Claude Lalanne, Nice, France
| | - Marie-Eve Chand
- Department of Radiation Oncology, University of Côte d'Azur, Fédération Claude Lalanne, Nice, France
| | - Jocelyn Gal
- Biostatistic unit, Centre Antoine-Lacassagne, 06189, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, University of Côte d'Azur, Fédération Claude Lalanne, Nice, France
| | - Daniel Lam Cham Kee
- Department of Radiation Oncology, University of Côte d'Azur, Fédération Claude Lalanne, Nice, France
| | - Jean Michel Hannoun-Lévi
- Department of Radiation Oncology, University of Côte d'Azur, Fédération Claude Lalanne, Nice, France.
| |
Collapse
|
22
|
Hannoun-Lévi JM, Lam Cham Kee D, Gal J, Schiappa R, Hannoun A, Fouche Y, Gautier M, Boulahssass R, Chand ME. Accelerated partial breast irradiation in the elderly: 5-Year results of the single fraction elderly breast irradiation (SiFEBI) phase I/II trial. Brachytherapy 2019; 19:90-96. [PMID: 31767533 DOI: 10.1016/j.brachy.2019.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 10/25/2019] [Accepted: 10/25/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE To evaluate the clinical outcomes of a very-accelerated partial breast irradiation (vAPBI) in the elderly based on a single fraction of multicatheter interstitial high-dose rate brachytherapy (MIB). Mature results with a median follow-up of 5 years. METHODS AND MATERIALS From November 2012 to September 2014, 26 patients (pts) (≥70) with early breast cancer were enrolled in a prospective phase II trial (NCT01727011). After lumpectomy, intraoperative catheter implant was performed for postoperative APBI (single fraction 16 Gy). Surveillance was performed twice a year after APBI. Oncologic outcome (local [LRFS], metastasis-free survival, cancer-specific survival, and overall survival [OS]) as well as late toxicity and cosmetic outcome were investigated. RESULTS Median age was 77 years [69-89]. After a median follow-up of 63 months [60-68], 5-year LRFS, metastasis-free survival, cancer-specific survival, and overall survival rates were 100%, 95.5%, 100%, and 88.5%, respectively. Late toxicity was observed in 5 pts (19.2%) with a total of five events: 3 pts G1 (60%); and 2 pts G2 (40%). The observed late side effects were breast pain in 1 pt (G2 cytosteatonecrosis with occasional acetaminophen consumption), hypopigmentation (puncture site) in 2 pts (G1) and breast fibrosis in 2 pts (G1: 1 pt; G2: 1 pt). Cosmetic evaluation was excellent for 21 pts (81%) and good for 2 pts (19%). CONCLUSION For elderly with early breast cancer, a vAPBI using a single fraction of postoperative MIB (16 Gy) provides excellent oncologic results, mainly in terms of local control and cancer death. Late toxicity and cosmetic profile are acceptable.
Collapse
Affiliation(s)
- Jean-Michel Hannoun-Lévi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France.
| | - Daniel Lam Cham Kee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Jocelyn Gal
- Biostatistic Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Renaud Schiappa
- Biostatistic Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | | | - Yves Fouche
- Department of Breast Surgery, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Unit, CHU de NICE, FHU ONCOAGE, University of Cote d'Azur, Nice, France
| | - Marie-Eve Chand
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| |
Collapse
|
23
|
Hypofractionated radiation therapy for invasive breast cancer: From moderate to extreme protocols. Cancer Radiother 2019; 23:874-882. [PMID: 31611051 DOI: 10.1016/j.canrad.2019.09.002] [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: 06/21/2019] [Accepted: 09/04/2019] [Indexed: 11/22/2022]
Abstract
Adjuvant irradiation is the standard treatment after breast conservative surgery. Normofractionated regimen with an overall treatment time of 5 to 6 weeks is often considered as a limiting factor for irradiation compliance. In order to answer this issue, moderate and more recently extreme hypofractionated protocols appeared. We report here oncological outcomes and toxicity of hypofractionated breast irradiation. After defining the frame of moderate and extreme hypofractionated breast irradiations based on overall treatment time, patient selection criteria were listed. According to their levels of proof, the results of moderate and extreme hypofractionated breast irradiation were analysed. Overall treatment time for moderate hypofractionated breast irradiation ranged from 3 to 4 weeks, while for extreme hypofractionated breast irradiation, it was less than 1 week. For moderate hypofractionated breast irradiation, whole breast irradiation was currently performed with or without lymph node irradiation. Moderate hypofractionated breast irradiation has proven to be as safe and as efficient as normofractionated breast irradiation with level IA evidence. For extreme hypofractionated breast irradiation, phase III randomized trials confirmed that accelerated partial breast irradiation was non-inferior in terms of local control compared to normofractionated whole breast irradiation (with external beam radiation therapy and multicatheter brachytherapy), with similar acute and late toxicity. While the use of intraoperative breast irradiation remains under debate, new very accelerated partial breast irradiation (overall treatment time not exceeding 2 days) protocols emerged with encouraging results. Accelerated partial breast irradiation is warranted for extreme hypofractionated breast irradiation and is indicated for low-risk breast cancers. Moderate and extreme hypofractionated breast irradiation regimens are validated and can be routinely proposed according to patient selection criteria.
Collapse
|
24
|
Jethwa KR, Park SS, Gonuguntla K, Wick SM, Vallow LA, Deufel CL, Whitaker TJ, Furutani KM, Ruddy KJ, Corbin KS, Hieken TJ, Mutter RW. In Reply to Hannoun-Levi and Hannoun. Int J Radiat Oncol Biol Phys 2019; 104:1177-1179. [PMID: 31039420 DOI: 10.1016/j.ijrobp.2019.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 04/11/2019] [Accepted: 04/13/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Krishan R Jethwa
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Stephanie M Wick
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Laura A Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Keith M Furutani
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
25
|
Dynamic Modulated Brachytherapy (DMBT) Balloon Applicator for Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2019; 104:953-961. [PMID: 30910767 DOI: 10.1016/j.ijrobp.2019.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/07/2019] [Accepted: 03/17/2019] [Indexed: 11/20/2022]
Abstract
PURPOSE To propose a novel high-dose-rate brachytherapy applicator for balloon-based dynamic modulated brachytherapy (DMBT) for accelerated partial breast irradiation (APBI) and to demonstrate its dosimetric advantage compared to the widely used Contura applicator. METHODS AND MATERIALS The DMBT balloon device consists of a fixed central channel enabling real-time, in vivo dosimetry and an outer motion-dynamic, adjustable-radius channel capable of moving to any angular position within the balloon. This design allows placement of dwell positions anywhere within the balloon volume, guaranteeing optimal placement and generation of the applicator and treatment plan, respectively. Thirteen clinical treatment plans for patients with early-stage breast cancer receiving APBI after lumpectomy using Contura were retrospectively obtained under institutional review board approval. New treatment plans were created by replacing the Contura with the DMBT device. DMBT plans were limited to 4 angular positions and an outer channel radius of 1.5 cm. The new plans were optimized to limit dose to ribs and skin while maintaining target coverage similar to that of the clinical plan. RESULTS Similar target coverage was obtained for the DMBT plans compared with clinical Contura plans. Across all patients the mean (standard deviation) reductions in D0.1 cc to the ribs and skin were 6.70% (6.28%) and 5.13% (6.54%), respectively. A threshold separation distance between the balloon surface and the organ at risk (OAR), below which dosimetric changes of greater than 5% were obtained, was observed to be 12 mm for ribs and skin. When both OARs were far from the balloon, DMBT plans were of similar quality to Contura plans, as expected. CONCLUSIONS This study demonstrates the superior ability of the APBI DMBT applicator to spare OARs while achieving target coverage comparable to current treatment plans, especially when in close proximity. The DMBT balloon may enable new modes of dynamic high-dose-rate treatment delivery and allow for ultrahypofractionated dose regimens to be safely used.
Collapse
|
26
|
Hannoun-Levi JM, Hannoun A. In Regard to Jethwa et al. Int J Radiat Oncol Biol Phys 2019; 104:1176-1177. [PMID: 31039419 DOI: 10.1016/j.ijrobp.2019.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 03/31/2019] [Accepted: 04/13/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | | |
Collapse
|