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Haussmann J, Budach W, Corradini S, Krug D, Jazmati D, Tamaskovics B, Bölke E, Pedotoa A, Kammers K, Matuschek C. Comparison of adverse events in partial- or whole breast radiotherapy: investigation of cosmesis, toxicities and quality of life in a meta-analysis of randomized trials. Radiat Oncol 2023; 18:181. [PMID: 37919752 PMCID: PMC10623828 DOI: 10.1186/s13014-023-02365-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE/OBJECTIVE Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. MATERIAL/METHODS We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. RESULTS Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09-0.18; p < 0.001); (OR = 0.16; 95% CI 0.07-0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22-3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45-0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". CONCLUSION The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, Ludwig Maximillian University, Munich, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alessia Pedotoa
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kai Kammers
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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Anderson B, Vicini F, Wazer D, Arthur D. Breast brachytherapy: Building a bright future on the foundation of a rich history of advancement in technology, technique, and patient-centered care. Brachytherapy 2023; 22:368-380. [PMID: 36740541 DOI: 10.1016/j.brachy.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 02/05/2023]
Abstract
For over 20 years, the concept of accelerated partial breast irradiation (APBI) has received considerable attention. Initially concentrating on the appropriateness of APBI as an alternative treatment to whole breast radiotherapy, investigation and innovation evolved towards dose delivery and technique appropriateness. The purpose of this article is to review the pertinent literature that supports the role brachytherapy serves in delivering APBI and the recognized brachytherapy techniques for dose delivery. Publications establishing techniques utilizing multicatheter brachytherapy, single-entry brachytherapy applicators, permanent breast seed implantation brachytherapy, noninvasive breast brachytherapy and electronic brachytherapy are described. The use of brachytherapy for repeat breast conservation therapy is additionally reviewed. A historical perspective and potential direction of future investigation and innovation are presented.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Lattimore CM, Meneveau MO, Petroni GR, Varhegyi NE, Squeo GC, Showalter TN, Showalter SL. Effects of a novel form of intraoperative radiation therapy on quality of life among patients with early-stage breast cancer. Brachytherapy 2022; 21:325-333. [PMID: 35120862 PMCID: PMC9149037 DOI: 10.1016/j.brachy.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate patient-perceived quality of life (QOL) among patients treated with a novel form of breast intraoperative radiation therapy (PB-IORT). METHODS AND MATERIALS Patients treated with PB-IORT as part of a phase II clinical trial from 2013 to 2020 were identified. Patients were given the European Organization for Research and Treatment of Cancer (EORTC) core 30-item Quality of Life Questionnaire (QLQ-C30) encompassing global health, functionality, and symptomatology at baseline, 1-month, 6-months, 12-months, and 24-months after PB-IORT. Scores were on a 100-point scale with change greater than 10 considered clinically significant. Scores at interval follow-up were compared to baseline using repeated measure modeling with an unstructured covariance matrix. RESULTS The cohort consisted of 303 patients, a majority of which were White (84.2%) with a median age of 64 years (IQR: 52, 76). One month after PB-IORT, a decline from baseline in physical (-2.5, 95% CI: -4.4 - -0.55, p = 0.01), role (-7.6, 95% CI: -11.7 - -3.5, p < 0.001), and social functioning (-3.0, 95% CI: -5.5 - -0.42, p = 0.02) were observed, which correlated with increased fatigue (8.4, 95% CI: 5.5-11.3, p < 0.001). At 6 months, nearly all QOL measures returned to baseline or improved. There were no statistically or clinically significant differences from baseline in overall global health. All functional and symptom scale differences were less than 10, indicating minimal clinical significance. CONCLUSIONS PB-IORT has minimal negative impact on QOL, further supporting this patient-centered treatment approach for early-stage breast cancer.
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Affiliation(s)
- Courtney M Lattimore
- Department of Surgery, University of Virginia Health System, Charlottesville, VA.
| | - Max O Meneveau
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Gina R Petroni
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Nikole E Varhegyi
- Division of Translational Research & Applied Statistics, Department of Public Health Sciences, University of Virginia Health System, Charlottesville, VA
| | - Gabriella C Squeo
- Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia Health System, VA 22908
| | - Shayna L Showalter
- Department of Surgery, University of Virginia Health System, Charlottesville, VA.
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O'Connor RÍ, Kiely PA, Dunne CP. The relationship between post-surgery infection and breast cancer recurrence. J Hosp Infect 2020; 106:522-535. [PMID: 32800825 DOI: 10.1016/j.jhin.2020.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/06/2020] [Indexed: 02/06/2023]
Abstract
Breast cancer is the second most prevalent form of cancer in women worldwide, with surgery remaining the standard treatment. The adverse impact of the surgery remains controversial. It has been suggested that systemic factors during the postoperative period may increase the risk of recurrence, specifically surgical site infection (SSI). The aim of this review was to critically appraise current published literature regarding the influence of SSIs, after primary breast cancer surgery, on breast cancer recurrence, and to delve into potential links between these. This systematic review adopted two approaches: to identify the incidence rates and risk factors related to SSI after primary breast cancer surgery; and, secondly, to examine breast cancer recurrence following SSI occurrence. Ninety-nine studies with 484,605 patients were eligible in the SSI-focused searches, and 53 studies with 17,569 patients for recurrence-focused. There was a 13.07% mean incidence of SSI. Six-hundred and thirty-eight Gram-positive and 442 Gram-negative isolates were identified, with methicillin-susceptible Staphylococcus aureus and Escherichia coli most commonly identified. There were 2077 cases of recurrence (11.8%), with 563 cases of local recurrence, 1186 cases of distant and 25 cases which recurred both locally and distantly. Five studies investigated the association between SSI and breast cancer recurrence with three concluding that an association did exist. In conclusion, there is association between SSI and adverse cancer outcomes, but the cellular link between them remains elusive. Confounding factors of retrospective study design, surgery type and SSI definition make results challenging to compare and interpret. A standardized prospective study with appropriate statistical power is justified.
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Affiliation(s)
- R Í O'Connor
- School of Medicine, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland; Bernal Institute, University of Limerick, Ireland
| | - P A Kiely
- School of Medicine, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland; Bernal Institute, University of Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland
| | - C P Dunne
- School of Medicine, University of Limerick, Ireland; Health Research Institute, University of Limerick, Ireland; Centre for Interventions in Infection, Inflammation & Immunity (4i), University of Limerick, Limerick, Ireland.
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Mi Y, Lv P, Wang F, Li L, Zhu M, Cao Q, Liu J, Dong M, Shi Y, Fan R. Efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy in breast-conserving surgery for early-stage breast cancer: a single-centre study in China. Jpn J Clin Oncol 2019; 49:1120-1125. [PMID: 31665413 DOI: 10.1093/jjco/hyz128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 07/30/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objective
The purpose of this study was to evaluate the efficacy, late complications, and cosmetic outcomes of targeted intraoperative radiotherapy for the treatment of Chinese patients with early-stage breast cancer.
Methods
Between September 2014 and May 2017, breast cancer patients undergoing targeted intraoperative radiotherapy at our facility were retrospectively recruited for this study. Intraoperative radiotherapy was performed with a 50-kV X-ray source in an Intrabeam system (Carl Zeiss Meditec, Oberkochen, Germany). The one-time prescribed irradiation dose to the tumour bed was 20 Gy. Recurrence, death, late complications, and cosmetic outcomes were recorded. Late radiotoxicity was assessed based on the grading criteria of the Radiation Therapy Oncology Group.
Results
A total of 77 patients who were treated with targeted intraoperative radiotherapy only were recruited. The cohort had a mean age of 58 years; patients with T1, N0, and invasive ductal carcinoma accounted for 75.3, 89.6, and 84.4%, respectively; the median follow-up duration was 40 months; there were 2 patients of recurrence and 2 patients of death. There were no patients of cardiac toxicity or skin or lung radiotoxicity of grade 2 or above. The main complications were breast oedema (18.2%), seroma (15.6%), chromatosis (9.1%), induration (7.8%), pain (5.2%), skin depression (2.6%), mild dry cough (2.6%), delayed wound healing (1.3%), and wound infection (1.3%). Seventy-three patients participated in the cosmetic outcome evaluation, which yielded an excellent or good rate of 95.9%.
Conclusions
Due to its low recurrence rates, lack of high-grade late radiotoxicity, and excellent cosmetic outcomes, targeted intraoperative radiotherapy may be a suitable treatment for select early-stage breast cancer patients in China.
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Affiliation(s)
- Yin Mi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Pengwei Lv
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Wang
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lin Li
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingzhi Zhu
- Department of Breast Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qinchen Cao
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junqi Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meilian Dong
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yonggang Shi
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruitai Fan
- Department of Radiation Oncology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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A literature review of the role of brachytherapy in the management of early-stage breast cancer. JOURNAL OF RADIOTHERAPY IN PRACTICE 2019. [DOI: 10.1017/s1460396919000700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:This review evaluates whether brachytherapy can be considered as an alternative to whole breast irradiation (WBI) using criteria such as local recurrence rates, overall survival rates and quality of life (QoL) factors. This is an important issue because of a decline in local recurrence rates, suggesting that some women at very low risk of recurrence may be incurring the negative long-term side effects of WBI without benefitting from a reduction in local recurrence and greater overall survival. As such, the purpose of this literature review is to evaluate whether brachytherapy is a credible alternative to external beam radiation with a particular focus on the impact it has on patient QoL.Methods:The search terms used were devised by using the Population Intervention Comparison Outcome framework, and a literature search was carried out using Boolean connectors and Medical Subject Headings in the PubMed database. The resultant articles were manually assessed for relevance and appraised using the Scottish Intercollegiate Guidelines Network tool. Additional papers were sourced from the citations of articles found using the search strategy. Government guidelines and regulations were also used following a manual search on the National Institute for Health and Care Excellence website. This process resulted in a total of 30 sources being included as part of the review.Results:Three types of brachytherapy were the foundation for the majority of the papers found: interstitial multi-catheter brachytherapy, intra-cavity brachytherapy and permanent seed implantation. The key themes that arose from the literature were that brachytherapy is equivalent to WBI both in terms of 5-year local recurrence rates and overall survival rates at 10–12 years. The findings showed that brachytherapy was superior to WBI for some QoL factors such as being less time-consuming and equal in terms of others such as breast cosmesis. The results did also show that brachytherapy does come with its own local toxicities that could impact upon QoL such as the poor breast cosmesis associated with some brachytherapy techniques.Conclusion:In conclusion, brachytherapy was deemed a safe or acceptable alternative to WBI, but there is a need for further research on the long-term local recurrence rates, survival rates and quality of life issues as the volume of evidence is still significantly smaller for brachytherapy than for WBI. Specifically, there needs to be further investigation as to which patients will benefit from being offered brachytherapy and the influence that factors such as co-morbidities, performance status and patient choice play in these decisions.
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Teichman SL, Do S, Lum S, Teichman TS, Preston W, Cochran SE, Garberoglio CA, Grove R, Davis CA, Slater JD, Bush DA. Improved long-term patient-reported health and well-being outcomes of early-stage breast cancer treated with partial breast proton therapy. Cancer Med 2018; 7:6064-6076. [PMID: 30453388 PMCID: PMC6308094 DOI: 10.1002/cam4.1881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 11/11/2022] Open
Abstract
Background Because early‐stage breast cancer can be treated successfully by a variety of breast‐conservation approaches, long‐term quality of life (QoL) is an important consideration in assessing treatment outcomes for these patients. This study compares patient‐reported QoL outcomes among women with stage 0‐2 disease treated via lumpectomy followed by whole breast irradiation (WBI) or partial breast proton irradiation (PBPT). Methods In this cross‐sectional study, 129 participants evaluated QoL several years post‐treatment by responding to subjective instruments, including established scalar questionnaires and self‐report measures. Responses were averaged between the two groups. Results At 6.5 years (median) postdiagnosis, participants’ demographic, and clinical characteristics were similar. Patient‐reported outcomes were reported as mean scale scores for the two groups, all displaying significant differences favoring PBPT, including: cosmetic breast cancer treatment outcome scale (BCTOS) (PBPT mean 1.45, WBI mean 1.88, P < 0.001); breast pain (PBPT mean 1.30, WBI mean 1.67, P < 0.05); breast texture (BPT mean 1.44, WBI mean 1.91, P < 0.001); clothing fit (PBPT mean 1.06, WBI 1.46, P < 0.001); fatigue (PBPT mean 2.24, WBI mean 3.77, P < 0.002); impact of daily life fatigue on personal relations (OBPT mean 0.83, WBI mean 2.15, P < 0.001); and self‐consciousness (appearance dissatisfaction) (PBPT mean 1.38, WBI mean 1.77, P < 0.004). Conclusion Patients’ responses suggest that PBPT is associated with improved overall QoL compared to standard whole breast treatment. These self‐perceptions are reported by patients who are 5‐10 years post‐treatment, and that PBPT may enhance QoL in a multitude of interrelated ways.
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Affiliation(s)
- Sandra L Teichman
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - Sharon Do
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - Sharon Lum
- Department of Surgical Oncology, Loma Linda University Medical Center, Loma Linda, California
| | - Theodore S Teichman
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - William Preston
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - Shelly E Cochran
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - Carlos A Garberoglio
- Department of Surgical Oncology, Loma Linda University Medical Center, Loma Linda, California
| | - Roger Grove
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - Carol A Davis
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - Jerry D Slater
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
| | - David A Bush
- Department of Radiation Medicine Loma, Linda University Medical Center, Loma Linda, California
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Pohanková D, Sirák I, Jandík P, Kašaova L, Grepl J, Motyčka P, Asqar A, Paluska P, Ninger V, Bydžovská I, Kopecky V, Petera J. Accelerated partial breast irradiation with perioperative multicatheter interstitial brachytherapy-A feasibility study. Brachytherapy 2018; 17:949-955. [PMID: 30227977 DOI: 10.1016/j.brachy.2018.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the feasibility of high-dose-rate perioperative multicatheter interstitial brachytherapy to deliver accelerated partial breast irradiation (APBI) in selected patients with early breast cancer. METHODS AND MATERIALS Perioperative multicatheter interstitial brachytherapy for APBI has been used at our department since 2012 for patients with low-risk breast cancer. Interstitial catheters were inserted perioperatively via hollow needles immediately following tumorectomy with sentinel node biopsy. APBI started on Day 6 after surgery. The prescribed dose was 34 Gy (10 fractions of 3.4 Gy bid). Hormonal therapy was prescribed in all cases. RESULTS Between June 2012 and December 2017, 125 patients were scheduled for APBI. Of these, APBI was not performed in 12 patients (9.6%) due to adverse prognostic factors identified on the definitive biopsy. We observed wound dehiscence in 2/113 cases (1.8%), inflammatory complications requiring antibiotics in 7/113 cases (6.2%), transient Grade I radiodermatitis in 6/113 patients (4.4%), and seroma which resolved spontaneously in 3/113 patients (2.7%). With median followup of 39 months (range 3.3-75.3) no relapses were observed. No late complications in Radiation Therapy Oncology Group Grade 3 or higher were documented. Cosmetic outcome in patients with followup > 2 years was excellent or good in 92%. CONCLUSION Our preliminary results show that the perioperative multicatheter interstitial high-dose-rate brachytherapy for APBI in selected patients with early breast cancer is feasible. This treatment schedule reduces treatment duration, spares the patients of repeated anesthesia, and enables precise application of the afterloading tubes under direct visual control.
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Affiliation(s)
- Denisa Pohanková
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Igor Sirák
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic.
| | - Pavel Jandík
- Department of Surgery, University Hospital, Hradec Králové, Czech Republic
| | - Linda Kašaova
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Jakub Grepl
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Petr Motyčka
- Department of Surgery, University Hospital, Hradec Králové, Czech Republic
| | - Ahmed Asqar
- Department of Surgery, University Hospital, Hradec Králové, Czech Republic
| | - Petr Paluska
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - Vladimír Ninger
- Department of Surgery, Hospital Chrudim, Chrudim, Czech Republic
| | - Ivana Bydžovská
- Department of Surgery, Hospital Chrudim, Chrudim, Czech Republic
| | - Viliam Kopecky
- Department of Surgery, Hospital Chrudim, Chrudim, Czech Republic
| | - Jiří Petera
- Department of Oncology and Radiotherapy, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
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Schäfer R, Strnad V, Polgár C, Uter W, Hildebrandt G, Ott OJ, Kauer-Dorner D, Knauerhase H, Major T, Lyczek J, Guinot JL, Dunst J, Miguelez CG, Slampa P, Allgäuer M, Lössl K, Kovács G, Fischedick AR, Fietkau R, Resch A, Kulik A, Arribas L, Niehoff P, Guedea F, Schlamann A, Gall C, Polat B. Quality-of-life results for accelerated partial breast irradiation with interstitial brachytherapy versus whole-breast irradiation in early breast cancer after breast-conserving surgery (GEC-ESTRO): 5-year results of a randomised, phase 3 trial. Lancet Oncol 2018; 19:834-844. [PMID: 29695348 DOI: 10.1016/s1470-2045(18)30195-5] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 02/27/2018] [Accepted: 03/01/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Previous results from the GEC-ESTRO trial showed that accelerated partial breast irradiation (APBI) using multicatheter brachytherapy in the treatment of early breast cancer after breast-conserving surgery was non-inferior to whole-breast irradiation in terms of local control and overall survival. Here, we present 5-year results of patient-reported quality of life. METHODS We did this randomised controlled phase 3 trial at 16 hospitals and medical centres in seven European countries. Patients aged 40 years or older with 0-IIA breast cancer were randomly assigned (1:1) after breast-conserving surgery (resection margins ≥2 mm) to receive either whole-breast irradiation of 50 Gy with a boost of 10 Gy or APBI using multicatheter brachytherapy. Randomisation was stratified by study centre, tumour type, and menopausal status, with a block size of ten and an automated dynamic algorithm. There was no masking of patients or investigators. The primary endpoint of the trial was ipsilateral local recurrence. Here, we present 5-year results of quality of life (a prespecified secondary endpoint). Quality-of-life questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30, breast cancer module QLQ-BR23) were completed before radiotherapy (baseline 1), immediately after radiotherapy (baseline 2), and during follow-up. We analysed the data according to treatment received (as-treated population). Recruitment was completed in 2009, and long-term follow-up is continuing. The trial is registered at ClinicalTrials.gov, number NCT00402519. FINDINGS Between April 20, 2004, and July 30, 2009, 633 patients had accelerated partial breast irradiation and 551 patients had whole-breast irradiation. Quality-of-life questionnaires at baseline 1 were available for 334 (53%) of 663 patients in the APBI group and 314 (57%) of 551 patients in the whole-breast irradiation group; the response rate was similar during follow-up. Global health status (range 0-100) was stable in both groups: at baseline 1, APBI group mean score 65·5 (SD 20·6) versus whole-breast irradiation group 64·6 (19·6), p=0·37; at 5 years, APBI group 66·2 (22·2) versus whole-breast irradiation group 66·0 (21·8), p=0·94. The only moderate, significant difference (difference of 10-20 points) between the groups was found in the breast symptoms scale. Breast symptom scores were significantly higher (ie, worse) after whole-breast irradiation than after APBI at baseline 2 (difference of means 13·6, 95% CI 9·7-17·5; p<0·0001) and at 3-month follow-up (difference of means 12·7, 95% CI 9·8-15·6; p<0·0001). INTERPRETATION APBI with multicatheter brachytherapy was not associated with worse quality of life compared with whole-breast irradiation. This finding supports APBI as an alternative treatment option after breast-conserving surgery for patients with early breast cancer. FUNDING German Cancer Aid.
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Affiliation(s)
- Rebekka Schäfer
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany.
| | - Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Oliver J Ott
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | | | - Hellen Knauerhase
- Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Jaroslaw Lyczek
- Podkarpacki Hospital Cancer Center Brzozow, Brzozow, Poland; Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skłodowskiej, Warsaw, Poland
| | - Jose Luis Guinot
- Department of Radiation Oncology, Valencian Institute of Oncology, Valencia, Spain
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Kiel, Kiel, Germany
| | | | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute and Faculty of Medicine, Brno, Czech Republic
| | - Michael Allgäuer
- Department of Radiation Oncology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Kristina Lössl
- Department of Radiation Oncology, University Hospital Bern, Inselspital, Switzerland
| | - György Kovács
- Interdisciplinary Brachytherapy Unit, University of Lubeck/Universitätsklinikum Schleswig-Holstein Campus Lubeck, Lubeck, Germany
| | | | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Alexandra Resch
- Department of Radiation Oncology, University Hospital AKH Wien, Vienna, Austria
| | - Anna Kulik
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skłodowskiej, Warsaw, Poland
| | - Leo Arribas
- Department of Radiation Oncology, Valencian Institute of Oncology, Valencia, Spain
| | - Peter Niehoff
- Department of Radiation Oncology, University Hospital Kiel, Kiel, Germany; Department of Radiotherapy, Sana Hospital Offenbach, Offenbach, Germany
| | - Ferran Guedea
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | - Annika Schlamann
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Erlangen, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
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Corica T, Nowak AK, Saunders CM, Bulsara MK, Taylor M, Williams NR, Keshtgar M, Joseph DJ, Vaidya JS. Cosmetic outcome as rated by patients, doctors, nurses and BCCT.core software assessed over 5 years in a subset of patients in the TARGIT-A Trial. Radiat Oncol 2018; 13:68. [PMID: 29653541 PMCID: PMC5899392 DOI: 10.1186/s13014-018-0998-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/13/2018] [Indexed: 11/24/2022] Open
Abstract
Background The purpose of this research was to assess agreement between four rating systems of cosmetic outcome measured in a subset of patients with early breast cancer participating in the randomised TARGIT-A trial. TARGIT-A compared risk-adapted single-dose intra-operative radiotherapy (TARGIT-IORT) to whole breast external beam radiotherapy (EBRT). Methods Patients, their Radiation Oncologist and Research Nurse completed a subjective cosmetic assessment questionnaire before radiotherapy and annually thereafter for five years. Objective data previously calculated by the validated BCCT.core software which utilizes digital photographs to score symmetry, colour and scar was also used. Agreement was assessed by the Kappa statistic and longitudinal changes were assessed by generalized estimating equations. Results Overall, an Excellent-Good (EG) cosmetic result was scored more often than a Fair-Poor (FP) result for both treatment groups across all time points, with patients who received TARGIT-IORT scoring EG more often than those who received EBRT however this was statistically significant at Year 5 only. There was modest agreement between the four rating systems with the highest Kappa score being moderate agreement which was between nurse and doctor scores at Year 1 with Kappa = 0.46 (p < 0.001), 95% CI (0.24, 0.68). Conclusion Despite similar overall findings between treatment groups and rating systems, the inter-rater agreement was only modest. This suggests that the four rating systems utilized may not necessarily be used interchangeably and it is arguable that for an outcome such as cosmetic appearance, the patient’s point of view is the most important. Trial Registration TARGIT-A ISRCTN34086741, Registered 21 July 2004, retrospectively registered. Electronic supplementary material The online version of this article (10.1186/s13014-018-0998-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tammy Corica
- Radiation Oncology Clinical Trials and Research Unit, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia. .,Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.
| | - Anna K Nowak
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia
| | | | - Max K Bulsara
- Institute for Health Research, University of Notre Dame, 19 Mouat Street, Fremantle, WA, 6160, Australia
| | - Mandy Taylor
- Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Norman R Williams
- Surgical & Interventional Trials Unit, Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, London, NW1 2FD, UK
| | - Mohammed Keshtgar
- Royal Free London Foundation NHS Trust, Division of Surgical Sciences, The Breast Unit, Pond Street, Hampstead, London, NW3 2QG, UK
| | - David J Joseph
- Medical School, University of Western Australia, Nedlands, WA, 6009, Australia.,Radiation Oncology, Comprehensive Cancer Centre, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
| | - Jayant S Vaidya
- Division of Surgery & Interventional Science, University College London, London W1W 7TS, UK; Whittington Hospital, Royal Free Hospital and University College Hospital, University College London, London, NW1 2FD, UK
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Accelerated partial breast irradiation for elderly women with early breast cancer: A compromise between whole breast irradiation and omission of radiotherapy. Brachytherapy 2017; 16:929-934. [DOI: 10.1016/j.brachy.2017.06.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 05/30/2017] [Accepted: 06/07/2017] [Indexed: 11/18/2022]
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12
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Meattini I, Saieva C, Miccinesi G, Desideri I, Francolini G, Scotti V, Marrazzo L, Pallotta S, Meacci F, Muntoni C, Bendinelli B, Sanchez LJ, Bernini M, Orzalesi L, Nori J, Bianchi S, Livi L. Accelerated partial breast irradiation using intensity modulated radiotherapy versus whole breast irradiation: Health-related quality of life final analysis from the Florence phase 3 trial. Eur J Cancer 2017; 76:17-26. [DOI: 10.1016/j.ejca.2017.01.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 12/07/2016] [Accepted: 01/24/2017] [Indexed: 11/24/2022]
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13
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Pérez M, Schootman M, Hall LE, Jeffe DB. Accelerated partial breast irradiation compared with whole breast radiation therapy: a breast cancer cohort study measuring change in radiation side-effects severity and quality of life. Breast Cancer Res Treat 2017; 162:329-342. [PMID: 28132391 PMCID: PMC5374079 DOI: 10.1007/s10549-017-4121-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 01/18/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Radiotherapy (RT) after breast-conserving surgery for early-stage breast cancer patients has similar survival benefits with whole breast RT (WBRT) or accelerated partial breast irradiation (APBI). However, the impact of RT type and side-effects severity on change in quality of life (QOL) is unknown. We examined changes in RT side-effects severity and QOL by RT type. METHODS We analyzed data from a cohort of 285 newly diagnosed early-stage breast cancer patients with tumor size ≤3.0 cm and lymph node-negative disease. Patients (93 [32.6%] stage 0; 49 [17.2%] non-white; mean age = 59.3 years) completed four interviews (6 weeks, 6, 12, and 24 months) after definitive surgical treatment. We measured severity of RT side effects, fatigue and skin irritation, using a 5-point scale (1 "not at all" to 5 "all the time") and measured QOL using the Functional Assessment of Cancer Therapy-Breast (FACT-B) and RAND 36-item Health Survey Vitality subscale. Repeated-measures analysis of covariance of each outcome controlled for demographic, clinical/treatment, and psychosocial factors. RESULTS Patients initiated RT by 6 months (113 received APBI; 172 received WBRT) and completed RT by 12 months. Patients receiving WBRT (vs. APBI) reported greater increase in fatigue and skin irritation severity from 6-week to 6-month interviews (each P < 0.001). Improvement in neither total FACT-B nor Vitality differed significantly by RT type over 2-year follow-up. CONCLUSIONS Findings suggest that early-stage breast cancer patients can benefit from less-severe, short-term side effects of APBI with no differential impact on QOL change within 2-year follow-up.
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Affiliation(s)
- M Pérez
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - M Schootman
- Saint Louis University College for Public Health and Social Justice, St. Louis, Missouri, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
| | - L E Hall
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - D B Jeffe
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri, USA
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Shaitelman SF, Amendola B, Khan A, Beriwal S, Rabinovitch R, Demanes DJ, Kim LH, Cuttino L. American Brachytherapy Society Task Group Report: Long-term control and toxicity with brachytherapy for localized breast cancer. Brachytherapy 2017; 16:13-21. [DOI: 10.1016/j.brachy.2016.04.392] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/26/2016] [Accepted: 04/26/2016] [Indexed: 01/22/2023]
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15
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Chand-Fouché ME, Lam Cham Kee D, Gautier M, Hannoun-Levi JM. Technique d’irradiation partielle du sein : radiothérapie externe et curiethérapie. Cancer Radiother 2016; 20:587-94. [DOI: 10.1016/j.canrad.2016.07.087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/12/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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Cosmesis and Breast-Related Quality of Life Outcomes After Intraoperative Radiation Therapy for Early Breast Cancer: A Substudy of the TARGIT-A Trial. Int J Radiat Oncol Biol Phys 2016; 96:55-64. [DOI: 10.1016/j.ijrobp.2016.04.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/05/2016] [Accepted: 04/17/2016] [Indexed: 11/20/2022]
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Obayomi-Davies O, Kole TP, Oppong B, Rudra S, Makariou EV, Campbell LD, Anjum HM, Collins SP, Unger K, Willey S, Tousimis E, Collins BT. Stereotactic Accelerated Partial Breast Irradiation for Early-Stage Breast Cancer: Rationale, Feasibility, and Early Experience Using the CyberKnife Radiosurgery Delivery Platform. Front Oncol 2016; 6:129. [PMID: 27242967 PMCID: PMC4876543 DOI: 10.3389/fonc.2016.00129] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 05/10/2016] [Indexed: 01/16/2023] Open
Abstract
PURPOSE The efficacy of accelerated partial breast irradiation (APBI) utilizing brachytherapy or conventional external beam radiation has been studied in early-stage breast cancer treated with breast-conserving surgery. Data regarding stereotactic treatment approaches are emerging. The CyberKnife linear accelerator enables excellent dose conformality to target structures while adjusting for target and patient motion. We report our institutional experience on the technical feasibility and rationale for stereotactic accelerated partial breast irradiation (SAPBI) delivery using the CyberKnife radiosurgery system. METHODS Ten patients completed CyberKnife SAPBI (CK-SAPBI) in 2013 at Georgetown University Hospital. Four gold fiducials were implanted around the lumpectomy cavity prior to treatment under ultrasound guidance. The synchrony system tracked intrafraction motion of the fiducials. The clinical target volume was defined on contrast enhanced CT scans using surgical clips and post-operative changes. A 5 mm expansion was added to create the planning treatment volume (PTV). A total dose of 30 Gy was delivered to the PTV in five consecutive fractions. Target and critical structure doses were assessed as per the National Surgical Adjuvant Breast and Bowel Project B-39 study. RESULTS At least three fiducials were tracked in 100% of cases. The Mean treated PTV was 70 cm(3) and the mean prescription isodose line was 80%. Mean dose to target volumes and constraints are as follows: 100% of the PTV received the prescription dose (PTV30). The volume of the ipsilateral breast receiving 30 Gy (V30) and above 15 Gy (V > 15) was 14 and 31%, respectively. The ipsilateral lung volume receiving 9 Gy (V9) was 3%, and the contralateral lung volume receiving 1.5 Gy (V1.5) was 8%. For left-sided breast cancers, the volume of heart receiving 1.5 Gy (V1.5) was 31%. Maximum skin dose was 36 Gy. At a median follow-up of 1.3 years, all patients have experienced excellent/good breast cosmesis outcomes, and no breast events have been recorded. CONCLUSION CyberKnife stereotactic accelerated partial breast irradiation is an appealing technique for partial breast irradiation offering improvements over existing APBI techniques. Our early findings indicate that CK-SAPBI delivered in five daily fractions is feasible, well tolerated, and is a reliable platform for delivering APBI.
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Affiliation(s)
- Olusola Obayomi-Davies
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Thomas P Kole
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Bridget Oppong
- Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Sonali Rudra
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Erini V Makariou
- Department of Radiology, MedStar Georgetown University Hospital , Washington, DC , USA
| | - Lloyd D Campbell
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Hozaifa M Anjum
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Sean P Collins
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Keith Unger
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Shawna Willey
- Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Eleni Tousimis
- Betty Lou Ourisman Breast Health Center, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
| | - Brian T Collins
- Department of Radiation Medicine, Lombardi Comprehensive Cancer Center, Georgetown University Hospital , Washington, DC , USA
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Stoll A, van Oepen A, Friebe M. Intraoperative delivery of cell-killing boost radiation – a review of current and future methods. MINIM INVASIV THER 2016; 25:176-87. [DOI: 10.3109/13645706.2016.1173563] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Chand-Fouché MÈ, Hannoun-Lévi JM. [State of the art and perspectives of accelerated partial breast irradiation in 2014]. Cancer Radiother 2014; 18:693-700. [PMID: 24998686 DOI: 10.1016/j.canrad.2014.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Revised: 03/04/2014] [Accepted: 03/26/2014] [Indexed: 10/25/2022]
Abstract
In the frame of treatment de-escalation and personalization, accelerated partial breast irradiation is taking its place in the breast cancer therapeutic options. This study analyzed the results of phase III randomized trials having compared accelerated partial breast irradiation versus whole breast irradiation. Currently, among those trails, six proposed some results regarding efficacy and/or toxicity. Globally, the non-randomized studies confirmed the expected results showing a low rate of local recurrence and toxicity. The first results of the phase III randomized trials showed encouraging data in terms of local control while the toxicity varied mainly according to the accelerated partial breast irradiation technique used. However, the follow-up of the majority of these studies remains insufficient. The strict respect of accelerated partial breast irradiation indications likely represents one of the key factors of the therapeutic success. The next results could allow proposing a better definition of the accelerated partial breast irradiation selection criteria.
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Affiliation(s)
- M-È Chand-Fouché
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06189 Nice cedex, France
| | - J-M Hannoun-Lévi
- Pôle de radiothérapie, centre Antoine-Lacassagne, université Nice-Sophia, 33, avenue de Valombrose, 06189 Nice cedex, France.
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Genebes C, Chand ME, Gal J, Gautier M, Raoust I, Ihrai T, Courdi A, Ferrero JM, Peyrottes I, Hannoun-Levi JM. Accelerated partial breast irradiation in the elderly: 5-year results of high-dose rate multi-catheter brachytherapy. Radiat Oncol 2014; 9:115. [PMID: 24886680 PMCID: PMC4045692 DOI: 10.1186/1748-717x-9-115] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 04/27/2014] [Indexed: 11/10/2022] Open
Abstract
Objective To evaluate clinical outcome after accelerated partial breast irradiation (APBI) in the elderly after high-dose-rate interstitial multi-catheter brachytherapy (HIBT). Methods and materials Between 2005 and 2013, 70 patients underwent APBI using HIBT. Catheter implant was performed intra or post-operatively (referred patients) after lumpectomy and axillary sentinel lymph node dissection. Once the pathological results confirmed the indication of APBI, planification CT-scan was performed to deliver 34 Gy/10f/5d or 32 Gy/8f/4d. Dose-volume adaptation was manually achieved (graphical optimization). Dosimetric results and clinical outcome were retrospectively analyzed. Physician cosmetic evaluation was reported. Results With a median follow-up of 60.9 months [4.6 – 90.1], median age was 80.7 years [62 – 93.1]. Regarding APBI ASTRO criteria, 61.4%, 18.6% and 20% were classified as suitable, cautionary and non-suitable respectively. Axillary sentinel lymph node dissection was performed in 94.3%; 8 pts (11.5%) presented an axillary involvement. A median dose of 34 Gy [32 – 35] in 8 to 10 fractions was delivered. Median CTV was 75.2 cc [16.9 – 210], median D90 EQD2 was 43.3 Gy [35 – 72.6] and median DHI was 0.54 [0.19 – 0.74]. One patient experienced ipsilateral recurrence (5-year local free recurrence rate: 97.6%. Five-year specific and overall survival rates were 97.9% and 93.2% respectively. Thirty-four patients (48%) presented 47 late complications classified grade 1 (80.8%) and grade 2 (19.2%) with no grade ≥ 3. Cosmetic results were considered excellent/good for 67 pts (95.7%). Conclusion APBI using HIBT and respecting strict rules of implantation and planification, represents a smart alternative between no post-operative irradiation and whole breast irradiation delivered over 6 consecutive weeks.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University of Nice-Sophia, 33, avenue de Valombrose, Nice 06189, France.
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Cuttino LW, Vicini FA. Early outcomes data for accelerated partial breast irradiation using balloon brachytherapy. Expert Rev Anticancer Ther 2014; 11:1351-5. [DOI: 10.1586/era.11.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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The importance of the implant quality in APBI - Gliwice experience. Dosimetric evaluation. J Contemp Brachytherapy 2013; 5:227-31. [PMID: 24474972 PMCID: PMC3899638 DOI: 10.5114/jcb.2013.39365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/04/2013] [Accepted: 12/31/2013] [Indexed: 11/29/2022] Open
Abstract
This study includes four years of our clinical trials to improve implant quality in multicatheter accelerated partial breast irradiation (APBI). The progress in dosimetric and volumetric parameters of the treatment plans was evaluated. One hundred and ninety-one women, for whom treatment plans were made based on three dimensional imaging, were selected for the study. To evaluate progress made in our APBI procedure, following parameters and indices were taken into account: percentage of the target volume receiving the reference dose (PTVref), minimum dose in the target volume expressed as a percentage of reference dose (PTVmin), dose homogeneity index (DHI), and conformity index (COIN). Additionally, the plan quality index was calculated for every group as the sum of mean values of four evaluated parameters. PTVref have increased from the mean value of 83.4% at the beginning to recent 94.8%. The maximum value equals to 95.4%. The same trend can be observed with PTVmin value, which has been improved from 51.7% to 70.1%, maximally. DHI and COIN mean values present similar progress. DHI value increased from 0.53 level to 0.68, and COIN from 0.58 in 2009 to 0.74. Plan quality index has increased from 2.46 in 2009 to 3.06, recently. The implant quality is crucial for the accurate dose distribution. This paper shows the progress that was made in APBI procedure to improve implant quality. Nowadays, our implant technique is based on three-dimensional CT imaging results in acceptable dose distributions.
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Garsa AA, Ferraro DJ, DeWees TA, Deshields TL, Margenthaler JA, Cyr AE, Naughton M, Aft R, Gillanders WE, Eberlein T, Matesa MA, Ochoa LL, Zoberi I. A prospective longitudinal clinical trial evaluating quality of life after breast-conserving surgery and high-dose-rate interstitial brachytherapy for early-stage breast cancer. Int J Radiat Oncol Biol Phys 2013; 87:1043-50. [PMID: 24161428 DOI: 10.1016/j.ijrobp.2013.09.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/15/2013] [Accepted: 09/06/2013] [Indexed: 11/12/2022]
Abstract
PURPOSE To prospectively examine quality of life (QOL) of patients with early stage breast cancer treated with accelerated partial breast irradiation (APBI) using high-dose-rate (HDR) interstitial brachytherapy. METHODS AND MATERIALS Between March 2004 and December 2008, 151 patients with early stage breast cancer were enrolled in a phase 2 prospective clinical trial. Eligible patients included those with Tis-T2 tumors measuring ≤3 cm excised with negative surgical margins and with no nodal involvement. Patients received 3.4 Gy twice daily to a total dose of 34 Gy. QOL was measured using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, version 3.0, and QLQ-BR23 questionnaires. The QLQ-C30 and QLQ-BR23 questionnaires were evaluated during pretreatment and then at 6 to 8 weeks, 3 to 4 months, 6 to 8 months, and 1 and 2 years after treatment. RESULTS The median follow-up was 55 months. Breast symptom scores remained stable in the months after treatment, and they significantly improved 6 to 8 months after treatment. Scores for emotional functioning, social functioning, and future perspective showed significant improvement 2 years after treatment. Symptomatic fat necrosis was associated with several changes in QOL, including increased pain, breast symptoms, systemic treatment side effects, dyspnea, and fatigue, as well as decreased role functioning, emotional functioning, and social functioning. CONCLUSIONS HDR multicatheter interstitial brachytherapy was well tolerated, with no significant detrimental effect on measured QOL scales/items through 2 years of follow-up. Compared to pretreatment scores, there was improvement in breast symptoms, emotional functioning, social functioning, and future perspective 2 years after treatment.
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Affiliation(s)
- Adam A Garsa
- Department of Radiation Oncology, Siteman Cancer Center, Barnes-Jewish Hospital and Washington University School of Medicine, St. Louis, Missouri
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Stewart AJ, Hepel JT, O’Farrell DA, Devlin PM, Price LL, Dale RG, Wazer DE. Equivalent uniform dose for accelerated partial breast irradiation using the MammoSite applicator. Radiother Oncol 2013; 108:232-5. [DOI: 10.1016/j.radonc.2013.06.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 06/18/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
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Hannoun-Levi JM, Gourgou-Bourgade S, Belkacemi Y, Chara-Bruneau C, Hennequin C, Quetin P, Orsini C, Brain E, Marsiglia H. GERICO-03 phase II trial of accelerated and partial breast irradiation in elderly women: Feasibility, reproducibility, and impact on functional status. Brachytherapy 2013; 12:285-92. [DOI: 10.1016/j.brachy.2012.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 06/08/2012] [Accepted: 06/15/2012] [Indexed: 11/12/2022]
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Breast conservation therapy utilizing partial breast brachytherapy for early-stage cancer of the breast: a retrospective review from the Saint Luke's Cancer Institute. Am J Clin Oncol 2013; 38:174-8. [PMID: 23608831 DOI: 10.1097/coc.0b013e31828f5b1f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) is a convenient alternative to whole-breast irradiation, as less overall time is needed for completion. The use of APBI outside the framework of large prospective clinical trials has markedly increased. To our knowledge, no high-volume, community-based breast program has published their experience with APBI. METHODS The records of 93 consecutive patients who underwent APBI utilizing Mammosite Radiation Therapy System from 2005 to 2010 at Saint Luke's Cancer Institute in Kansas City, MO, were retrospectively reviewed. The Kaplan-Meier method was used to estimate the ipsilateral breast recurrence rate and recurrence-free survival. RESULTS Median age at diagnosis was 63 years (range, 45 to 86 y) and mean follow-up was 29 months. Patient stratification ASTRO consensus classifications for APBI was 37% suitable, 57% cautionary, and 6% unsuitable. The 3-year breast control rate was 98.7%. Three-year overall recurrence-free survival was 94.4%, and 3-year mastectomy-free survival was 97.4%. Using univariate analysis, no tumor or patient factors were associated with ipsilateral breast recurrence. However, tumor grade (P<0.05), stage (P=0.04), estrogen receptor status (P<0.001), progesterone receptor status (P<0.001), tumor size (P<0.001), and ASTRO suitability criteria (P=0.027) were associated with overall recurrence-free survival. No differences were observed when outcomes of patients with ductal carcinoma in situ were compared with those with invasive disease. CONCLUSIONS In our high-volume community-based program, APBI outcomes are comparable with those reported from large academic institutions. We also found relationships between tumor stage, grade, negative estrogen receptor status, and ASTRO suitability criteria with overall recurrence rates. The continued careful application of APBI in appropriately selected patients appears warranted until phase III trials comparing this modality to whole-breast irradiation have matured.
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Welzel G, Boch A, Sperk E, Hofmann F, Kraus-Tiefenbacher U, Gerhardt A, Suetterlin M, Wenz F. Radiation-related quality of life parameters after targeted intraoperative radiotherapy versus whole breast radiotherapy in patients with breast cancer: results from the randomized phase III trial TARGIT-A. Radiat Oncol 2013; 8:9. [PMID: 23294485 PMCID: PMC3896671 DOI: 10.1186/1748-717x-8-9] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 01/01/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is a new treatment approach for early stage breast cancer. This study reports on the effects of IORT on radiation-related quality of life (QoL) parameters. METHODS Two hundred and thirty women with stage I-III breast cancer (age, 31 to 84 years) were entered into the study. A single-center subgroup of 87 women from the two arms of the randomized phase III trial TARGIT-A (TARGeted Intra-operative radioTherapy versus whole breast radiotherapy for breast cancer) was analyzed. Furthermore, results were compared to non-randomized control groups: n = 90 receiving IORT as a tumor bed boost followed by external beam whole breast radiotherapy (EBRT) outside of TARGIT-A (IORT-boost), and n = 53 treated with EBRT followed by an external-beam boost (EBRT-boost). QoL was collected using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 (QLQ-C30) and BR23 (QLQ-BR23). The mean follow-up period in the TARGIT-A groups was 32 versus 39 months in the non-randomized control groups. RESULTS Patients receiving IORT alone reported less general pain (21.3 points), breast (7.0 points) and arm (15.1 points) symptoms, and better role functioning (78.7 points) as patients receiving EBRT (40.9; 19.0; 32.8; and 60.5 points, respectively, P < 0.01). Patients receiving IORT alone also had fewer breast symptoms than TARGIT-A patients receiving IORT followed by EBRT for high risk features on final pathology (IORT-EBRT; 7.0 versus 29.7 points, P < 0.01). There were no significant differences between TARGIT-A patients receiving IORT-EBRT compared to non-randomized IORT-boost or EBRT-boost patients and patients receiving EBRT without a boost. CONCLUSIONS In the randomized setting, important radiation-related QoL parameters after IORT were superior to EBRT. Non-randomized comparisons showed equivalent parameters in the IORT-EBRT group and the control groups.
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Affiliation(s)
- Grit Welzel
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Angela Boch
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Elena Sperk
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Frank Hofmann
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Uta Kraus-Tiefenbacher
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Axel Gerhardt
- Department of Gynecology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Marc Suetterlin
- Department of Gynecology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, 68167, Germany
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Moser EC, Vrieling C. Accelerated partial breast irradiation: the need for well-defined patient selection criteria, improved volume definitions, close follow-up and discussion of salvage treatment. Breast 2012; 21:707-15. [PMID: 23127279 DOI: 10.1016/j.breast.2012.09.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 08/17/2012] [Accepted: 09/23/2012] [Indexed: 12/24/2022] Open
Abstract
Breast-conserving therapy, including whole breast irradiation, has become a well-established alternative to mastectomy in early-stage breast cancer patients, with similar survival rates and better cosmetic outcome. However, many women are still treated with mastectomy, due to logistical issues related to the long course of radiotherapy (RT). To reduce mastectomy rates and/or omission of RT after breast-conserving surgery, shorter, hypofractionated RT treatments have been introduced. More recently, the necessity of routinely treating the entire breast in all patients has been questioned, leading to the development of partial breast radiotherapy. With accelerated partial breast irradiation (APBI) these two approaches have been combined: the tumor bed with a 1-2 cm margin is irradiated either intra-operatively (single fraction) or postoperatively over 5-15 days. Different techniques have been developed, including interstitial brachytherapy, intra-cavity brachytherapy, intra-operative radiotherapy and external beam radiotherapy. These techniques are being evaluated in several ongoing phase III studies. Since its introduction, APBI has been the subject of continuous debate. ASTRO and GEC-ESTRO have published guidelines for patient selection for APBI, and strongly recommend that APBI be carried out within ongoing clinical trials. Recently, the patient selection criteria for APBI have also been up for debate, following the publication of results from different groups that do/do not confirm a difference in recurrence risk among the ASTRO defined risk groups. This paper reviews the different APBI techniques, current recommendations for patient selection, available clinical data and ongoing clinical trials. A case report is included to illustrate the need for careful follow-up of patients treated with APBI.
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Affiliation(s)
- Elizabeth C Moser
- Breast Unit/Department of Radiotherapy, Champalimaud Cancer Centre, Lisbon, Portugal.
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Deneve JL, Hoefer RA, Harris EER, Laronga C. Accelerated Partial Breast Irradiation: A Review and Description of an Early North American Surgical Experience with the Intrabeam Delivery System. Cancer Control 2012; 19:295-308. [DOI: 10.1177/107327481201900406] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jeremiah L. Deneve
- Department of Women's Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Richard A. Hoefer
- Dorothy G. Hoefer Comprehensive Breast Center, Sentara Cancer Network, Newport News, Virginia
| | - Eleanor E. R. Harris
- Radiation Oncology Program at the H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Christine Laronga
- Department of Women's Oncology H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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Brachytherapy in accelerated partial breast irradiation (APBI) - review of treatment methods. J Contemp Brachytherapy 2012; 4:152-64. [PMID: 23346145 PMCID: PMC3551377 DOI: 10.5114/jcb.2012.30682] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 09/03/2012] [Accepted: 09/06/2012] [Indexed: 11/17/2022] Open
Abstract
Breast conserving surgery (BCS) with following radiotherapy (EBRT) of the conserved breast became widely accepted in the last decades as the treatment of early invasive breast cancer. In an early stage of breast cancer, research has shown that the area requiring radiation treatment to prevent cancer from local recurrence is the breast tissue that surrounds the area where the initial cancer was removed. Accelerated partial breast irradiation (APBI) is an approach that treats only the lumpectomy bed with 1-2 cm margin, rather than the whole breast and as a result allows accelerated delivery of the radiation dose in four to five days. Published results of APBI are very promising. It is evident that APBI will play a role in the management of a selected group of early breast cancer. We discuss current status, indications, technical aspects and recently published results of APBI using different brachytherapy techniques.
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Valente SA, Levine GM, Guerra LE, Silverstein MJ. Breast cancer recurrence after inadvertent malpositioning of a partial breast radiation catheter. Breast J 2012; 18:591-5. [PMID: 23009321 DOI: 10.1111/tbj.12012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Accelerated partial breast irradiation (APBI) is an alternative to receiving whole breast radiation in carefully selected patients. Because breast cancer local recurrence rates are low and follow-up has been short-term, the exact cause of recurrences after APBI has been difficult to evaluate. We report the first case of documented radiation balloon catheter malpositioning that resulted in local recurrence. Patients undergo CT imaging of the breast after radiation balloon catheter placement for radiotherapy treatment planning, which evaluates adequate conformance of the balloon to the surrounding breast parenchyma and confirms a >7 mm distance between the balloon surface and the skin surface. Although true local recurrences are rare in appropriately selected partial breast irradiation candidates, inadvertent malpositioning of the radiation treatment catheter can increase the risk. This case is presented to illustrate the importance of comparing CT radiation planning images, with treatment catheter in place, to the original diagnostic breast imaging studies to confirm proper catheter positioning (in addition to measuring balloon to skin distance and conformance) prior to initiating radiotherapy.
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Affiliation(s)
- Stephanie A Valente
- University of Southern California, Keck School of Medicine, Division of Breast and Soft Tissue Surgery, Los Angeles, CA 90033, USA.
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Bourgier C, Dumas I, Marsiglia H, Rossier C, Taright N, Biron B, Auzac G. Irradiation partielle accélérée du cancer du sein : aspect théorique. Cancer Radiother 2012; 16:470-2. [DOI: 10.1016/j.canrad.2012.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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Albuquerque K, Tell D, Lobo P, Millbrandt L, Mathews HL, Janusek LW. Impact of partial versus whole breast radiation therapy on fatigue, perceived stress, quality of life and natural killer cell activity in women with breast cancer. BMC Cancer 2012; 12:251. [PMID: 22708709 PMCID: PMC3542587 DOI: 10.1186/1471-2407-12-251] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 05/29/2012] [Indexed: 12/02/2022] Open
Abstract
Introduction This pilot study used a prospective longitudinal design to compare the effect of adjuvant whole breast radiation therapy (WBRT) versus partial breast radiation therapy (PBRT) on fatigue, perceived stress, quality of life and natural killer cell activity (NKCA) in women receiving radiation after breast cancer surgery. Methods Women (N = 30) with early-stage breast cancer received either PBRT, Mammosite brachytherapy at dose of 34 Gy 10 fractions/5 days, (N = 15) or WBRT, 3-D conformal techniques at dose of 50 Gy +10 Gy Boost/30 fractions, (N = 15). Treatment was determined by the attending oncologist after discussion with the patient and the choice was based on tumor stage and clinical need. Women were assessed prior to initiation of radiation therapy and twice after completion of radiation therapy. At each assessment, blood was obtained for determination of NKCA and the following instruments were administered: Perceived Stress Scale (PSS), Functional Assessment of Cancer Therapy-Fatigue (FACT-F), and Functional Assessment of Cancer Therapy-General (FACT-G). Hierarchical linear modeling (HLM) was used to evaluate group differences in initial outcomes and change in outcomes over time. Results Fatigue (FACT-F) levels, which were similar prior to radiation therapy, demonstrated a significant difference in trajectory. Women who received PBRT reported progressively lower fatigue; conversely fatigue worsened over time for women who received WBRT. No difference in perceived stress was observed between women who received PBRT or WBRT. Both groups of women reported similar levels of quality of life (FACT-G) prior to initiation of radiation therapy. However, HLM analysis revealed significant group differences in the trajectory of quality of life, such that women receiving PBRT exhibited a linear increase in quality of life over time after completion of radiation therapy; whereas women receiving WBRT showed a decreasing trajectory. NKCA was also similar between therapy groups but additional post hoc analysis revealed that better quality of life significantly predicted higher NKCA regardless of therapy. Conclusions Compared to WBRT, PBRT results in more rapid recovery from cancer-related fatigue with improved restoration of quality of life after radiation therapy. Additionally, better quality of life predicts higher NKCA against tumor targets, emphasizing the importance of fostering quality of life for women undergoing adjuvant radiation therapy.
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Affiliation(s)
- Kevin Albuquerque
- Department of Radiation Oncology, Loyola University Health System, Maywood, IL, USA.
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Hannoun-Lévi JM, Peiffert D. [In response to the presentation of Dr. B. Smith performed during the 2011 San Antonio Breast Cancer Symposium (SABCS) about the results of brachytherapy use for accelerated and partial breast irradiation]. Cancer Radiother 2012; 16:244-5. [PMID: 22561286 DOI: 10.1016/j.canrad.2012.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 02/17/2012] [Accepted: 02/20/2012] [Indexed: 11/26/2022]
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Azoury F, Heymann S, Acevedo C, Spielmann M, Vielh P, Garbay JR, Taghian AG, Marsiglia H, Bourgier C. Phase II trial of 3D-conformal accelerated partial breast irradiation: Lessons learned from patients and physicians’ evaluation. Radiother Oncol 2012; 103:193-8. [DOI: 10.1016/j.radonc.2012.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 03/09/2012] [Accepted: 03/20/2012] [Indexed: 11/27/2022]
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Haie-Meder C, Siebert FA, Pötter R. Image guided, adaptive, accelerated, high dose brachytherapy as model for advanced small volume radiotherapy. Radiother Oncol 2011; 100:333-43. [PMID: 21963284 DOI: 10.1016/j.radonc.2011.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 11/16/2022]
Abstract
Brachytherapy has consistently provided a very conformal radiation therapy modality. Over the last two decades this has been associated with significant improvements in imaging for brachytherapy applications (prostate, gynecology), resulting in many positive advances in treatment planning, application techniques and clinical outcome. This is emphasized by the increased use of brachytherapy in Europe with gynecology as continuous basis and prostate and breast as more recently growing fields. Image guidance enables exact knowledge of the applicator together with improved visualization of tumor and target volumes as well as of organs at risk providing the basis for very individualized 3D and 4D treatment planning. In this commentary the most important recent developments in prostate, gynecological and breast brachytherapy are reviewed, with a focus on European recent and current research aiming at the definition of areas for important future research. Moreover the positive impact of GEC-ESTRO recommendations and the highlights of brachytherapy physics are discussed what altogether presents a full overview of modern image guided brachytherapy. An overview is finally provided on past and current international brachytherapy publications focusing on "Radiotherapy and Oncology". These data show tremendous increase in almost all research areas over the last three decades strongly influenced recently by translational research in regard to imaging and technology. In order to provide high level clinical evidence for future brachytherapy practice the strong need for comprehensive prospective clinical research addressing brachytherapy issues is high-lighted.
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A comparison of quality of life of early breast cancer patients treated with accelerated partial breast irradiation versus whole breast irradiation in China. Breast Cancer Res Treat 2011; 133:545-52. [PMID: 21960112 DOI: 10.1007/s10549-011-1793-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 09/15/2011] [Indexed: 01/25/2023]
Abstract
To compare quality of life (QoL) of early breast cancer patients treated with either accelerated partial breast irradiation (APBI) or whole breast irradiation (WBI) after breast-conserving therapy in China. The functional assessment of chronic illness therapy-Breast, traditional Chinese version 4 (FACT-B) instruments were given to 84 women (31 APBI and 53 WBI) who attended the radiotherapy clinic between July 2006 and May 2009 at Cancer Center of Sun Yat-sen University. Baseline characteristics and Karnofsky performance status scores were not different between the two groups. The median follow-up period in the APBI group was 29 versus 34 months in the WBI group. The APBI group scores in the physical domain, functional domain, social domain, and breast-specific concerns of FACT-B were 23.01 ± 3.91, 17.97 ± 4.99, 20.87 ± 4.80, and 22.55 ± 5.45, respectively, and were not significantly different from those of the WBI group (22.80 ± 3.50, 17.50 ± 4.40, 20.13 ± 5.31, 23.81 ± 4.65, respectively, P = 0.987, P = 0.476, P = 0.442, P = 0.330, respectively). However, the scores of the APBI group with respect to the emotional domains were lower compared to those of the WBI group (16.84 ± 3.86 vs. 19.47 ± 3.45, respectively, P = 0.002). Compared with women who underwent WBI, women treated with APBI were shown to have no significantly better QoL outcome, and yet had worse emotional response to their treatment.
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Dragun AE, Harper JL, Olyejar SE, Zunzunegui RG, Wazer DE. The use of adjuvant high-dose-rate breast brachytherapy in patients with collagen vascular disease: A collaborative experience. Brachytherapy 2011; 10:121-7. [DOI: 10.1016/j.brachy.2010.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Revised: 05/06/2010] [Accepted: 05/07/2010] [Indexed: 10/19/2022]
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Étude pilote française de phase II d’irradiation partielle accélérée du sein conformationnelle tridimensionnelle bi-fractionnée hebdomadaire de 40Gy. Cancer Radiother 2010; 14:718-26. [DOI: 10.1016/j.canrad.2010.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 04/13/2010] [Accepted: 05/13/2010] [Indexed: 11/19/2022]
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Belkacémi Y, Gligorov J, Chauvet MP, Tsoutsou PG, Boussen H, Bourgier C. [Radiotherapy and combined therapy in breast cancer: standards and innovations in the adjuvant setting]. J Gynecol Obstet Hum Reprod 2010; 39:F63-F69. [PMID: 21067872 DOI: 10.1016/j.jgyn.2010.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Due to the significant advances in the diagnosis and treatment of breast cancer seen in the last decades, increased survival rates and better outcomes of patients are being observed. The role of radiotherapy remains pivotal in the treatment of early breast cancer. In the adjuvant setting, whole breast irradiation remains the standard of care using a relatively well standardized radiation technique. The recent technology advances and 3D conformal radiotherapy allow for better volumes definition resulting to increased organ at risk--sparing and therefore treatment optimization. Sophisticated techniques and emerging options (such as accelerated partial breast irradiation) are not routinely used yet outside of a clinical trial. Moreover, new drugs and targeted therapies have recently been introduced to the clinical practice for treatment individualization according to the specific tumours' prognosis and/or prediction of the drugs' efficacy based on new biological tools. Regarding the synergistic effect of these molecules with ionizing radiation, rigorous prospective evaluation of combined therapy is important to ensure improved long-term benefit/risk ratio. In this review, the significant advances of radiotherapy and combined therapy in the new era of breast cancer management will be discussed.
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Affiliation(s)
- Y Belkacémi
- Service d'oncologie-radiothérapie, CHU Henri-Mondor, AP-HP et faculté de médecine-université de Paris XII, 51, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
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Wilder RB, Curcio LD, Khanijou RK, Eisner ME, Kakkis JL, Chittenden L, Agustin J, Lizarde J, Mesa AV, Macedo JC, Ravera J, Tokita KM. Preliminary Results in 173 Breast Cancer Patients Treated with Post-Lumpectomy MammoSite Single-Lumen Brachytherapy or Multi-Catheter Brachytherapy. Breast J 2010; 16:581-6. [DOI: 10.1111/j.1524-4741.2010.00977.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Njeh CF, Saunders MW, Langton CM. Accelerated Partial Breast Irradiation (APBI): A review of available techniques. Radiat Oncol 2010; 5:90. [PMID: 20920346 PMCID: PMC2958971 DOI: 10.1186/1748-717x-5-90] [Citation(s) in RCA: 144] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 10/04/2010] [Indexed: 01/08/2023] Open
Abstract
Breast conservation therapy (BCT) is the procedure of choice for the management of the early stage breast cancer. However, its utilization has not been maximized because of logistics issues associated with the protracted treatment involved with the radiation treatment. Accelerated Partial Breast Irradiation (APBI) is an approach that treats only the lumpectomy bed plus a 1-2 cm margin, rather than the whole breast. Hence because of the small volume of irradiation a higher dose can be delivered in a shorter period of time. There has been growing interest for APBI and various approaches have been developed under phase I-III clinical studies; these include multicatheter interstitial brachytherapy, balloon catheter brachytherapy, conformal external beam radiation therapy and intra-operative radiation therapy (IORT). Balloon-based brachytherapy approaches include Mammosite, Axxent electronic brachytherapy and Contura, Hybrid brachytherapy devices include SAVI and ClearPath. This paper reviews the different techniques, identifying the weaknesses and strength of each approach and proposes a direction for future research and development. It is evident that APBI will play a role in the management of a selected group of early breast cancer. However, the relative role of the different techniques is yet to be clearly identified.
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Affiliation(s)
- Christopher F Njeh
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Mark W Saunders
- Radiation Oncology Department, Texas Oncology Tyler, 910 East Houston Street, Tyler, Texas, USA
| | - Christian M Langton
- Physics, Faculty of Science and Technology, Queensland University of Technology, Brisbane, Australia
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Welzel G, Hofmann F, Blank E, Kraus-Tiefenbacher U, Hermann B, Sütterlin M, Wenz F. Health-related quality of life after breast-conserving surgery and intraoperative radiotherapy for breast cancer using low-kilovoltage X-rays. Ann Surg Oncol 2010; 17 Suppl 3:359-67. [PMID: 20853059 DOI: 10.1245/s10434-010-1257-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) is currently being evaluated as a novel approach during breast-conserving surgery (BCS). IORT can be used either as a tumor bed boost followed by external-beam radiotherapy (EBRT) or as a single treatment. In a matched-pair study, we assessed quality of life (QoL) in 69 patients with early breast cancer treated with BCS and/or IORT and/or EBRT. METHODS Patients were matched for age and time since BCS. IORT was provided with 50 kV x-rays (Intrabeam) delivering 20 Gy at the applicator surface. EBRT (46 to 50 Gy in 2-Gy fractions in the IORT with EBRT group, and 56 Gy in 2-Gy fractions in the EBRT group) was initiated after completion of wound healing and/or chemotherapy. The mailed questionnaires included the European Organization for the Research and Treatment of Cancer QLQ-C30 and BR23, FACT-F, HADS, Body Image Scale, and Rosenberg Self-Esteem Scale. At 18 to 70 months' follow-up (median 47 months), all patients were disease free. RESULTS We found only a few differences between the three groups. There was a trend toward more pain (mean ± standard deviation; 42.8 ± 32.9 vs. 27.5 ± 34.7) and reduced QoL (57.6 ± 20.7 vs. 70.3 ± 23.9) after IORT with EBRT compared with EBRT, respectively. IORT patients reported comparable QoL (70.3 ± 23.0), and less breast symptoms and body image concerns compared to EBRT (8.6 ± 12.3 vs. 19.2 ± 23.8, and 1.7 ± 3.3 vs. 3.4 ± 4.4, respectively). IORT alone resulted in significantly fewer breast symptoms (8.6 ± 12.3; P = 0.012) and less pain (23.9 ± 24.5, P = 0.041) compared with IORT with EBRT (26.1 ± 27.6; 42.8 ± 32.9, respectively). CONCLUSIONS Patients with early breast cancer after BCS and IORT with or without EBRT present with comparable QoL like patients receiving EBRT without a boost. IORT patients show the lowest rate of breast symptoms.
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Affiliation(s)
- Grit Welzel
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, Mannheim, Germany.
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Biagioli MC, Harris EE. Accelerated Partial Breast Irradiation: Potential Roles following Breast-Conserving Surgery. Cancer Control 2010; 17:191-204. [DOI: 10.1177/107327481001700308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Multiple randomized trials comparing mastectomy to lumpectomy and whole breast irradiation (WBI) have shown equivalent survival outcomes in early-stage breast cancer. WBI requires a treatment course of several weeks, which has resulted in limited access to breast-conserving therapy in certain populations. A shorter accelerated course of partial breast irradiation (APBI) has been investigated recently. Methods This article reviews the current medical literature, including randomized trials and prospective institutional studies of APBI and the current recommendations regarding the use of this emerging technique. Results Several APBI techniques have been developed, including brachytherapy and external beam methods. The longest follow-up data are available for multicatheter interstitial brachytherapy, a technique that is not commonly used. Other methods, including balloon brachytherapy and external beam three-dimensional conformal techniques, have limited follow-up that shows similar local control rates to whole breast irradiation in highly selected patients. Guidelines for the appropriate use of APBI have been published. Conclusions While APBI may increase access to breast conservation therapy for some women with early-stage breast cancer, follow-up data demonstrating the efficacy of this relatively new treatment approach are limited. Therefore, strict evidence-based selection criteria should be applied when evaluating patients who may be appropriate for APBI.
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Kim Y, Werts ED, Trombetta MG, Miften M. Evaluation of the interfractional biological effective dose (BED) variation in MammoSite high dose rate brachytherapy. J Appl Clin Med Phys 2010; 11:3228. [PMID: 20717092 PMCID: PMC5720443 DOI: 10.1120/jacmp.v11i3.3228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 05/10/2010] [Accepted: 05/03/2010] [Indexed: 11/23/2022] Open
Abstract
The objective of this work is to evaluate the interfractional biological effective dose (BED) variation in MammoSite high dose rate (HDR) brachytherapy. Dose distributions of 19 patients who received 34 Gy in 10 fractions were evaluated. A method was employed to account for nonuniform dose distribution in the BED calculation. Furthermore, a range of alpha/beta values was utilized for specific clinical end points: fibrosis, telangiectasia, erythema, desquamation and breast carcinoma. Two scenarios were simulated to calculate the BED value using: i) the same dose distribution of fraction 1 over fractions 2-10 (constant case, CC), and ii) the actual delivered dose distribution for each fraction 1-10 (interfractiondose variation case, IVC). Although the average BED difference (IVC - CC) was < 0.7 Gy for all clinical endpoints, the range of difference for fibrosis and telangiectasia reached -11% to +3% and -9% to +9% for one of the patients, respectively. By disregarding high inhomogeneity in HDR brachytherapy, the conventional BED calculation tends to overestimate the BED for fibrosis by 16% on average, while it underestimates the BED for erythema (7.6%) and desquamation (10.2%). In conclusion, the BED calculation accounting for the nonuniform dose distribution provides a more clinically relevant description of the clinical delivered dose. Though the average BED difference was clinically insignificant, the maximum difference of BED for late effects can differ by a single fractional dose (10%) for a specific patient due to the interfraction dose variation in MammoSite treatment.
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Affiliation(s)
- Yongbok Kim
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA 15212-4772 , USA.
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Toscas JI, Linero D, Rubio I, Hidalgo A, Arnalte R, Escudé L, Cozzi L, Fogliata A, Miralbell R. Boosting the tumor bed from deep-seated tumors in early-stage breast cancer: a planning study between electron, photon, and proton beams. Radiother Oncol 2010; 96:192-8. [PMID: 20538361 DOI: 10.1016/j.radonc.2010.05.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2010] [Revised: 05/14/2010] [Accepted: 05/14/2010] [Indexed: 11/15/2022]
Abstract
PURPOSE To assess the potential dosimetric advantages and drawbacks of photon beams (modulated or not), electron beams (EB), and protons as a boost for the tumor bed in deep-seated early-stage breast cancer. MATERIAL AND METHODS Planning CTs of 14 women with deep-seated tumors (i.e., > or =4 cm depth) were selected. The clinical target volume (CTV) was defined as the area of architectural distortion surrounded by surgical clips. The planning treatment volume (PTV) was the CTV plus 1cm margin. A dose of 16 Gy in 2 Gy fractions was prescribed. Organs at risk (OARs) were heart, lungs, breasts, and a 5-mm thick skin segment on the breast surface. Dose-volume metrics were defined to quantify the quality of concurrent treatment plans assessing target coverage and sparing of OAR. The following treatment techniques were assessed: photon beams with either static 3D-conformal, dynamic arc (DCA), static gantry intensity-modulated beams (IMRT), or RapidArc (RA); a single conformal EB; and intensity-modulated proton beams (IMPT). The goal for this planning effort was to cover 100% of the CTV with 95% of the prescribed dose and to minimize the volume inside the CTV receiving >107% of the dose. RESULTS All techniques but DCA and EB achieved the planning objective for the CTV with an inhomogeneity ranging from 2% to 11%. RA showed the best conformity, EB the worst. Contra-lateral breast and lung were spared by all techniques with mean doses <0.5 Gy (zero for protons). The ipsi-lateral lung received a mean dose <10% of that prescribed with photon beams and <2% with IMPT, increasing to 17% with EB. The heart, in left-sided breast tumors, received also the highest dose with EB. The skin was best protected with RA with a mean dose of 5.4 Gy and V(15Gy)=2.4%. CONCLUSIONS Boosting the tumor bed in early-stage breast cancer with optimized photon or proton beams may be preferred to EB especially for deep-seated targets. The marked OAR (i.e., ipsi-lateral breast, lung, heart, and skin surface) dose-sparing effect may allow for a potential long-term toxicity risk reduction and better cosmesis. DCA or RA may also be considered alternative treatment options for patients eligible for accelerated partial breast irradiation trials.
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Ahmed HM, DiPiro PJ, Devlin PM, Nguyen ML, Bellon JR. Mammographic Appearance Following Accelerated Partial Breast Irradiation by Using MammoSite Brachytherapy. Radiology 2010; 255:362-8. [DOI: 10.1148/radiol.10091625] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Livi L, Scotti V, Saieva C, Meattini I, Detti B, Simontacchi G, Cardillo CD, Paiar F, Mangoni M, Marrazzo L, Agresti B, Cataliotti L, Bianchi S, Biti G. Outcome After Conservative Surgery and Breast Irradiation in 5,717 Patients With Breast Cancer: Implications for Supraclavicular Nodal Irradiation. Int J Radiat Oncol Biol Phys 2010; 76:978-83. [DOI: 10.1016/j.ijrobp.2009.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 02/26/2009] [Accepted: 03/02/2009] [Indexed: 11/26/2022]
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Polgár C, Van Limbergen E, Pötter R, Kovács G, Polo A, Lyczek J, Hildebrandt G, Niehoff P, Guinot JL, Guedea F, Johansson B, Ott OJ, Major T, Strnad V. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiother Oncol 2010; 94:264-73. [PMID: 20181402 DOI: 10.1016/j.radonc.2010.01.014] [Citation(s) in RCA: 444] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 01/04/2010] [Accepted: 01/23/2010] [Indexed: 01/08/2023]
Abstract
PURPOSE To give recommendations on patient selection criteria for the use of accelerated partial-breast irradiation (APBI) based on available clinical evidence complemented by expert opinion. METHODS AND MATERIALS Overall, 340 articles were identified by a systematic search of the PubMed database using the keywords "partial-breast irradiation" and "APBI". This search was complemented by searches of reference lists of articles and handsearching of relevant conference abstracts and book chapters. Of these, 3 randomized and 19 prospective non-randomized studies with a minimum median follow-up time of 4 years were identified. The authors reviewed the published clinical evidence on APBI, complemented by relevant clinical and pathological studies of standard breast-conserving therapy and, through a series of personal communications, formulated the recommendations presented in this article. RESULTS The GEC-ESTRO Breast Cancer Working Group recommends three categories guiding patient selection for APBI: (1) a low-risk group for whom APBI outside the context of a clinical trial is an acceptable treatment option; including patients ageing at least 50 years with unicentric, unifocal, pT1-2 (<or=30 mm) pN0, non-lobular invasive breast cancer without the presence of an extensive intraductal component (EIC) and lympho-vascular invasion (LVI) and with negative surgical margins of at least 2mm, (2) a high-risk group, for whom APBI is considered contraindicated; including patients ageing <or=40 years; having positive margins, and/or multicentric or large (>30 mm) tumours, and/or EIC positive or LVI positive tumours, and/or 4 or more positive lymph nodes or unknown axillary status (pNx), and (3) an intermediate-risk group, for whom APBI is considered acceptable only in the context of prospective clinical trials. CONCLUSIONS These recommendations will provide a clinical guidance regarding the use of APBI outside the context of a clinical trial before large-scale randomized clinical trial outcome data become available. Furthermore they should promote further clinical research focusing on controversial issues in the treatment of early-stage breast carcinoma.
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Affiliation(s)
- Csaba Polgár
- Department of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
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