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Mutter RW, Golafshar MA, Buras MR, Comstock BP, Jacobson M, DeWees T, Remmes NB, Francis LN, Boughey JC, Ruddy KJ, McGee LA, Afzal A, Vallow LA, Furutani KM, Deufel CL, Shumway DA, Kim H, Liu MC, Degnim AC, Jakub JW, Vern-Gross TZ, Wong WW, Patel SH, Vargas CE, Stish BJ, Waddle MR, Pafundi DH, Halyard MY, Corbin KS, Hieken TJ, Park SS. Dose de-intensified 3-day photon, proton, or brachytherapy: a nonrandomized controlled partial breast irradiation trial. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03389-3. [PMID: 39299551 DOI: 10.1016/j.ijrobp.2024.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 08/19/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND The optimal approach for partial breast irradiation (PBI) is unknown. We investigated a novel de-intensified 3-fraction PBI regimen for photons, protons, and brachytherapy. METHODS A multicenter nonrandomized controlled trial with primary outcome of adverse cosmesis at 3 years versus pre-PBI. Eligibility criteria were ≥ age 50 years treated with breast-conserving surgery for node-negative estrogen receptor positive (ER+) invasive breast cancer or any ductal carcinoma in-situ (DCIS) measuring ≤ 2.5 cm. Photon and proton PBI were prescribed 21.9 Gy (RBE) and brachytherapy 21 Gy in 3 fractions. Radiotherapy technique and use of adjuvant endocrine therapy was selected at physician and patient discretion. RESULTS Between June 17, 2015 and July 13, 2017, 161 eligible patients were treated with photons (56), protons (49), or brachytherapy (56). Median patient age was 66.8 years. 126 (78.3%) had invasive breast cancer (all ER+) and 35 (21.7%) had DCIS (88.6% ER+). 54.0% of patients with invasive breast cancer and 25.8% of patients with ER+ DCIS initiated and adhered to prescribed endocrine therapy. The proportion of patients with adverse cosmesis (by trained nurse assessment) was 14.5% at baseline, 2.3% at 3 years (difference -12.2%, 95% CI (-100%, -6.4%)). Adverse cosmesis at last-follow-up, with median follow-up 5 years, was 5.7% by nurse assessment, 5.6% by panel assessment of digital photographs, and 5.2% by patient self-report. There were no observed clinically meaningful changes in other patient reported outcomes, and just two grade 2 or higher adverse events, both grade 2, in the brachytherapy cohort. 5-year local recurrence-free and progression-free survival were 98.0% and 95.5%, respectively. There were no local recurrences amongst 60 patients with invasive breast cancer and Ki67 ≤ 13.25%. CONCLUSIONS De-intensified 3-day PBI provided favorable disease control, tolerability, and cosmetic outcomes, meeting the pre-specified criteria for acceptability. This approach is an attractive option for small node-negative ER+ BC and DCIS patients. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02453737.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA; Department of Pharmacology, Mayo Clinic, Rochester, MN.
| | - Michael A Golafshar
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | - Matthew R Buras
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | - Bryce P Comstock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Maddi Jacobson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Todd DeWees
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | | | - Leah N Francis
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Kathryn J Ruddy
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Laura A Vallow
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | - Keith M Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Haeyoung Kim
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA; Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Minetta C Liu
- Division of Medical Oncology Mayo Clinic, Rochester, Minnesota
| | - Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - James W Jakub
- Department of Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Mark R Waddle
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Deanna H Pafundi
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | - Tina J Hieken
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
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Yeh J, Chew G, Ng SL, Ooi WM, Loh SW, Hyett A, Leech T, Bevington E, Huynh J, Sim J, Foroudi F, Ng SP, Chao M. Stabilised Hyaluronic Acid (sHA) gel as a novel marker for breast cancer tumour bed cavity: Surgical feasibility. Clin Transl Radiat Oncol 2024; 45:100745. [PMID: 38406647 PMCID: PMC10885548 DOI: 10.1016/j.ctro.2024.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction Consistent delineation of the breast conserving surgery (BCS) tumour bed (TB) for breast cancer remains a challenge for radiation oncologists. Accurate delineation allows for better local control and reduces toxicity when planning partial breast or TB boost radiation therapy (RT). Methods In the operating theatre (OT) breast surgeons inserted stabilised hyaluronic acid (sHA) gel as small drops approximately one cm into the walls surrounding the resection cavity. Surgical feasibility was determined by the rate of successful sHA gel insertion procedure, the ease of insertion as rated by surgeons, the time required for insertion procedure, the quantity used, and any adverse events (AE) relating to sHA gel insertion. Results Thirty-five patients were enrolled. All patients underwent sHA gel insertion successfully. The procedure added a median of 2.8 min to the OT time and was rated as 'easy' in 89 % of patients. There were no immediate AE in OT. Five (14 %) patients experienced a grade 2 or higher AE. Three of the five patients were prescribed oral antibiotics for breast infection. Two of the five patients experienced a grade 3 AE - haematoma which required evacuation in OT day 1 post-BCS, and infected seroma which required drainage and washout in OT 2 months post-BCS. All five patients recovered and underwent the planned adjuvant therapies for their BC. The AE data reflects common risks with standard BCS and are not clearly attributed to sHA gel insertion alone. Conclusion We show that sHA gel is surgically feasible as a marker to help define the TB cavity for post-BCS adjuvant MRI-based RT planning.
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Affiliation(s)
- Janice Yeh
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Grace Chew
- Department of Breast Surgery, Austin Health, Victoria, Australia
- University of Melbourne, Victoria, Australia
| | - Suat Li Ng
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Wei Ming Ooi
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Su-Wen Loh
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Anthony Hyett
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Tristan Leech
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Elaine Bevington
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Jenny Huynh
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Jenny Sim
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
- University of Melbourne, Victoria, Australia
| | - Michael Chao
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
- Genesis Care, Ringwood Private Hospital, Victoria, Australia
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Mitchell S, Lee H, DuPree BB, Beyer DC, Ulissey M, Grobmyer SR, Gass J, Boolbol S, Storm-Dickerson T. A novel, adaptable, radiographically opaque, multi-plane continuous filament marker for optimizing tissue identification, radiation planning, and radiographic follow-up. Gland Surg 2020; 8:609-617. [PMID: 32042667 DOI: 10.21037/gs.2019.10.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In breast cancer treatment, marking the tumor bed is an important aspect of the surgical component of therapy. Clear delineation of the tumor bed allows radiation oncologists a defined target for planning and delivering postoperative radiation therapy (XRT). Tumor bed marking also allows radiographic follow-up of the tumor bed on subsequent breast imaging. The aim of this assessment is to evaluate the ease and feasibility of utilizing a tumor bed filament marker (VeraFormÒ, Videra Surgical inc., USA) as a marker in post-operative benign surgical sites and malignant breast surgical tumor beds in breast cancer surgery. Methods The filament marker is a novel radiopaque surgical filament that in lieu of clips and other markers is implanted in the surgical tumor bed during breast surgery. Following development of the filament marker, the researchers used breast phantoms and radiographic images to develop a series of geometric patterns of placement options that optimize comprehensive multi-plane radiographic interpretation of the exact tumor bed or surgical margin. Three breast surgeons at 3 separate institutions then used this filament as a continuous multi-plane marker in 20 patients during breast conservation surgery. In these patients, the filament marker was thus used to mark the tumor bed (breast cancer surgery) or surgical site (benign breast disease) instead of the more traditional devices such as clips or other metallic open framework devices. We then assessed 2 important factors related to this device; (I) the ease, feasibility, and accuracy of in vivo placement with oncoplastic and non-oncoplastic breast conservation surgery techniques; (II) the radiographic footprint this device left on standard imaging protocols of post-operative mammogram (MMG), computed tomography (CT) scan, breast magnetic resonance imaging (MRI) examinations, and ultrasounds (USs) for both routine follow-up imaging and for standard radiation planning. Results There were no adverse events reported with the use of this device. The cases were then reviewed by a multidisciplinary team that included the original surgeon, a breast radiologist, and radiation oncologist. Their unanimous evaluation was that the filament marker clearly delineated all sides and planes of the tumor bed (cancer surgery) or surgical site (benign disease). Regardless of surgical technique utilized, this information provided precise 3D guidance for radiation planning and delivery as well as radiographic follow-up. The surgeons involved reported that delineating the bed with the filament marker was a quick and easy procedure and did not interfere with performing the planned surgical technique. Radiologists, surgeons, and radiation oncologists found that the filament marker was not only radiographically opaque on CT and MMG, but also caused no significant artifact on CT, MRI, US, or MMG. Conclusions The continuous multi-plane filament marker is a new device that fulfills the heretofore unmet need for safe and improved tumor bed and tissue site marking. It is an easy to place, non-palpable continuous multi-plane radiographic opaque tissue marker that seems to better delineate the tumor bed, regardless of type of breast surgery performed, while providing a more accurate 3D image for radiation planning and radiographic follow-up on MMG MRI, CT and US.
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Affiliation(s)
- Sunny Mitchell
- Department of Surgery, Montefiore Nyack Hospital, Nyack, NY, USA
| | - Henry Lee
- Department of Radiation Oncology; New York Presbyterian-Lawrence Hospital, Columbia University College of Physicians & Surgeons, Bronxville, NY, USA
| | - Beth Baughman DuPree
- Sedona Breast care, Department of Surgery, Cancer Centers of Northern Arizona Healthcare, Sedona, AZ, USA
| | - David C Beyer
- Department of Radiation Oncology, Cancer Centers of Northern Arizona Healthcare, Sedona, AZ, USA
| | - Michael Ulissey
- Department of Radiology, The University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Stephen R Grobmyer
- Oncology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jennifer Gass
- Department of Surgery, Women & Infants Hospital, Brown University, Providence, RI, USA
| | - Susan Boolbol
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine, New York, NY, USA
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