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Unterkirhere O, Stenger-Weisser A, Kaever A, Hoeng L, Jeller D, Logaritsch P, Glanzmann C, Studer G. Single-Institution Prospective Evaluation of Moderately Hypofractionated Whole-Breast Radiation Therapy With Simultaneous Integrated Boost With or Without Lymphatic Drainage Irradiation After Breast-Conserving Surgery. Adv Radiat Oncol 2023; 8:101270. [PMID: 38047219 PMCID: PMC10692289 DOI: 10.1016/j.adro.2023.101270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose We report treatment outcomes for patients who received adjuvant moderate hypofractionated whole-breast radiation therapy with simultaneous integrated boost (SIB-mhWBRT) after breast-conserving surgery. Methods and Materials SIB-mhWBRT for patients with breast cancer was introduced in our department in July 2017. This prospective evaluation includes 424 consecutive patients treated with SIB-mhWBRT for stage I-III invasive breast cancer (n = 391) and/or ductal carcinoma in situ (n = 33) until December 2021. SIB-mhWBRT was applied with 40 Gy in 15 daily fractions over 3 weeks according to the START B trial, with an SIB dose to the tumor bed of 48 Gy according to Radiation Therapy Oncology Group 1005/UK-IMPORT-HIGH, delivered as 3-dinemsional conformal radiation therapy (RT; n = 402), intensity modulated RT (n = 4), or volumetric modulated arc therapy (n = 18). The mean patient age was 60 years (range, 27-88). Since May 2018, patients with indications for lymphatic pathway RT were included (n = 62). Baseline parameters and follow-up data were recorded and reported, including objective assessment of treatment-related outcomes and subjective patient-reported outcome measures (PROMs). Results Mean/median follow-up was 29/33 months (range, 2-60). Acute toxicity grade 0, 1, 2, and 3 was observed in 25.0%, 61.4%, 13.3%, and 0%, respectively, at the completion of RT. Data of 281, 266, 243, 172, and 58 patients were available for 6-month and 1-, 2-, 3-, and 4-year follow-up, respectively. Grade 2 late effects were identified in 8.5%, 6.0%, 4.9%, 2.2%, and 10.2% and grade 3 in 2.8%, 1.1%, 1.2%, 0%, and 0% of patients at 6-month and 1-, 2-, 3-, and 4-year follow-up, respectively. Medical treatment of breast edema was the only grade 3 late effect observed. PROM cosmesis results were evaluated as excellent-good, fair, and poor in 97.2%, 2.5%, and 0.4%; 96.5%, 3.1%, and 0.4%; 97.4%, 2.2%, and 0.4%; 97.5%, 2.5%, and 0%; and 96.5%, 3.5%, and 0.0% at 6 months and 1, 2, 3, and 4 years post-RT, respectively. For all patients, the 3-year overall, cancer-specific, and disease-free survival rates were 98.2%, 99.1%, and 95.9%, respectively. Three-year risk of any locoregional recurrence was 0.6%. No mortality or relapse was observed in patients with ductal carcinoma in situ. Conclusions SIB-mhWBRT demonstrated very favorable side effect profiles and cosmesis/PROMs. Three-year results demonstrate excellent locoregional control. This short-term regimen offers substantial patient comfort and improves institutional efficacy.
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Affiliation(s)
- Olga Unterkirhere
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Laura Hoeng
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | - David Jeller
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Gabriela Studer
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
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Chitapanarux I, Nobnop W, Onchan W, Klunklin P, Nanna T, Sitathanee C, Kulpisitthicharoen S, Sripan P. Hypofractionated whole breast irradiation with simultaneous integrated boost in breast cancer using helical tomotherapy with or without regional nodal irradiation: A report of acute toxicities. Front Oncol 2023; 13:1122093. [PMID: 37007149 PMCID: PMC10064045 DOI: 10.3389/fonc.2023.1122093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/08/2023] [Indexed: 03/19/2023] Open
Abstract
PurposeWe prospectively investigated the acute toxicities focusing on skin and hematologic function in breast cancer patients who received hypofractionated whole breast irradiation with simultaneous integrated boost (HF-WBI-SIB) with helical tomotherapy (HT), with or without regional nodal irradiation (RNI).MethodsThe dose of WBI and RNI was 42.4 Gy in 16 fractions. Tumor bed was prescribed to 49.6 Gy in 16 fractions simultaneously. The association between the worst grade of acute toxicities during treatment and receiving RNI was analyzed. The integral dose to the whole body between the two groups was also compared.ResultsBetween May 2021 and May 2022, 85 patients were enrolled; 61 patients received HF-WBI-SIB only (71.8%) and 24 patients (28.2%) received HF-WBI-SIB with RNI. Grade 2 acute skin toxicity was found in 1.2%. The most frequent grade 2 or more hematologic toxicity was leukopenia, which occurred in 4.8% and 11% in the 2nd and 3rd week, respectively. Mean whole body integral dose was significantly higher in patients treated with RNI compared to patients treated without RNI: 162.8 ± 32.8 vs. 120.3 ± 34.7 Gy-L (p-value < 0.001). There was no statistically significant difference in acute grade 2 or more skin and hematologic toxicities between the two groups.ConclusionsHF-WBI-SIB with or without RNI is feasible with acceptable acute skin and hematologic toxicities. RNI and whole body integral dose were not associated with these acute toxicities.
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Affiliation(s)
- Imjai Chitapanarux
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Northern Thai Research Group of Radiation Oncology (NTRG-RO), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- *Correspondence: Imjai Chitapanarux, ,
| | - Wannapha Nobnop
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Northern Thai Research Group of Radiation Oncology (NTRG-RO), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wimrak Onchan
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Northern Thai Research Group of Radiation Oncology (NTRG-RO), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pitchayaponne Klunklin
- Division of Radiation Oncology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Northern Thai Research Group of Radiation Oncology (NTRG-RO), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thongtra Nanna
- Division of Radiation Oncology, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Chomporn Sitathanee
- Division of Radiation Oncology, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | | | - Patumrat Sripan
- Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
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Dicuonzo S, Leonardi MC, Raimondi S, Corrao G, Bagnardi V, Gerardi MA, Morra A, Zerella MA, Zaffaroni M, Pansini F, Cattani F, Luraschi R, Fodor C, Veronesi P, Orecchia R, Rojas DP, Jereczek-Fossa BA. Acute and intermediate toxicity of 3-week radiotherapy with simultaneous integrated boost using TomoDirect: prospective series of 287 early breast cancer patients. Clin Transl Oncol 2021; 23:1415-1428. [PMID: 33537865 DOI: 10.1007/s12094-020-02538-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: 08/27/2020] [Accepted: 11/27/2020] [Indexed: 11/26/2022]
Abstract
AIMS To report toxicity of a hypofractionated scheme of whole-breast (WB) intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to the tumor bed (TB) using Tomotherapy® with Direct modality. METHODS Patients with early breast cancer, undergoing radiotherapy (RT) in 15 daily fractions to WB (prescription dose 40.05 Gy) and SIB to the TB (48 Gy), between 2013 and 2017, was analyzed. Primary endpoint was acute and intermediate toxicity assessed at the end and within 6 months from RT, according to Radiation Therapy Oncology Group (RTOG) scale. Secondary endpoints included early chronic toxicity at 12-months follow-up, using the Late Effects Normal Tissue Task Subjective, Objective, Management, and Analytic (LENT-SOMA) scale, and cosmesis using Harvard criteria. RESULTS The study population was of 287 patients. Acute and intermediate toxicity was collected among 183 patients with data available at the end of RT and within 6 months, 85 (46%) experienced G2 toxicity and 84 (46%) G1 toxicity, while 14 (8%) did not report toxicity at any time. A significant reduction of any grade toxicity was observed between the two time points, with the majority of patients reporting no clinically relevant toxicity at 6 months. At univariate analysis, age < 40 years, breast volume > 1000 cm3 and Dmax ≤ 115% of prescription dose were predictive factors of clinically relevant acute toxicity (G ≥ 2) at any time. At multivariable analysis, only age and breast volume were confirmed as predictive factors, with Relative Risks (95% Confidence Intervals): 2.02 (1.13-3.63) and 1.84 (1.26-2.67), respectively. At 12-month follow-up, 113 patients had complete information on any toxicity with 53% of toxicity G < 2, while cosmetic evaluation, available for 102 patients, reported a good-excellent result for 86% of patients. CONCLUSIONS Hypofractionated WB IMRT with a SIB to the TB, delivered with TomoDirect modality, is safe and well-tolerated. Most patients reported no toxicity after 6 months and good-excellent cosmesis. Predictive factors of clinically relevant toxicity might be considered during treatment planning in order to further reduce side effects.
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Affiliation(s)
- S Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M C Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - S Raimondi
- Molecular and Pharmaco-Epidemiology Unit, Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - G Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - V Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - M A Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - A Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M A Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - F Pansini
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - F Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - R Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - C Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - P Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - R Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - D P Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - B A Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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Chatterjee S, Mahata A, Mandal S, Chakraborty S. Simultaneous Integrated Boost: Improving the Patient Journey During Breast Cancer Radiotherapy Safely. Clin Oncol (R Coll Radiol) 2019; 31:266. [PMID: 30600192 DOI: 10.1016/j.clon.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/11/2018] [Indexed: 11/25/2022]
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Palumbo I, Mariucci C, Falcinelli L, Perrucci E, Lancellotta V, Podlesko AM, Marcantonini M, Saldi S, Bini V, Aristei C. Hypofractionated whole breast radiotherapy with or without hypofractionated boost in early stage breast cancer patients: a mono-institutional analysis of skin and subcutaneous toxicity. Breast Cancer 2018; 26:290-304. [PMID: 30341747 DOI: 10.1007/s12282-018-0923-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/10/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Our study evaluated skin and subcutaneous toxicity analyzing its correlation with patient- and treatment-related factors in a large mono-institutional series of women with early stage breast cancer treated with adjuvant hypofractionated whole breast radiotherapy (WBRT) with or without a sequential hypofractionated boost (HB). METHODS Two hundred and nineteen patients, median age 62 years, received adjuvant hypofractionated WBRT in 16 fractions to a total dose of 42.4 Gy. Patients with negative prognostic factors received a HB of 2.65 Gy for 4 or 5 (patients with focal positive surgical margins) fractions. Systemic adjuvant treatments were hormonal therapy (HT) and/or chemotherapy (CHT) and/or Trastuzumab. Toxicities were assessed using the Common Terminology Criteria for Adverse Events (CTCAE 4.03) scale at 5th, 10th, 16th, 20th day from the start of radiotherapy (RT) and 1, 6 and 12 months after the end of RT. Univariate and multivariate analysis estimated toxicity predictive factors. RESULTS No case of treatment interruption and no acute or late G3 toxicities occurred. In the univariate analysis HB administration resulted a risk factor for acute toxicity, while CHT administration and number of excised lymph nodes ≥ 10 resulted a risk factor for late toxicity. In the multivariate analysis none of the evaluated factors emerged a risk factor for acute and/or late toxicity. CONCLUSIONS Our results confirmed that hypofractionated WBRT even followed by a HB resulted safe and well tolerated. Longer follow-up is warranted to estimate late toxicity and treatment outcomes.
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Affiliation(s)
- Isabella Palumbo
- Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, 06156, Perugia, Italy.
| | | | | | | | - Valentina Lancellotta
- Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, 06156, Perugia, Italy
| | | | | | - Simonetta Saldi
- Radiation Oncology Section, University of Perugia, Perugia, Italy
| | - Vittorio Bini
- Internal Medicine Endocrine and Metabolic Science Section, University of Perugia, Perugia, Italy
| | - Cynthia Aristei
- Radiation Oncology Section, Department of Surgical and Biomedical Sciences, University of Perugia and Perugia General Hospital, 06156, Perugia, Italy
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Mu J, Xi D, Ding Y, Gu W, Li Q. Chair Heterogeneity Index: Describing the dose heterogeneity inside the tumor volume where there is a boost volume. Sci Rep 2018; 8:9763. [PMID: 29950564 PMCID: PMC6021440 DOI: 10.1038/s41598-018-28110-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/11/2018] [Indexed: 11/09/2022] Open
Abstract
In this report, Chair Heterogeneity Index (CHI) was introduced to assess the dose heterogeneity inside the target with a boost volume. CHI was defined by dividing (VRx − VDl) by (VDm − VDh): VRx, VDl, VDm and VDh were four points selected from the target cumulative dose volume histogram curve. The effectiveness of CHI was validated by assessing the treatment plans for nasopharyngeal cancer (NPC, 12 cases), breast cancer after breast-conserving-surgery (BC, 10 cases), and stereotactic radiosurgery after whole brain irradiation (SRS, 9 cases). Our results indicate that both CHI and HI of the target can distinguish Volumetric Modulated Arc Therapy (VMAT) from Intensity Modulated Radiation Therapy (IMRT, p < 0.05) while the mean differences in CHI (NPC 1.16, BC 1.19 and SRS 3.3) were larger than those in HI (NPC 0.03, BC 0.02 and SRS 0.02). In addition, CHI of the combination volume (the target minus the boost) were statistically higher in VMAT than IMRT in all three kinds of cancer. In conclusion, CHI was effective in assessing the dose heterogeneity inside a target containing a boost volume.
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Affiliation(s)
- Jinming Mu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Dan Xi
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Yun Ding
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Qilin Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China.
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Xi D, Ding Y, Hu R, Gu W, Mu J, Li Q. Advantages of a technique using two 50 degree arcs in simultaneous integrated boost radiotherapy for left-sidebreast cancer. Sci Rep 2017; 7:14748. [PMID: 29116237 PMCID: PMC5677093 DOI: 10.1038/s41598-017-15307-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/25/2017] [Indexed: 11/26/2022] Open
Abstract
This study evaluated radiotherapy techniques with 15 cases for simultaneous integrated boost to treat whole left breast and tumor bed following breast conserving surgery. Treatment plans were generated using three techniques: volumetric modulated arc therapy (VMAT) with a partial arc of 190° (1ARC), VMAT with two tangential mini-arcs of 50° each (2TARC) and intensity modulated radiation therapy with four fixed angle fields (4IMRT). Dosimetric parameters for the whole breast (Target), the boost tumor bed (Boost), and surrounding normal organs were compared. Chair Index (CHI) was introduced to evaluate the dose homogeneity in Target given the two levels of prescription dose. The dose coverage in Target was better in 1ARC and 2TARC than that in 4IMRT. The mean CHI in 1ARC (2.47) and 2TARC (2.62) were higher than that in 4IMRT (1.71, p < 0.05), and this indicated the dose homogeneity of Target was better in 1ARC and 2TARC than that in 4IMRT. The mean doses to right lung, and contralateral breast in 4IMRT were lower than those in 2TARC but the differences between them were small. 2TARC was better than 4IMRT with respect to the dose to ipsilateral lung and heart. Overall, 2TARC was optimal among three techniques.
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Affiliation(s)
- Dan Xi
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Yun Ding
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Rui Hu
- Department of Radiation Oncology, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 213003, China
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Jinming Mu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Qilin Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China.
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