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Alkner S, Wieslander E, Lundstedt D, Berg M, Kristensen I, Andersson Y, Bergkvist L, Frisell J, Olofsson Bagge R, Sund M, Christiansen P, Davide Gentilini O, Kontos M, Kühn T, Reimer T, Rydén L, Filtenborg Tvedskov T, Vrou Offersen B, Dahl Nissen H, de Boniface J. Quality assessment of radiotherapy in the prospective randomized SENOMAC trial. Radiother Oncol 2024; 197:110372. [PMID: 38866204 DOI: 10.1016/j.radonc.2024.110372] [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: 04/03/2024] [Revised: 05/15/2024] [Accepted: 06/04/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND AND PURPOSE Recommendations for regional radiotherapy (RT) of sentinel lymph node (SLN)-positive breast cancer are debated. We here report a RT quality assessment of the SENOMAC trial. MATERIALS AND METHODS The SENOMAC trial randomized clinically node-negative breast cancer patients with 1-2 SLN macrometastases to completion axillary lymph node dissection (cALND) or SLN biopsy only between 2015-2021. Adjuvant RT followed national guidelines. RT plans for patients included in Sweden and Denmark until June 2019 were collected (N = 1176) and compared to case report forms (CRF). Dose to level I (N = 270) and the humeral head (N = 321) was analyzed in detail. RESULTS CRF-data and RT plans agreed in 99.3 % (breast/chest wall) and in 96.6 % of patients (regional RT). Congruence for whether level I was an intended RT target was lower (78 %). In accordance with Danish national guidelines, level I was more often an intended target in the SLN biopsy only arm (N = 334/611, 55 %,) than in the cALND arm (N = 174/565, 31 %,). When an intended target, level I received prescribed dose to 100 % (IQR 98-100 %) of the volume. However, even when not an intended target, full dose was delivered to > 80 % of level I (IQR 75-90 %). The intentional inclusion of level I in the target volume more than doubled the dose received by ≥ 50 % of the humeral head. CONCLUSION Congruence between CRF data and RT plans was excellent. Level I received a high dose coverage even when not intentionally included in the target. Including level I in target significantly increased dose to the humeral head.
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Affiliation(s)
- Sara Alkner
- Department of Oncology, Faculty of Medicine, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden; Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden.
| | - Elinore Wieslander
- Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Dan Lundstedt
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Oncology at Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin Berg
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ingrid Kristensen
- Skåne University Hospital Lund, Department of Hematology, Oncology and Radiation Physics, Lund, Sweden
| | - Yvette Andersson
- Department of Surgery, Vastmanland Hospital Vasteras, Vasteras, Sweden; Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Leif Bergkvist
- Centre for Clinical Research, Uppsala University and Region Vastmanland, Vastmanland Hospital Vasteras, Sweden
| | - Jan Frisell
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Breast Center Karolinska, Karolinska Comprehensive Cancer Center, Karolinska University Hospital, Stockholm, Sweden
| | - Roger Olofsson Bagge
- Sahlgrenska Center for Cancer Research, Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Malin Sund
- Department of Surgery, University of Helsinki and Helsinki University Hospital, Finland; Department of Diagnostics and Intervention/ Surgery, Umeå University, Sweden
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Oreste Davide Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Michalis Kontos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | - Thorsten Kühn
- Die Filderklinik, Breast Center, Filderstadt, Germany; Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Rostock, Germany
| | - Lisa Rydén
- Department of Oncology, Faculty of Medicine, Institute of Clinical Sciences Lund, Lund University, Lund, Sweden; Skåne University Hospital , Department of Gastroenterology and Surgery, Malmö, Sweden
| | - Tove Filtenborg Tvedskov
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Breast Surgery, Gentofte Hospital, Gentofte, Denmark
| | - Birgitte Vrou Offersen
- Department of Oncology, Aarhus University Hospital, Aarhus University, Aarhus, Denmark; Department of Experimental Clinical Oncology, Danish Center for Particle Therapy, Aarhus, Denmark
| | - Henrik Dahl Nissen
- Department of Oncology, Vejle Hospital, University Hospital of Southern Denmark, Vejle, Denmark
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Capio St. Goran's Hospital, Stockholm, Sweden
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Boersma LJ, Bijker N, Stam MR. Reporting breast cancer radiation therapy details in studies and daily practice: Nice-to-have or a must-have? Radiother Oncol 2024:110429. [PMID: 39029590 DOI: 10.1016/j.radonc.2024.110429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 06/25/2024] [Indexed: 07/21/2024]
Affiliation(s)
- Liesbeth J Boersma
- Department of Radiation Oncology (Maastro), GROW Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - Nina Bijker
- Amsterdam University Medical Centre, Dept. of Radiation Oncology, Amsterdam, the Netherlands
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Kaidar-Person O, Meattini I, Boersma LJ, Becherini C, Cortes J, Curigliano G, de Azambuja E, Harbeck N, Rugo HS, Del Mastro L, Gennari A, Isacke CM, Vestmø Maraldo M, Marangoni E, Nader Marta G, Mjaaland I, Salvestrini V, Spanic T, Visani L, Morandi A, Lambertini M, Livi L, Coles CE, Poortmans P, Offersen BV. Essential requirements for reporting radiation therapy in breast cancer clinical trials: An international multi-disciplinary consensus endorsed by the European Society for Radiotherapy and Oncology (ESTRO). Radiother Oncol 2024; 195:110060. [PMID: 38122852 DOI: 10.1016/j.radonc.2023.110060] [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: 10/07/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023]
Abstract
The European Society for Radiotherapy and Oncology (ESTRO) has advocated the establishment of guidelines to optimise precision radiotherapy (RT) in conjunction with contemporary therapeutics for cancer care. Quality assurance in RT (QART) plays a pivotal role in influencing treatment outcomes. Clinical trials incorporating QART protocols have demonstrated improved survival rates with minimal associated toxicity. Nonetheless, in routine clinical practice, there can be variability in the indications for RT, dosage, fractionation, and treatment planning, leading to uncertainty. In pivotal trials reporting outcomes of systemic therapy for breast cancer, there is limited information available regarding RT, and the potential interaction between modern systemic therapy and RT remains largely uncharted. This article is grounded in a consensus recommendation endorsed by ESTRO, formulated by international breast cancer experts. The consensus was reached through a modified Delphi process and was presented at an international meeting convened in Florence, Italy, in June 2023. These recommendations are regarded as both optimal and essential standards, with the latter aiming to define the minimum requirements. A template for a case report form (CRF) has been devised, which can be utilised by all clinical breast cancer trials involving RT. Optimal requirements include adherence to predefined RT planning protocols and centralised QART. Essential requirements aim to reduce variations and deviations from the guidelines in RT, even when RT is not the primary focus of the trial. These recommendations underscore the significance of implementing these practices in both clinical trials and daily clinical routines to generate high-quality data.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; The School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; GROW-School for Oncology and Reproduction (Maastro), Maastricht University, Maastricht, the Netherlands
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Liesbeth J Boersma
- GROW-School for Oncology and Reproduction (Maastro), Maastricht University, Maastricht, the Netherlands
| | - Carlotta Becherini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Javier Cortes
- International Breast Cancer Center (IBCC), Pangaea Oncology, Quironsalud Group & Medical Scientia Innovation Research (MedSIR), Barcelona, Spain; Faculty of Biomedical and Health Sciences, Department of Medicine, Universidad Europea de Madrid, Madrid, Spain
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato - Oncology (DIPO), University of Milan, Milan, Italy
| | - Evandro de Azambuja
- Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), Brussels, Belgium
| | - Nadia Harbeck
- Department of Gynecology and Obstetrics and CCCMunich, Breast Center, LMU University Hospital, Munich, Germany
| | - Hope S Rugo
- Medicine and Winterhof Family Professor of Breast Oncology, University of California San Francisco Comprehensive Cancer Center, San Francisco, CA, USA
| | - Lucia Del Mastro
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy; Department of Medical Oncology, UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alessandra Gennari
- Department of Translational Medicine, University Piemonte Orientale, Novara, Italy
| | - Clare M Isacke
- Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK
| | - Maja Vestmø Maraldo
- Department of Clinical Oncology, Center of Cancer and Organ Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Elisabetta Marangoni
- Laboratory of Preclinical Investigation, Translational Research Department, Institut Curie, Paris, France
| | - Gustavo Nader Marta
- Department of Radiation Oncology, Hospital Sírio-Libanês, Sao Paulo, Brazil; Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Ingvil Mjaaland
- Department of Oncology and Hematology, Stavanger University Hospital, Stavanger, Norway
| | - Viola Salvestrini
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Tanja Spanic
- Europa Donna - The European Breast Cancer Coalition, Milan, Italy; Europa Donna Slovenia, Ljubljana, Slovenia
| | - Luca Visani
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Andrea Morandi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy; Department of Medical Oncology, UOC Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Lorenzo Livi
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | | | - Philip Poortmans
- Department of radiation oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk-Antwerp, Belgium
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Danish Centre for Particle Therapy, Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Brooks C, Miles E, Hoskin PJ. Radiotherapy trial quality assurance processes: a systematic review. Lancet Oncol 2024; 25:e104-e113. [PMID: 38423056 DOI: 10.1016/s1470-2045(23)00625-3] [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: 08/24/2023] [Revised: 10/05/2023] [Accepted: 11/28/2023] [Indexed: 03/02/2024]
Abstract
Quality assurance remains a neglected component of many trials, particularly for technical interventions, such as surgery and radiotherapy, for which quality of treatment is an important component in defining outcomes. We aimed to evaluate evidence for the processes used in radiotherapy quality assurance of clinical trials. A systematic review was undertaken focusing on use of a pre-trial outlining benchmark case and subsequent on-trial individual case reviews of outlining for recruited patients. These pre-trial and on-trial checks are used to ensure consistency and standardisation of treatment for each patient recruited to the trial by confirming protocol compliance. Non-adherence to the trial protocol has been shown to have a negative effect on trial outcomes. 29 studies published between January, 2000, and December, 2022, were identified that reported on either outlining benchmark case results or outlining individual case review results, or both. The trials identified varied in their use of radiotherapy quality assurance practices and reporting of outcomes was inconsistent. Deviations from trial protocols were frequent, particularly regarding outlining. Studies correlating benchmark case results with on-trial individual case reviews provided mixed results, meaning firm conclusions could not be drawn regarding the influence of the pre-trial benchmark case on subsequent on-trial performance. The optimal radiotherapy quality assurance processes were unclear, and there was little evidence available. Improved reporting of outcomes from radiotherapy quality assurance programmes is needed to develop an evidence base for the optimal approach to radiotherapy quality assurance in trials.
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Affiliation(s)
- Chloe Brooks
- National Radiotherapy Trials Quality Assurance Group (RTTQA), National Institute for Health and Care Research, Mount Vernon Cancer Centre, Northwood, UK.
| | - Elizabeth Miles
- National Radiotherapy Trials Quality Assurance Group (RTTQA), National Institute for Health and Care Research, Mount Vernon Cancer Centre, Northwood, UK
| | - Peter J Hoskin
- Mount Vernon Cancer Centre and Division of Cancer Sciences, University of Manchester, Manchester, UK
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5
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Kaidar-Person O, Tramm T, Kuehn T, Gentilini O, Prat A, Montay-Gruel P, Meattini I, Poortmans P. Optimising of axillary therapy in breast cancer: lessons from the past to plan for a better future. LA RADIOLOGIA MEDICA 2024; 129:315-327. [PMID: 37922004 DOI: 10.1007/s11547-023-01743-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/12/2023] [Indexed: 11/05/2023]
Abstract
In this narrative review, we aim to explore the ability of radiation therapy to eradicate breast cancer regional node metastasis. It is a journey through data of older trials without systemic therapy showing the magnitude of axillary therapy (surgery versus radiation) on cancer control. Considering that both systemic and loco-regional therapies were shown to reduce any recurrence with a complex interaction, our review includes surgical, radiation, and radiobiology consideration for breast cancer, and provide our view of future practise. The aim is to provide information optimise radiation therapy in the era of primary systemic therapy.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Radiation Unit, Sheba Tel Hashomer, Ramat Gan, Israel.
- School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
- Department Radiation Oncology (Maastro), GROW-School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, The Netherlands.
| | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Oreste Gentilini
- Breast Surgery, IRCCS Ospedale San Raffaele, Milano, Italy
- Università Vita-Salute San Raffaele, UniSR, Milano, Italy
| | - Aleix Prat
- University of Barcelona, Barcelona, Spain
- Cancer Insititute, IDIBAPS, Barcelona, Spain
| | | | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy
- Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
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6
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Wintraecken VM, Boersma LJ, van Roozendaal LM, de Vries J, van Kuijk SMJ, Vane MLG, van Dalen T, van der Hage JA, Strobbe LJA, Linn SC, Lobbes MBI, Poortmans PMP, Tjan-Heijnen VCG, van de Vijver KKBT, Westenberg AH, de Wilt JHW, Smidt ML, Simons JM. Quality assurance of radiation therapy after breast-conserving surgery among patients in the BOOG 2013-08 trial. Radiother Oncol 2024; 191:110069. [PMID: 38141879 DOI: 10.1016/j.radonc.2023.110069] [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: 11/02/2023] [Revised: 12/11/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND AND PURPOSE In the BOOG 2013-08 trial (NCT02271828), cT1-2N0 breast cancer patients were randomized between breast conserving surgery with or without sentinel lymph node biopsy (SLNB) followed by whole breast radiotherapy (WBRT). While awaiting primary endpoint results (axillary recurrence rate), this study aims to perform a quality assurance analysis on protocol adherence and (incidental) axillary radiation therapy (RT) dose. MATERIALS AND METHODS Patients were enrolled between 2015 and 2022. Data on prescribed RT and (in 25% of included patients) planning target volumes (PTV) parameters were recorded for axillary levels I-IV and compared between treatment arms. Multivariable linear regression analysis was performed to determine prognostic variables for incidental axillary RT dose. RESULTS 1,439/1,461 included patients (98.5%) were treated according to protocol and 87 patients (5.9%) received regional RT (SLNB 10.9%, no-SLNB 1.5 %). In 326 patients included in the subgroup analysis, the mean incidental PTV dose at axilla level I was 59.5% of the prescribed breast RT dose. In 5 patients (1.5%) the mean PTV dose at level I was ≥95% of the prescribed breast dose. No statistically or clinically significant differences regarding incidental axillary RT dose were found between treatment arms. Tumour bed boost (yes/no) was associated with a higher incidental mean dose in level I (R2 = 0.035, F(6, 263) = 1.532, p 0.168). CONCLUSION The results indicate that RT-protocol adherence was high, and that incidental axillary RT dose was low in the BOOG 2013-08 trial. Potential differences between treatmentarms regarding the primary endpoint can thus not be attributed to different axillary radiation doses.
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Affiliation(s)
- V M Wintraecken
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.
| | - L J Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - L M van Roozendaal
- Department of Surgical Oncology, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - J de Vries
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands; Board member Adrz, Goes, the Netherlands
| | - S M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - M L G Vane
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - T van Dalen
- Division of Surgical Oncology, Diakonessenhuis Hospital, Utrecht, the Netherlands; Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - J A van der Hage
- Division of Surgical Oncology, Leids University Medical Center, Leiden, the Netherlands
| | - L J A Strobbe
- Division of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - S C Linn
- Division of Medical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - M B I Lobbes
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - P M P Poortmans
- Department of Radiation Oncology, Iridium Network, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - V C G Tjan-Heijnen
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Division of Medical Oncology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - K K B T van de Vijver
- Department of Pathology, Ghent University Hospital, Ghent, Belgium; Department of Diagnostic Sciences, Cancer Research Institute Ghent (CRIG), Ghent University, Ghent, Belgium; Center for Gynecological Oncology Amsterdam (CGOA), Department of Gynecology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - A H Westenberg
- Radiation Oncology, Radiotherapiegroep location Arnhem, Arnhem, the Netherlands
| | - J H W de Wilt
- Division of Surgical Oncology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M L Smidt
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - J M Simons
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiotherapy, Erasmus Medical Centre, Rotterdam, the Netherlands
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Abouegylah M, Elemary O, Ahmed AA, ElFeky AM, Fayed H, Gawish M, Mahmoud AA, Gawish A. Impact of breath hold on regional nodal irradiation and heart volume in field in left breast cancer adjuvant irradiation. Clin Transl Oncol 2024; 26:288-296. [PMID: 37382756 DOI: 10.1007/s12094-023-03256-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE Compared to the free-breathing technique, adjuvant left breast irradiation after breast-conserving surgery or mastectomy using the breath-hold method significantly reduces the heart mean dose, Left anterior descending artery, and ipsilateral lung doses. Movement with deep inspiration may also reduce heart volume in the field and regional node doses. MATERIALS AND METHODS Pre-radiotherapy planning CT was performed in the free-breathing, and breath-hold techniques using RPM, demographic information, clinicopathological data, heart volume in the field, heart mean dose, LAD mean dose, and regional nodal doses were calculated in both free breathing and DIBH. Fifty patients with left breast cancer receiving left breast adjuvant radiation were enrolled. RESULTS There was no significant difference in axillary LN coverage between the two techniques, except for SCL maximum dose, Axilla I node maximum dose, and Axilla II minimum dose in favor of the breath hold technique. The mean age was 47.54 years, 78% had GII IDC, 66% had positive LVSI results, and 74% of patients had T2. The breath hold strategy resulted in considerably decreased mean heart dose (p = 0.000), LAD dose (p = 0.000), ipsilateral lung mean dose (p = 0.012), and heart volume if the field (p = 0.013). The mean cardiac dosage and the dose of the LAD were significantly correlated (p = 0.000, R = 0.673). Heart volume in the field and heart mean dosage was not significantly correlated (p = 0.285, r = - 0.108). CONCLUSION When compared to free breathing scans, DIBH procedures result in considerably reduced dosage to the OAR and no appreciable changes in dose exposure to regional lymph node stations in patients with left-sided breast cancer.
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Affiliation(s)
- Mohamed Abouegylah
- Department of Clinical Oncology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - O Elemary
- Department of Clinical Oncology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | | | - Amany Mostafa ElFeky
- Department of Clinical Oncology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Haytham Fayed
- Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mostafa Gawish
- Department of General Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Amr A Mahmoud
- Department of Clinical Oncology, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt
| | - Ahmed Gawish
- Department of Radiation Oncology, University Hospital Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
- Department of Radiation Oncology, Marburg Ion-Beam Therapy Center (MIT), Heidelberg University Hospital, Marburg, Germany.
- Department of Radiation Oncology, Marburg University Hospital, Marburg, Germany.
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8
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Leonardi MC, Pepa M, Zaffaroni M, Vincini MG, Luraschi R, Vigorito S, Morra A, Dicuonzo S, Mazzola GC, Gerardi MA, Zerella MA, Cante D, Petrucci E, Borzì G, Marrocco M, Chieregato M, Iadanza L, Lobefalo F, Valenti M, Cavallo A, Russo S, Guernieri M, Malatesta T, Meaglia I, Liotta M, Palumbo I, Marcantonini M, Mezzenga E, Falivene S, Arrichiello C, Barbero MP, Ivaldi GB, Catalano G, Vidali C, Giannitto C, Ciabattoni A, Meattini I, Aristei C, Orecchia R, Cattani F, Jereczek-Fossa BA. Impact of inter-observer variability on first axillary level dosimetry in breast cancer radiotherapy: An AIRO multi-institutional study. TUMORI JOURNAL 2023; 109:570-575. [PMID: 37688419 DOI: 10.1177/03008916231196801] [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] [Indexed: 09/10/2023]
Abstract
This study quantified the incidental dose to the first axillary level (L1) in locoregional treatment plan for breast cancer. Eighteen radiotherapy centres contoured L1-L4 on three different patients (P1,2,3), created the L2-L4 planning target volume (single centre planning target volume, SC-PTV) and elaborated a locoregional treatment plan. The L2-L4 gold standard clinical target volume (CTV) along with the gold standard L1 contour (GS-L1) were created by an expert consensus. The SC-PTV was then replaced by the GS-PTV and the incidental dose to GS-L1 was measured. Dosimetric data were analysed with Kruskal-Wallis test. Plans were intensity modulated radiotherapy (IMRT)-based. P3 with 90° arm setup had statistically significant higher L1 dose across the board than P1 and P2, with the mean dose (Dmean) reaching clinical significance. Dmean of P1 and P2 was consistent with the literature (77.4% and 74.7%, respectively). The incidental dose depended mostly on L1 proportion included in the breast fields, underlining the importance of the setup, even in case of IMRT.
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Affiliation(s)
| | - Matteo Pepa
- Division of Radiation Oncology, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Mattia Zaffaroni
- Division of Radiation Oncology, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | | | - Rosa Luraschi
- Unit of Medical Physics, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Sabrina Vigorito
- Unit of Medical Physics, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Anna Morra
- Division of Radiation Oncology, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | | | | | | | - Domenico Cante
- Radiotherapy Department, ASL TO4 Ivrea Community Hospital, Ivrea, Italy
| | - Edoardo Petrucci
- Unit of Medical Physics, ASL TO4 Ivrea Community Hospital, Ivrea, Italy
| | | | | | | | - Luciano Iadanza
- Unit of Medical Physics, Azienda Ospedaliera di Rilievo Nazionale San Pio, Benevento, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Centre IRCCS, Milano, Italy
| | - Marco Valenti
- Unit of Medical Physics, Ospedali Riuniti Umberto I, G.M. Lancisi, G. Salesi, Ancona, Italy
| | - Anna Cavallo
- Unit of Medical Physics, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Serenella Russo
- Unit of Medical Physics, AUSL Toscana Centro, Ospedale Santa Maria Annunziata, Firenze, Italy
| | - Marika Guernieri
- Medical Physics Unit, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Tiziana Malatesta
- Unit of Medical Physics, Ospedale Fatebenefratelli Isola Tiberina - Gemelli Isola, Roma, Italy
| | - Ilaria Meaglia
- Department of Radiation Oncology, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Marco Liotta
- Unit of Medical Physics, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | - Isabella Palumbo
- Radiation Oncology section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Marta Marcantonini
- Medical Physics Unit, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Emilio Mezzenga
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori "Dino Amadori", Meldola, Italy
| | - Sara Falivene
- Department of Radiotherapy, ASL Napoli1 Centro - Ospedale del Mare, Napoli, Italy
| | - Cecilia Arrichiello
- Unit of Radiotherapy, Istituto Nazionale Tumori - IRCCS - Fondazione G. Pascale, Napoli, Italy
| | - Maria Paola Barbero
- Unit of Medical Physics, Azienda Ospedaliera Nazionale SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | - Gianpiero Catalano
- Department of Radiotherapy, IRCCS MultiMedica, Sesto San Giovanni, Italy
| | - Cristiana Vidali
- Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Caterina Giannitto
- Division of Radiology, Istituto Europeo di Oncologia IRCCS, Milano, Italy
| | | | - Icro Meattini
- Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Firenze, Italy
| | - Cynthia Aristei
- Radiation Oncology section, University of Perugia and Perugia General Hospital, Perugia, Italy
| | - Roberto Orecchia
- Scientific Direction, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Federica Cattani
- Unit of Medical Physics, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, Istituto Europeo di Oncologia, IRCCS, Milano, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
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9
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Banys-Paluchowski M, Hartmann S, Ditsch N, Krawczyk N, Kühn T, de Boniface J, Banys-Kotomska J, Rody A, Krug D. Locoregional Therapy: From Mastectomy to Reconstruction, Targeted Surgery, and Ultra-Hypofractionated Radiotherapy. Breast Care (Basel) 2023; 18:428-439. [PMID: 38130814 PMCID: PMC10731028 DOI: 10.1159/000533748] [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: 04/25/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Background The past 3 decades have seen an unprecedented shift toward treatment de-escalation in surgical therapy of breast cancer. Summary Radical mastectomy has been replaced by breast-conserving and oncoplastic approaches in most patients, and full axillary lymph node dissection by less radical staging procedures, such as sentinel lymph node biopsy and targeted axillary dissection. Further, attempts have been made to spare healthy tissue while increasing the probability of removing the tumor with clear margins, thus improving cosmetic results and minimizing the risk of local recurrence. In this context, modern probe-guided localization techniques have been introduced to guide surgical excision. This progress was accompanied by the development of targeted systemic therapies. At the same time, radiotherapy for breast cancer has undergone significant changes. The use of hypofractionation has decreased the typical length of a treatment course from 5-6 weeks to 1-3 weeks. Partial breast irradiation is now a valid option for de-escalation in patients with low-risk features. Axillary radiotherapy achieves similar recurrence rates and decreases the risk of lymphedema in patients with limited sentinel node involvement. Key Messages Taken together, these advances are important steps toward individualization of locoregional management strategies. This highlights the importance of interdisciplinary approaches for de-escalation of locoregional therapies.
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, Rostock, Germany
| | - Nina Ditsch
- Breast Cancer Center, Department of Gynaecology and Obstetrics, University Hospital Augsburg, Augsburg, Germany
| | - Natalia Krawczyk
- Department of Gynecology and Obstetrics, Heinrich-Heine-University Düsseldorf, Dusseldorf, Germany
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Die Filderklinik, Filderstadt, Germany
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Capio St. Göran’s Hospital, Stockholm, Sweden
| | - Joanna Banys-Kotomska
- I Department and Clinic of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Achim Rody
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Lubeck, Lubeck, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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10
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Kaidar-Person O, Pfob A, Gentilini OD, Borisch B, Bosch A, Cardoso MJ, Curigliano G, De Boniface J, Denkert C, Hauser N, Heil J, Knauer M, Kühn T, Lee HB, Loibl S, Mannhart M, Meattini I, Montagna G, Pinker K, Poulakaki F, Rubio IT, Sager P, Steyerova P, Tausch C, Tramm T, Vrancken Peeters MJ, Wyld L, Yu JH, Weber WP, Poortmans P, Dubsky P. The Lucerne Toolbox 2 to optimise axillary management for early breast cancer: a multidisciplinary expert consensus. EClinicalMedicine 2023; 61:102085. [PMID: 37528842 PMCID: PMC10388578 DOI: 10.1016/j.eclinm.2023.102085] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/20/2023] [Accepted: 06/20/2023] [Indexed: 08/03/2023] Open
Abstract
Clinical axillary lymph node management in early breast cancer has evolved from being merely an aspect of surgical management and now includes the entire multidisciplinary team. The second edition of the "Lucerne Toolbox", a multidisciplinary consortium of European cancer societies and patient representatives, addresses the challenges of clinical axillary lymph node management, from diagnosis to local therapy of the axilla. Five working packages were developed, following the patients' journey and addressing specific clinical scenarios. Panellists voted on 72 statements, reaching consensus (agreement of 75% or more) in 52.8%, majority (51%-74% agreement) in 43.1%, and no decision in 4.2%. Based on the votes, targeted imaging and standardized pathology of lymph nodes should be a prerequisite to planning local and systemic therapy, axillary lymph node dissection can be replaced by sentinel lymph node biopsy ( ± targeted approaches) in a majority of scenarios; and positive patient outcomes should be driven by both low recurrence risks and low rates of lymphoedema.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - André Pfob
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- National Center for Tumor Diseases (NCT) and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | | | - Bettina Borisch
- Department of Histopathology, University of Geneva, 1202 Geneva, Switzerland
| | - Ana Bosch
- Division of Oncology, Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lasarettsgatan 23A, 22241, Lund, Sweden
| | - Maria João Cardoso
- Breast Unit, Champalimaud Foundation and University of Lisbon Faculty of Medicine, Lisbon, Portugal
| | - Giuseppe Curigliano
- Division of New Drugs and Early Drug Development, European Institute of Oncology IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milano MI, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Jana De Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Surgery, Breast Centre, Capio St Göran's Hospital, Stockholm, Sweden
| | - Carsten Denkert
- Institute of Pathology, Philipps-University Marburg and University Hospital Marburg, Marburg, Germany
| | - Nik Hauser
- Breast Center, Hirslanden Clinic Aarau, Frauenarztzentrum Aargau AG, Baden, Switzerland
| | - Jörg Heil
- Department of Obstetrics & Gynecology, Heidelberg University Hospital, Germany
- Breast Center Heidelberg, Klinik St. Elisabeth, Heidelberg, Germany
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, University of Ulm, Germany
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | - Sibylle Loibl
- German Breast Group (GBG), C/o GBG Forschungs GmbH 63263 - Neu-Isenberg/, Germany
- Centre for Haematology and Oncology Bethanien, Frankfurt, Germany
| | | | - Icro Meattini
- Radiation Oncology Unit, Azienda Ospedaliero Universitaria Careggi, University of Florence, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences “M. Serio”, University of Florence, Florence, Italy
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katja Pinker
- Breast Imaging Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Isabel T. Rubio
- Breast Surgical Oncology, Clinica Universidad de Navarra, Madrid, Spain
| | - Patrizia Sager
- Breast Center Bern-Biel, Hirslanden Clinic Salem, Bern, Switzerland
| | - Petra Steyerova
- Breast Cancer Screening and Diagnostic Center, Clinic of Radiology, General University Hospital in Prague, Prague, Czech Republic
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology Netherlands Cancer Institute, Antoni van Leeuwenhoek & Amsterdam University Medical Center, Netherlands
| | - Lynda Wyld
- Department of Oncology and Metabolism, The University of Sheffield, The Medical School, Sheffield, UK
| | - Jong Han Yu
- Division of Breast Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Walter Paul Weber
- Breast Center, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Peter Dubsky
- Breast Center, Hirslanden Clinic St Anna, 6006, Lucerne, Switzerland
- University of Lucerne, Faculty of Health Sciences and Medicine, Lucerne, Switzerland
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11
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Laws A, Kantor O, King TA. Surgical Management of the Axilla for Breast Cancer. Hematol Oncol Clin North Am 2023; 37:51-77. [PMID: 36435614 DOI: 10.1016/j.hoc.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This review discusses the contemporary surgical management of the axilla in patients with breast cancer. Surgical paradigms are highlighted by clinical nodal status at presentation and treatment approach, including upfront surgery and neoadjuvant systemic therapy settings. This review focuses on the increasing opportunities for de-escalating the extent of axillary surgery in the era of sentinel lymph node biopsy, while also reviewing the remaining indications for axillary clearance with axillary lymph node dissection.
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Affiliation(s)
- Alison Laws
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Olga Kantor
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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12
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Reimer T. Omission of axillary sentinel lymph node biopsy in early invasive breast cancer. Breast 2023; 67:124-128. [PMID: 36658052 PMCID: PMC9982316 DOI: 10.1016/j.breast.2023.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023] Open
Abstract
Local treatment of the axilla in clinically node-negative (cN0) early breast cancer patients with routine sentinel lymph node biopsy (SLNB) is debated after publication of ACOSOG Z0011 data in 2010. Currently, prospective randomized surgical trials investigating the omission of SLNB in upfront breast-conserving surgery (BCS) and in the neoadjuvant setting, respectively. Several prospective randomized trials (SOUND, INSEMA, BOOG 2013-08, and NAUTILUS) with axillary observation alone versus SLNB in cN0 patients and primary BCS have primary objectives to evaluate oncologic safety when omitting SLNB. The Italian SOUND trial was the earliest to open in 2012 and has completed accrual in 2017. First oncologic outcome data are expected soon for SOUND and at the end of 2024 for INSEMA. Improvements in systemic treatments for breast cancer have increased the rates of pathologic complete response (pCR) in patients receiving neoadjuvant systemic therapy (NAST), offering the opportunity to de-escalate surgery in patients who have a pCR. Two prospective single-arm trials (EUBREAST-01, ASICS) include only patients with the highest likelihood of having a pCR after NAST (triple-negative or HER2-positive breast cancer) and type of surgery will be defined according to the response to NAST rather than on the classical T and N status. The ongoing trials will hopefully help us to understand whether we might take the best therapeutic decisions without the pathologic evaluation of nodal status.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059, Rostock, Germany.
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13
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Reimer T, Stachs A, Veselinovic K, Polata S, Müller T, Kühn T, Heil J, Ataseven B, Reitsamer R, Hildebrandt G, Knauer M, Golatta M, Stefek A, Zahm DM, Thill M, Nekljudova V, Krug D, Loibl S, Gerber B. Patient-reported outcomes for the Intergroup Sentinel Mamma study (INSEMA): A randomised trial with persistent impact of axillary surgery on arm and breast symptoms in patients with early breast cancer. EClinicalMedicine 2023; 55:101756. [PMID: 36457648 PMCID: PMC9706517 DOI: 10.1016/j.eclinm.2022.101756] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In clinically node-negative breast cancer patients, the INSEMA trial (NCT02466737) assessed the non-inferiority of avoiding sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND). Here we present patient-reported outcomes (PROs) as a secondary endpoint. METHODS PROs were assessed for patients with no axillary surgery, SLNB alone, and ALND. Quality of life (QoL) questionnaire EORTC QLQ-C30 and its breast cancer module (BR23) were used at baseline (pre-surgery) and 1, 3, 6, 12, and 18 months after surgery. The QoL scores were compared using repeated measures mixed models based on the safety set. FINDINGS Between 2015 and 2019, 5502 patients were recruited for the first randomization, and 5154 were included in the intent-to-treat set (4124 SLNB versus 1030 no SLNB). In the case of one to three macrometastases after SLNB, 485 patients underwent second randomization (242 SLNB alone versus 243 ALND). Questionnaire completion response remained high throughout the trial: over 70% at all time points for the first randomization. There were significant differences for the BRBS (breast symptoms) and BRAS (arm symptoms) scores favoring the no SLNB group in all post-baseline assessments. Patients in the SLNB group showed significantly and clinically relevant higher scores for BRAS (differences in mean values ≥5.0 points at all times), including pain, arm swelling, and impaired mobility in all postoperative visits, with the highest difference at one month after surgery. Scoring of the QLQ-C30 questionnaire revealed no relevant differences between the treatment groups, although some comparisons were statistically significant. INTERPRETATION This is one of the first randomized trials investigating the omission of SLNB in clinically node-negative patients and the first to report comprehensive QoL data. Patients with no SLNB benefitted regarding arm symptoms/functioning, while no relevant differences in other scales were seen. FUNDING Supported by German Cancer Aid (Deutsche Krebshilfe, Bonn, Germany), Grant No. 110580 and Grant No. 70110580 to University Medicine Rostock.
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Affiliation(s)
- Toralf Reimer
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany
- Corresponding author. Department of Obstetrics and Gynecology, The University of Rostock, Suedring 81, 18059 Rostock, Germany.
| | - Angrit Stachs
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany
| | - Kristina Veselinovic
- Department of Obstetrics and Gynecology, University of Ulm, Prittwitzstr. 43, 89075 Ulm, Germany
| | - Silke Polata
- Breast Center, Evangelisches Waldkrankenhaus Spandau, Stadtrandstr. 555, 13589 Berlin, Germany
| | - Thomas Müller
- Women's Hospital, Klinikum Hanau GmbH, Leimenstr. 20, 63450 Hanau, Germany
| | - Thorsten Kühn
- Women's Hospital, Klinikum Esslingen, Hirschlandstr. 97, 73730 Esslingen, Germany
| | - Jörg Heil
- Breast Unit, University Hospital, University of Heidelberg, Im Neuenheimer Feld 460, 69120 Heidelberg, Germany
| | - Beyhan Ataseven
- Department of Gynecology and Gynecologic Oncology, Evang. Kliniken Essen-Mitte, Henricistr. 92, 45136 Essen, Germany
- Department of Obstetrics and Gynecology, LMU University Hospital, Marchioninistr. 15, 81377 Munich, Germany
| | - Roland Reitsamer
- Breast Center, LKH Salzburg, Paracelsus Medical University Clinics, Müllner Hauptstr. 48, A-5020 Salzburg, Austria
| | - Guido Hildebrandt
- Department of Radiotherapy, University of Rostock, Südring 75, 18059 Rostock, Germany
| | - Michael Knauer
- Brustzentrum Ost, Rohrschacher Str. 286, CH-9016 St. Gallen, Switzerland
| | - Michael Golatta
- Breast Unit, Sankt Elisabeth Hospital, Max-Reger-Str. 5-7, 69121 Heidelberg, Germany
| | - Andrea Stefek
- Women's Hospital, Johanniter-Hospital Stendal, Wendstr. 31, 39576 Stendal, Germany
| | - Dirk-Michael Zahm
- Breast Center, SRH Waldklinikum Gera, Str. des Friedens 122, 07548 Gera, Germany
| | - Marc Thill
- Department of Gynecology and Gynecological Oncology, Agaplesion Markus Hospital, W.-Epstein-Str. 4, 60431 Frankfurt/Main, Germany
| | | | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str., 24105 Kiel, Germany
| | - Sibylle Loibl
- German Breast Group, Dornhofstr. 10, 63263 Neu-Isenburg, Germany
| | - Bernd Gerber
- Department of Obstetrics and Gynecology, University of Rostock, Südring 81, 18059 Rostock, Germany
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14
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Espenel S, Chargari C, Blanchard P, Bockel S, Morel D, Rivera S, Levy A, Deutsch E. Practice changing data and emerging concepts from recent radiation therapy randomised clinical trials. Eur J Cancer 2022; 171:242-258. [PMID: 35779346 DOI: 10.1016/j.ejca.2022.04.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/19/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Oncology treatments are constantly and rapidly evolving. We aimed at highlighting the latest radiation therapy practice changing trials and emerging concepts, through an overview of recent randomised clinical trials (RCTs). MATERIALS AND METHODS Requests were performed in the Medline database to identify all publications reporting radiation therapy RCTs from 2018 to 2021. RESULTS Recent RCTs sustained the role of newer combinatorial strategies through radioimmunotherapy for early stage or metastatic lung cancer, newer pro-apoptotic agents (e.g. debio 1143 in locoregionally advanced head and neck squamous cell carcinoma) or nanoparticles (e.g. NBTXR3 in locally advanced soft-tissue sarcoma). High-tech radiotherapy allows intensifying treatments and gaining ground in some indications through the development of stereotactic body radiotherapy for example. First randomised evidence on personalised radiation therapy through imaging-based (18FDG positron emission tomography-computed tomography for lung cancer or early stage unfavourable Hodgkin lymphoma, PMSA positron emission tomography-computed tomography or magnetic resonance imaging for high-risk prostate cancer) or biological biomarkers (PSA for prostate cancer, HPV for head and neck cancer, etc) were conducted to more tailored treatments, with more favourable outcomes. Patients' quality of life and satisfaction appeared to be increasing aims. RCTs have validated (ultra)hypofractionated schemes in many indications as for breast, prostate or rectal cancer, resulting in equivalent outcomes and toxicities, more convenient for patients and favouring shared decision making. CONCLUSION Radiation therapy is a dynamic field of research, and many RCTs have greatly impacted therapeutic standards over the last years. Investments in radiotherapy research should facilitate the transfer of innovation to clinic.
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Affiliation(s)
- Sophie Espenel
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France.
| | - Cyrus Chargari
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Institut de Recherche Biomédicale des Armées, F-91220, Brétigny sur Orge, France.
| | - Pierre Blanchard
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Faculté de Médecine, F-94270, Le Kremlin Bicêtre, France; Oncostat, Inserm U-1018, F-94805, Villejuif, France.
| | - Sophie Bockel
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France.
| | - Daphne Morel
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France.
| | - Sofia Rivera
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Inserm U-1030, Laboratoire de Radiothérapie Moléculaire et d'Innovation Thérapeutique, F-94805, Villejuif, France.
| | - Antonin Levy
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Faculté de Médecine, F-94270, Le Kremlin Bicêtre, France; Université Paris-Saclay, Inserm U-1030, Laboratoire de Radiothérapie Moléculaire et d'Innovation Thérapeutique, F-94805, Villejuif, France.
| | - Eric Deutsch
- Gustave Roussy, Département de Radiothérapie, F-94805, Villejuif, France; Université Paris-Saclay, Faculté de Médecine, F-94270, Le Kremlin Bicêtre, France; Université Paris-Saclay, Inserm U-1030, Laboratoire de Radiothérapie Moléculaire et d'Innovation Thérapeutique, F-94805, Villejuif, France.
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15
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Wolf J, Kurz S, Rothe T, Serpa M, Scholber J, Erbes T, Gkika E, Baltas D, Verma V, Krug D, Juhasz-Böss I, Grosu AL, Nicolay NH, Sprave T. Incidental irradiation of the regional lymph nodes during deep inspiration breath-hold radiation therapy in left-sided breast cancer patients: a dosimetric analysis. BMC Cancer 2022; 22:682. [PMID: 35729505 PMCID: PMC9210647 DOI: 10.1186/s12885-022-09784-x] [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: 04/21/2022] [Accepted: 06/01/2022] [Indexed: 12/01/2022] Open
Abstract
Background Radiotherapy using the deep inspiration breath-hold (DIBH) technique compared with free breathing (FB) can achieve substantial reduction of heart and lung doses in left-sided breast cancer cases. The anatomical organ movement in deep inspiration also cause unintended exposure of locoregional lymph nodes to the irradiation field. Methods From 2017–2020, 148 patients with left-sided breast cancer underwent breast conserving surgery (BCS) or mastectomy (ME) with axillary lymph node staging, followed by adjuvant irradiation in DIBH technique. Neoadjuvant or adjuvant systemic therapy was administered depending on hormone receptor and HER2-status. CT scans in FB and DIBH position with individual coaching and determination of the breathing amplitude during the radiation planning CT were performed for all patients. Intrafractional 3D position monitoring of the patient surface in deep inspiration and gating was performed using Sentinel and Catalyst HD 3D surface scanning systems (C-RAD, Catalyst, C-RAD AB, Uppsala, Sweden). Three-dimensional treatment planning was performed using standard tangential treatment portals (6 or 18 MV). The delineation of ipsilateral locoregional lymph nodes was done on the FB and the DIBH CT-scan according to the RTOG recommendations. Results The mean doses (Dmean) in axillary lymph node (AL) level I, II and III in DIBH were 32.28 Gy (range 2.87–51.7), 20.1 Gy (range 0.44–53.84) and 3.84 Gy (range 0.25–39.23) vs. 34.93 Gy (range 10.52–50.40), 16.40 Gy (range 0.38–52.40) and 3.06 Gy (range 0.21–40.48) in FB (p < 0.0001). Accordingly, in DIBH the Dmean for AL level I were reduced by 7.59%, whereas for AL level II and III increased by 22.56% and 25.49%, respectively. The Dmean for the supraclavicular lymph nodes (SC) in DIBH was 0.82 Gy (range 0.23–4.11), as compared to 0.84 Gy (range 0.22–10.80) with FB (p = 0.002). This results in a mean dose reduction of 2.38% in DIBH. The Dmean for internal mammary lymph nodes (IM) was 12.77 Gy (range 1.45–39.09) in DIBH vs. 11.17 Gy (range 1.34–44.24) in FB (p = 0.005). This yields a mean dose increase of 14.32% in DIBH. Conclusions The DIBH technique may result in changes in the incidental dose exposure of regional lymph node areas.
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Affiliation(s)
- Jule Wolf
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Steffen Kurz
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thomas Rothe
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Marco Serpa
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Jutta Scholber
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Thalia Erbes
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Eleni Gkika
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Dimos Baltas
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Vivek Verma
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Anca-Ligia Grosu
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Nils H Nicolay
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany.,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.,Department of Molecular and Radiation Oncology, German Cancer Research Center (Dkfz), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Tanja Sprave
- Department of Radiation Oncology, University Hospital of Freiburg, Robert-Koch-Strasse 3, 79106, Freiburg, Germany. .,German Cancer Research Center (Dkfz), German Cancer Consortium (DKTK) Partner Site Freiburg, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany.
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16
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Haussmann J, Budach W, Strnad V, Corradini S, Krug D, Schmidt L, Tamaskovics B, Bölke E, Simiantonakis I, Kammers K, Matuschek C. Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:2967. [PMID: 34199281 PMCID: PMC8231985 DOI: 10.3390/cancers13122967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE/OBJECTIVE The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials. MATERIAL AND METHODS We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes. RESULTS For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively). CONCLUSION Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Vratislav Strnad
- Department of Radiation Oncology, University Erlangen, 91054 Erlangen, Germany;
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU (Ludwig Maximillian), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Ioannis Simiantonakis
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
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17
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Krug D, Vonthein R, Schreiber A, Boicev AD, Zimmer J, Laubach R, Weidner N, Dinges S, Hipp M, Schneider R, Weinstrauch E, Martin T, Hörner-Rieber J, Olbrich D, Illen A, Heßler N, König IR, Dellas K, Dunst J. Impact of guideline changes on adoption of hypofractionation and breast cancer patient characteristics in the randomized controlled HYPOSIB trial. Strahlenther Onkol 2020; 197:802-811. [PMID: 33320286 PMCID: PMC8397631 DOI: 10.1007/s00066-020-01730-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 11/30/2020] [Indexed: 12/17/2022]
Abstract
Purpose Hypofractionated radiotherapy is the standard of care for adjuvant whole breast radiotherapy (RT). However, adoption has been slow. The indication for regional nodal irradiation has been expanded to include patients with 0–3 involved lymph nodes. We investigated the impact of the publication of the updated German S3 guidelines in 2017 on adoption of hypofractionation and enrollment of patients with lymph node involvement within a randomized controlled phase III trial. Methods In the experimental arm of the HYPOSIB trial (NCT02474641), hypofractionated RT with simultaneous integrated boost (SIB) was used. In the standard arm, RT could be given as hypofractionated RT with sequential boost (HFseq), normofractionated RT with sequential boost (NFseq), or normofractionated RT with SIB (NFSIB). The cutoff date for the updated German S3 guidelines was December 17, 2017. Temporal trends were analyzed by generalized linear regression models. Multiple logistic regression models were used to investigate the influence of time (prior to/after guideline) and setting (university hospital/other institutions) on the fractionation patterns. Results Enrollment of patients with involved lymph nodes was low throughout the trial. Adoption of HFseq increased over time and when using the guideline publication date as cutoff. Results of the multiple logistic regressions showed an interaction between time and setting. Furthermore, the use of HFseq was significantly more common in university hospitals. Conclusion The use of HFseq in the standard arm increased over the course of the HYPOSIB trial and after publication of the S3 guideline update. This was primarily driven by patients treated in university hospitals. Enrolment of patients with lymph node involvement was low throughout the trial.
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Affiliation(s)
- David Krug
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Reinhard Vonthein
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Andreas Schreiber
- Praxis für Strahlentherapie Dr. med. Andreas Schreiber, Dresden, Germany
| | - Alexander D Boicev
- Klinik für Strahlentherapie und Radioonkologie, Heinrich-Braun-Klinikum Zwickau, Zwickau, Germany
| | - Jörg Zimmer
- Praxis für Strahlentherapie Dr. med. Andreas Schreiber, Dresden, Germany
| | - Reinhold Laubach
- Klinik für Radio-Onkologie, St. Marien-Krankenhaus Siegen, Siegen, Germany
| | - Nicola Weidner
- Klinik für Strahlentherapie, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Stefan Dinges
- Klinik für Strahlentherapie & Radioonkologie, Klinikum Lüneburg, Lüneburg, Germany
| | - Matthias Hipp
- Klinik für Strahlentherapie, Klinikum Amberg, Amberg, Germany
| | - Ralf Schneider
- Klinik für Strahlentherapie, Helios-Kliniken Schwerin, Schwerin, Germany
| | - Evelyn Weinstrauch
- Praxis für Radioonkologie, Johanniter-Zentren für Medizinische Versorgung Stendal, Stendal, Germany
| | - Thomas Martin
- Medizinisches Versorgungszentrum Fachbereich RadioOnkologie, Klinikum Bremen-Mitte, Bremen, Germany
| | - Juliane Hörner-Rieber
- RadioOnkologie und Strahlentherapie, UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Denise Olbrich
- ZKS Lübeck (Zentrum für klinische Studien Lübeck), Universität zu Lübeck, Lübeck, Germany
| | - Alicia Illen
- ZKS Lübeck (Zentrum für klinische Studien Lübeck), Universität zu Lübeck, Lübeck, Germany
| | - Nicole Heßler
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Inke R König
- Institut für Medizinische Biometrie und Statistik, Universität zu Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Kathrin Dellas
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
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