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Kaidar-Person O, Offersen BV, Tramm T, Christiansen P, Damsgaard TE, Kothari A, Poortmans P. The King is in the altogether: Radiation therapy after oncoplastic breast surgery. Breast 2023; 72:103584. [PMID: 37783134 PMCID: PMC10562190 DOI: 10.1016/j.breast.2023.103584] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/24/2023] [Indexed: 10/04/2023] Open
Abstract
Breast cancer is the most common malignancy, and the majority of the patients are diagnosed at an early disease stage. Breast conservation is the preferred locoregional approach, and oncoplastic breast conservation surgery is becoming more popular. This narrative review aims to discuss the challenges and uncertainties in target volume definition for postoperative radiation after these procedures, to improve radiation therapy decisions and encourage multidisciplinary.
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Affiliation(s)
- Orit Kaidar-Person
- Breast Radiation Unit, Oncology Institute, Sheba Tel Hashomer, Ramat Gan, Israel; Tel Aviv University, Israel.
| | | | - Trine Tramm
- Department of Pathology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Denmark
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Denmark
| | - Tine Engberg Damsgaard
- Department of Plastic Surgery and Burns Treatment, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.
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Shukla U, Langner UW, Linshaw D, Tan S, Huber KE, Miller CJ, Yu E, Leonard KL, Sueyoshi M, Diamond B, Edmonson D, Wazer DE, Gass J, Hepel JT. Comparison of Tumor Bed Delineation Using a Novel Radiopaque Filament Marker Versus Surgical Clips for Targeting Breast Cancer Radiotherapy. Am J Clin Oncol 2023; 46:427-432. [PMID: 37440682 DOI: 10.1097/coc.0000000000001028] [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: 07/15/2023]
Abstract
BACKGROUND Accuracy of tumor bed (TB) delineation is essential for targeting boost doses or partial breast irradiation. Multiple studies have shown high interobserver variability with standardly used surgical clip markers (CMs). We hypothesize that a radiopaque filament marker (FM) woven along the TB will improve TB delineation consistency. METHODS An FDA-approved FM was intraoperatively used to outline the TB of patients undergoing lumpectomy. Between January 2020 and January 2022, consecutive patients with FM placed after either (1) lumpectomy or (2) lumpectomy with oncoplastic reconstruction were identified and compared with those with CM. Six "experts" (radiation oncologists specializing in breast cancer) across 2 institutions independently defined all TBs. Three metrics (volume variance, dice coefficient, and center of mass [COM] deviation). Two-tailed paired samples t tests were performed to compare FM and CM cohorts. RESULTS Twenty-eight total patients were evaluated (14 FM and 14 CM). In aggregate, differences in volume between expert contours were 29.7% (SD ± 58.8%) with FM and 55.4% (SD ± 105.9%) with CM ( P < 0.001). The average dice coefficient in patients with FM was 0.54 (SD ± 0.15), and with CM was 0.44 (SD ± 0.22) ( P < 0.001). The average COM deviation was 0.63 cm (SD ± 0.53 cm) for FM and 1.05 cm (SD ± 0.93 cm) for CM; ( P < 0.001). In the subset of patients who underwent lumpectomy with oncoplastic reconstruction, the difference in average volume was 21.8% (SD ± 20.4%) with FM and 52.2% (SD ± 64.5%) with CM ( P <0.001). The average dice coefficient was 0.53 (SD ± 0.12) for FM versus 0.39 (SD ± 0.24) for CM ( P < 0.001). The average COM difference was 0.53 cm (SD ± 0.29 cm) with FM versus 1.25 cm (SD ± 1.08 cm) with CM ( P < 0.001). CONCLUSION FM consistently outperformed CM in the setting of both standard lumpectomy and complex oncoplastic reconstruction. These data suggest the superiority of FM in TB delineation.
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Affiliation(s)
- Utkarsh Shukla
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Ulrich W Langner
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - David Linshaw
- Department of Surgical Oncology, University of Massachusetts School of Medicine, Worcester, MA
- Program in Women's Oncology, Women and Infants' Hospital, Providence, RI
| | - Sydney Tan
- Warren Alpert Medical School of Brown University
| | - Kathryn E Huber
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Chelsea J Miller
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Esther Yu
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Kara L Leonard
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Mark Sueyoshi
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Brett Diamond
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - David Edmonson
- Warren Alpert Medical School of Brown University
- Program in Women's Oncology, Women and Infants' Hospital, Providence, RI
| | - David E Wazer
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
| | - Jennifer Gass
- Warren Alpert Medical School of Brown University
- Program in Women's Oncology, Women and Infants' Hospital, Providence, RI
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, Tufts University School of Medicine, Boston
- Department of Radiation Oncology, Lifespan Cancer Institute
- Warren Alpert Medical School of Brown University
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Beddok A, Kirova Y, Laki F, Reyal F, Vincent Salomon A, Servois V, Fourquet A. The place of the boost in the breast cancer treatment: State of art. Radiother Oncol 2022; 170:55-63. [DOI: 10.1016/j.radonc.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/01/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
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Acree P, Kapadia A, Mahatme R, Zhang L, Patel D, Almoney C, Park G, Kofsky M, Matin S, Habibi M. Review of Current Accepted Practices in Identification of the Breast Lumpectomy Tumor Bed. Adv Radiat Oncol 2022; 7:100848. [PMID: 36148372 PMCID: PMC9486415 DOI: 10.1016/j.adro.2021.100848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 11/01/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Of the 260,000 women diagnosed with breast cancer annually in the United States, more than 60% are treated with breast-conserving surgery or lumpectomy, followed by radiation to decrease the chance of local recurrence. More than 70% of breast cancer recurrences are localized to the original tumor cavity. Hence, targeted radiation therapy after lumpectomy is critical for recurrence prevention. With 30,000 patients annually opting for oncoplastic reconstruction of the breast after lumpectomy to improve cosmesis, the resulting tissue rearrangement increases the difficulty for radiation oncologists to accurately delineate the cavity when planning radiation therapy. Owing to the absence of a standardized protocol, it is important to assess the efficacy of various methods used to mark the tumor cavity for improved delineation. Methods and Materials A keyword search and analysis was used to compile relevant articles on PubMed (National Center for Biotechnology Information). Results Currently, a common practice for tumor cavity localization is applying titanium surgical clips to the borders of lumpectomy cavity. Tissue movement and seroma formation both impact the positioning of surgical clips within the tumor cavity and lead to significant interobserver variability. Furthermore, the main application of surgical clips is to control the small vessels during surgery, and that can create confusion when the same clips are used for tumor bed localization. All alternative solutions present more precise tumor bed delineation but possess individual concerns with workflow integration, patient comfort, and accuracy. Though liquid-based fiducials were found to be the most effective for delineating tumor cavities, there are still drawbacks for clinical use. Conclusions These findings should encourage medical innovators to develop novel techniques for tumor cavity marking to increase delineation accuracy and effectively target at-risk tissue. Future solutions in this space should consider the properties of liquid-based fiducial markers to improve radiation oncologists' ability to precisely delineate the tumor cavity.
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Koch CA, Corey G, Liu ZA, Han K, Fyles A. Partial Breast Irradiation and Surgical Clip Usage for Tumor Bed Delineation After Breast-Conserving Surgery in Canada: A Radiation Oncology Perspective. Adv Radiat Oncol 2021; 6:100701. [PMID: 34409206 PMCID: PMC8360935 DOI: 10.1016/j.adro.2021.100701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Our purpose was to evaluate the usage and perceived benefit of surgical clips for breast radiation therapy planning in Canada, focusing on partial breast irradiation (PBI) after breast-conserving surgery. METHODS AND MATERIALS A retrospective institutional review identified patients eligible for PBI based on clinicopathologic criteria, and tumor bed visualization was determined from computed tomography-planning scans. An online survey was subsequently distributed to Canadian radiation oncologists addressing the usage and added value of surgical clips for breast radiation therapy planning purposes. The survey also evaluated PBI usage and regimens. Responses were collected over a 4-week period. PBI regimen usage at our institution was also reviewed from May 1 to December 18, 2020. RESULTS Based on clinicopathologic criteria, 306 patients were identified between 2013 and 2018 who were eligible for PBI. However, only 24% (72/306) of cases were noted to have surgical clips, of which over 50% did not assist in tumor bed localization due to inconsistent clip positioning. Similarly, nearly two-thirds (28/43) of survey respondents indicated that surgical clips are placed in the tumor bed in less than 50% of cases. Almost all respondents (42/43) indicated that surgical clips facilitate breast radiation therapy planning and favor the development of guidelines to increase the consistent placement of surgical clips in the tumor bed after breast-conserving surgery. Approximately two-thirds of respondents (28/43) offer PBI to eligible patients as routine treatment, with moderate hypofractionated regimens most commonly recommended. However, the 1-week daily regimen of 26 Gy in 5 fractions is now offered to the majority (77%) of patients at our institution. CONCLUSIONS There was strong agreement among Canadian radiation oncologists that surgical clip placement facilitates breast radiation therapy planning, and most favor the development of surgical guidelines for the consistent placement of surgical clips in this setting. With the growing use of PBI, accurate localization of the tumor bed is extremely important.
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Affiliation(s)
- Christine Anne Koch
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Gemma Corey
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Zhihui Amy Liu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Kathy Han
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Lee G, Tsui H, Koch CA, Fyles A. Are we missing the post-operative cavity in whole breast radiotherapy? J Med Imaging Radiat Sci 2021; 52:207-213. [PMID: 33926849 DOI: 10.1016/j.jmir.2021.03.003] [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: 02/05/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND/PURPOSE Whole breast radiotherapy (RT) following breast-conserving surgery is a standard treatment option in early-stage breast cancer patients. The whole breast RT technique targets the entire breast, traditionally identified based on breast palpation and the lumpectomy scar. The aim of this study is to evaluate dosimetry of the tumour bed (cavity) and location of recurrence in women treated with breast radiotherapy without explicit cavity delineation. MATERIALS/METHODS 50 consecutive women previously treated with whole breast RT were retrospectively contoured to define the post-operative cavity with a 1.0 cm expansion for planning target volume (cPTV). The cavity and cPTV dosimetric coverage [volume receiving 92%(V92%) and 95%(V95%) prescription] were calculated. Cavity and cPTV location were classified as inside, at edge or outside of previous treatment fields and recurrence rates were collected. RESULTS Forty-five (90%) women had cavities located inside the previous treatment fields (CAVin) and 5 women (10%) had cavities located outside(4) or at edge(1) of previous fields (CAVout/edge). CAVout/edge were located in extreme aspects of the breast: lateral(3); medial(1); or superior(1). Mean cavity_V92% was 91.6% vs 98.5% for CAVout/edge vs CAVin (p = 0.042). Mean cPTV_V92% was 78.7% vs 97.2% for cPTVout/edge vs cPTVin (p<0.001). At 5-year follow-up, 20% (1/5) of the CAVout/edge had 1 in-breast recurrence near the cavity (at previous field edge). Within the CAVin cohort, 11 patients were lost to follow-up and 6% (2/34) patients had in-breast recurrence. CONCLUSIONS In patients treated with whole breast RT without cavity delineation, 10% did not have ideal dosimetric coverage of the cavity. Cavity delineation in treatment planning provides optimal tumour bed coverage for patients undergoing whole breast RT, and is of particular importance for the coverage of cavities located in the extreme margins of the breast.
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Affiliation(s)
- Grace Lee
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
| | - Hugh Tsui
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada
| | - C Anne Koch
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
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Riina MD, Rashad R, Cohen S, Brownlee Z, Sioshansi S, Hepel J, Chatterjee A, Huber KE. The Effectiveness of Intraoperative Clip Placement in Improving Radiation Therapy Boost Targeting After Oncoplastic Surgery. Pract Radiat Oncol 2020; 10:e348-e356. [DOI: 10.1016/j.prro.2019.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/01/2019] [Accepted: 12/11/2019] [Indexed: 11/28/2022]
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The use of hyaluronic acid hydrogel as a tumour bed marker in breast-conserving therapy. Radiother Oncol 2020; 152:8-13. [PMID: 32738260 DOI: 10.1016/j.radonc.2020.07.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 07/12/2020] [Accepted: 07/23/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate usefulness of hyaluronic acid (HA) hydrogel as a tumour bed marker in breast conserving therapy (BCT). To analyze inter- (Inter-OV) and intraobserver (Intra-OV) variability of contouring boost target volume (CTVboost) in external beam radiotherapy (EBRT). MATERIALS AND METHODS Thirty-two patients in the HA group and 30 patients in the control group with an early stage breast cancer were included in the study. During the surgery 1-3 ml of HA hydrogel was injected into breast to mark the tumour bed for every patient in the HA group. Moreover, surgical clips were placed underneath the lumpectomy cavity. Patients in the control group were marked only by metal markers. Three radiation oncologists delineated CTVboost twice for every patient. Three parameters were calculated to quantify contouring variability: coefficient of variation for volumes (COVV), center of mass displacement (CoMd) and conformity index (CI). RESULTS There were no significant differences between mean values of COVV for HA and control group, neither for Intra-OV (0.14 vs 0.13) nor Inter-OV (0.19 vs 0.18) calculations. The mean CoMd were 6.1 mm and 9.1 mm for Inter-OV calculations and 3.9 mm and 6.4 mm for Intra-OV in the HA and the control group respectively. The mean CI for Intra-OV improved from 0.61 to 0.65 and from 0.47 to 0.56 for Inter-OV in the control and HA group respectively. CONCLUSION HA hydrogel used as a tumour bed marker improves tumour bed visibility and reduces inter- and intraobserver variability of EBRT boost target volume delineations.
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Liu J, Chen M, Li Z, Sun Y, Wang H, Wang Y. Application of titanium clip marking in localization of 37 cases of rectal cancer before radiotherapy. PRECISION RADIATION ONCOLOGY 2020. [DOI: 10.1002/pro6.1090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jin‐qi Liu
- Shandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical Sciences Jinan China
| | - Ming Chen
- Shandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical Sciences Jinan China
| | - Zeng‐jun Li
- Shandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical Sciences Jinan China
| | - Yong‐min Sun
- Shandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical Sciences Jinan China
| | - Hai‐peng Wang
- Shandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical Sciences Jinan China
| | - Ya‐wei Wang
- Shandong Cancer Hospital and InstituteShandong First Medical University and Shandong Academy of Medical Sciences Jinan China
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Tse T, Knowles S, Bélec J, Caudrelier JM, Lock M, Brackstone M, Arnaout A. Consensus statement on tumour bed localization for radiation after oncoplastic breast surgery. ACTA ACUST UNITED AC 2020; 27:e326-e331. [PMID: 32669940 DOI: 10.3747/co.27.5977] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Oncoplastic surgery (ops) is becoming the new standard of care for breast-conserving surgery, leading to some challenges with adjuvant radiation, particularly when accurate tumour bed (tbd) delineation is needed for focused radiation (that is, accelerated partial breast irradiation or boost radiation). Currently, no guidelines have been published concerning tbd localization for adjuvant targeted radiation after ops. Methods A modified Delphi method was used to establish consensus by a panel of 20 experts in surgical and radiation oncology at the Canadian Locally Advanced Breast Cancer National Consensus Group and in a subsequent online member survey. Results These are the main recommendations:■ Surgical clips are necessary and should, at a minimum, be placed along the 4 side walls of the cavity, plus 1-4 clips at the posterior margin if necessary.■ Operative reports should include pertinent information to help guide the radiation oncologists.■ Breast surgeons and radiation oncologists should have a basic understanding of ops techniques and work on "speaking a common language."■ Careful consideration is needed when determining the value of targeted radiation, such as boost, in higher-level ops procedures with extensive tissue rearrangement. Conclusions The panel developed a total of 6 recommendations on tbd delineation for more focused radiation therapy after ops, with more than 80% agreement on each statement. All are summarized, together with the corresponding evidence or expert opinion.
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Affiliation(s)
- T Tse
- Department of Surgery, University of Ottawa, Ottawa, ON
| | - S Knowles
- Department of Surgery, Western University, London, ON
| | - J Bélec
- Department of Radiation Oncology, University of Ottawa, Ottawa, ON
| | - J M Caudrelier
- Department of Radiation Oncology, University of Ottawa, Ottawa, ON
| | - M Lock
- Department of Radiation Oncology, Western University, London, ON
| | - M Brackstone
- Department of Surgery, Western University, London, ON
| | - A Arnaout
- Department of Surgery, University of Ottawa, Ottawa, ON
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Sun LC, Su Y, Ding XC, Xu DS, Li CM, Wang L, Li WL, Sun XD, Yu JM, Meng X. In vitro and in vivo evaluation of the safety and efficacy of a novel liquid fiducial marker for image-guided radiotherapy. Oncol Lett 2020; 20:569-580. [PMID: 32565982 PMCID: PMC7286123 DOI: 10.3892/ol.2020.11591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 03/26/2020] [Indexed: 12/30/2022] Open
Abstract
The true extent of a tumor is difficult to visualize, during radiotherapy, using current modalities. In the present study, the safety and feasibility of a mixture of N-butyl cyanoacrylate and lipiodol (NBCA/Lip) was evaluated in order to investigate the optimal combination for application as a fiducial marker for radiotherapy. Four combinations of NBCA/Lip injection (1:1–0.1, 1:1–0.15, 1:3–0.1 and 1:3–0.15 ml) were injected into the subcutaneous tissue of BALB/c mice. The changes in gross histopathology, body weight, skin score, marker volume, neutrophil and macrophage counts were observed to analyze the effects of the different mixing ratios and injection volumes, in order to identify the best combination. Evaluation according to the International Organization for Standardization criteria was further conducted in order to test the biocompatibility of the mixture, including an acute systematic assay with mice, cytotoxicity with L929 fibroblasts and delayed-type hypersensitivity tests with guinea pigs and an intradermal test with rabbits. The results revealed that at the seventh week, 42 markers (42/48; 87.5%) were still visible using computed tomography (CT) imaging. No serious adverse effects were observed throughout the study period; however, the combination of 1:1–0.1 ml had the lowest body weight and worst skin score. A review of the histopathological reaction to NBCA/Lip revealed a combination of acute inflammation, chronic inflammation, granulation tissue, foreign-body reaction and fibrous capsule formation. The 1:1 NBCA combination ratio resulted in the most intense tissue repair reaction and a slower degradation rate of markers. In general, the combination of 1:3–0.15 ml had a better fusion with local tissue, maintained a stable imaging nodule on CT images for 7 weeks and the final biocompatibility test demonstrated its safety. Overall, the findings of the present study demonstrated NBCA/Lip as a safe and feasible fiducial marker, when using the 1:3–0.15 ml combination.
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Affiliation(s)
- Liang-Chao Sun
- Department of Radiation Oncology and Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, Shandong 300060, P.R. China.,Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Yi Su
- Department of Radiotherapy, The Affiliated Yantai Yuhuangding Hospital of Qingdao University Institution, Yantai, Shandong 264001, P.R. China
| | - Xing-Chen Ding
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Dong-Shui Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Cheng-Ming Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Lu Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Wan-Long Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Xin-Dong Sun
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Jin-Ming Yu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
| | - Xue Meng
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
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Mitchell S, Lee H, DuPree BB, Beyer DC, Ulissey M, Grobmyer SR, Gass J, Boolbol S, Storm-Dickerson T. A novel, adaptable, radiographically opaque, multi-plane continuous filament marker for optimizing tissue identification, radiation planning, and radiographic follow-up. Gland Surg 2020; 8:609-617. [PMID: 32042667 DOI: 10.21037/gs.2019.10.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background In breast cancer treatment, marking the tumor bed is an important aspect of the surgical component of therapy. Clear delineation of the tumor bed allows radiation oncologists a defined target for planning and delivering postoperative radiation therapy (XRT). Tumor bed marking also allows radiographic follow-up of the tumor bed on subsequent breast imaging. The aim of this assessment is to evaluate the ease and feasibility of utilizing a tumor bed filament marker (VeraFormÒ, Videra Surgical inc., USA) as a marker in post-operative benign surgical sites and malignant breast surgical tumor beds in breast cancer surgery. Methods The filament marker is a novel radiopaque surgical filament that in lieu of clips and other markers is implanted in the surgical tumor bed during breast surgery. Following development of the filament marker, the researchers used breast phantoms and radiographic images to develop a series of geometric patterns of placement options that optimize comprehensive multi-plane radiographic interpretation of the exact tumor bed or surgical margin. Three breast surgeons at 3 separate institutions then used this filament as a continuous multi-plane marker in 20 patients during breast conservation surgery. In these patients, the filament marker was thus used to mark the tumor bed (breast cancer surgery) or surgical site (benign breast disease) instead of the more traditional devices such as clips or other metallic open framework devices. We then assessed 2 important factors related to this device; (I) the ease, feasibility, and accuracy of in vivo placement with oncoplastic and non-oncoplastic breast conservation surgery techniques; (II) the radiographic footprint this device left on standard imaging protocols of post-operative mammogram (MMG), computed tomography (CT) scan, breast magnetic resonance imaging (MRI) examinations, and ultrasounds (USs) for both routine follow-up imaging and for standard radiation planning. Results There were no adverse events reported with the use of this device. The cases were then reviewed by a multidisciplinary team that included the original surgeon, a breast radiologist, and radiation oncologist. Their unanimous evaluation was that the filament marker clearly delineated all sides and planes of the tumor bed (cancer surgery) or surgical site (benign disease). Regardless of surgical technique utilized, this information provided precise 3D guidance for radiation planning and delivery as well as radiographic follow-up. The surgeons involved reported that delineating the bed with the filament marker was a quick and easy procedure and did not interfere with performing the planned surgical technique. Radiologists, surgeons, and radiation oncologists found that the filament marker was not only radiographically opaque on CT and MMG, but also caused no significant artifact on CT, MRI, US, or MMG. Conclusions The continuous multi-plane filament marker is a new device that fulfills the heretofore unmet need for safe and improved tumor bed and tissue site marking. It is an easy to place, non-palpable continuous multi-plane radiographic opaque tissue marker that seems to better delineate the tumor bed, regardless of type of breast surgery performed, while providing a more accurate 3D image for radiation planning and radiographic follow-up on MMG MRI, CT and US.
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Affiliation(s)
- Sunny Mitchell
- Department of Surgery, Montefiore Nyack Hospital, Nyack, NY, USA
| | - Henry Lee
- Department of Radiation Oncology; New York Presbyterian-Lawrence Hospital, Columbia University College of Physicians & Surgeons, Bronxville, NY, USA
| | - Beth Baughman DuPree
- Sedona Breast care, Department of Surgery, Cancer Centers of Northern Arizona Healthcare, Sedona, AZ, USA
| | - David C Beyer
- Department of Radiation Oncology, Cancer Centers of Northern Arizona Healthcare, Sedona, AZ, USA
| | - Michael Ulissey
- Department of Radiology, The University of Texas Health Sciences Center, San Antonio, TX, USA
| | - Stephen R Grobmyer
- Oncology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jennifer Gass
- Department of Surgery, Women & Infants Hospital, Brown University, Providence, RI, USA
| | - Susan Boolbol
- Department of Surgery, Mount Sinai Beth Israel, Icahn School of Medicine, New York, NY, USA
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Foster B, Sindhu K, Hepel J, Wazer D, Graves T, Taneja C, Wiggins D, Leonard K. Three-Dimensional Bioabsorbable Tissue Marker Placement is Associated with Decreased Tumor Bed Volume Among Patients Receiving Radiation Therapy for Breast Cancer. Pract Radiat Oncol 2019; 9:e134-e141. [DOI: 10.1016/j.prro.2018.09.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/04/2018] [Accepted: 09/19/2018] [Indexed: 11/16/2022]
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14
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Fiducial placement for recurrent gastric cancer. Arab J Gastroenterol 2019; 20:56-58. [PMID: 30745013 DOI: 10.1016/j.ajg.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 09/07/2018] [Accepted: 01/25/2019] [Indexed: 11/20/2022]
Abstract
A 53-year-old male was diagnosed with invasive adenocarcinoma of the pre-pyloric region. Imaging studies ruled out metastatic disease. The patient underwent neo-adjuvant chemotherapy followed by a partial gastrectomy. CT scan at 18 months' post-resection demonstrated right upper quadrant lesions suspicious for metastatic disease. EUS exam shows two round hypoechoic lesions. Fine needle aspiration with suction was performed with on-site cytology confirming malignant cells in the masses. Five gold fiducial markers were placed. Final pathology confirmed adenocarcinoma. The patient was subsequently started on stereotactic body radiation therapy (SBRT) with good results. This is the first case report EUS-guided fiducial markers for recurrent gastric cancer post-gastrectomy.
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Struik GM, Hoekstra N, Klem TM, Ghandi A, Verduijn GM, Swaak-Kragten AT, Schoonbeek A, de Vries KC, Sattler MA, Verhoef K, Birnie E, Pignol JP. Injection of radiopaque hydrogel at time of lumpectomy improves the target definition for adjuvant radiotherapy. Radiother Oncol 2018; 131:8-13. [PMID: 30773191 DOI: 10.1016/j.radonc.2018.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 10/14/2018] [Accepted: 11/04/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE During oncoplastic breast-conserving surgery (BCS), the surgical cavity is closed to reduce seroma formation. This makes the radiotherapy target definition using clips challenging, leading to poor inter-observer agreement and potentially geographical misses. We hypothesize that injecting a radiopaque hydrogel in the lumpectomy cavity before closure improves radiotherapy target definition and agreement between observers. MATERIALS AND METHODS Women undergoing BCS in a single university hospital were prospectively accrued in the study. Three to 9 ml of iodined PolyEthylene Glycol (PEG) hydrogel and clips were inserted in the lumpectomy cavity. A CT-scan was performed at 4 to 6 weeks. CT images of BCS patients with standard clips only were used as control group, matched on age, specimen weight, and distance between clips. Six radiation oncologists delineated the tumor bed volumes and rated the cavity visualization scores (CVS). The primary endpoint was the agreement between observers measured using a Conformity Index (Cx). RESULTS Forty-two patients were included, 21 hydrogel procedures and 21 controls, resulting in 315 observer pairs. The feasibility of the intervention was 100%. The median Cx was higher in the intervention group (Cx = 0.70, IQR [0.54-0.79]) than in the control group (Cx = 0.54, IQR [0.42-0.66]), p < 0.00, as were the CVS (3.5 [2.5-4.5] versus 2.5 [2-3.5], p < 0.001). The rate of surgical site infections was similar to literature. CONCLUSIONS The use of radiopaque PEG enables to identify the lumpectomy cavity, resulting in a high inter-observer agreement for radiotherapy target definition. This intervention is easy to perform and blend well into current practice.
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Affiliation(s)
- Gerson M Struik
- Franciscus Gasthuis and Vlietland, Department of Surgery, Rotterdam, the Netherlands; Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands
| | - Nienke Hoekstra
- Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands
| | - Taco M Klem
- Franciscus Gasthuis and Vlietland, Department of Surgery, Rotterdam, the Netherlands
| | - Ali Ghandi
- Franciscus Gasthuis and Vlietland, Department of Radiology, Rotterdam, the Netherlands
| | - Gerda M Verduijn
- Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands
| | | | - Alja Schoonbeek
- Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands
| | - Kim C de Vries
- Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands
| | - Margriet A Sattler
- Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands
| | - Kees Verhoef
- Erasmus MC, Department of Surgery, Rotterdam, the Netherlands
| | - Erwin Birnie
- Franciscus Gasthuis and Vlietland, Department of Statistics and Education, Rotterdam, the Netherlands
| | - Jean-Philippe Pignol
- Erasmus MC, Department of Radiation Oncology, Rotterdam, the Netherlands; Dalhousie University, Department of Radiation Oncology, Halifax, Canada.
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Monten C, Veldeman L, Vandecasteele K, Oltéanu L, De Gersem W, Vercauteren T, Mulliez T, Van Den Broecke R, Depypere H, De Neve W, Lievens Y. External partial breast irradiation in prone position: how to improve accuracy? Acta Oncol 2018; 57:1339-1345. [PMID: 29873283 DOI: 10.1080/0284186x.2018.1481294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION In view of the limited incremental benefit between whole breast irradiation (WBI), accelerated partial breast irradiation (APBI) and omission of radiotherapy in favorable early-stage breast cancer (ESBC), APBI can only be justified if it combines adequate target coverage with the lowest achievable toxicity. Interobserver exercises demonstrated the difficulty of precise target delineation, especially in prone position; information on accuracy is even scarcer. We tested the impact of inserting an additional indicator clip, marking the depth of the tumor in the breast, and the added value of a preoperative CT in treatment position on precision and accuracy. MATERIAL AND METHODS In 12 patients, tumor bed delineation was performed by four radiation oncologists, with CTVstandard (clinical target volume) based on standard delineation guidelines, CTVclip resulting from a 1-2-cm symmetrical expansion with the indicator clip as center and CTVclip_CT expanding from the midpoint between the indicator clip and preoperative gross tumor volume (GTV) as center. Precision was measured as the mean pairwise Jaccard index (JIpairs) between observers, accuracy as the mean overlap between GTV and respective CTVs. RESULTS JIpairs was 0.38 for CTVstandard, 0.75 for CTVclip and 0.59 for CTVclip_CT. Overlap rate of GTV with CTVs was respectively 0.48, 0.67 and improved further to 0.88 for CTVclip_CT. High-dose coverage of GTV (D95 and D90) improved with an indicator clip, but the most optimal result was reached when preoperative CT was added. CONCLUSIONS If EB-APBI in prone position is aimed for, an indicator clip intended to mark the depth of the tumor increases the probability of accurate target coverage, but cannot entirely replace the added value of a preoperative CT in treatment position. Avoiding the cost and effort of such CT implies a risk of missing the target, especially when small volumes are aimed for. Increasing target volumes to reduces this risk, questions the concept of APBI.
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Affiliation(s)
- Chris Monten
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Liv Veldeman
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | | | - Luiza Oltéanu
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Werner De Gersem
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Tom Vercauteren
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Thomas Mulliez
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | | | - Herman Depypere
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Belgium
| | - Wilfried De Neve
- Department of Radiation Oncology, Ghent University Hospital, Belgium
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital, Belgium
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Winters ZE, Horsnell J, Elvers KT, Maxwell AJ, Jones LJ, Shaaban AM, Schmid P, Williams NR, Beswick A, Greenwood R, Ingram JC, Saunders C, Vaidya JS, Esserman L, Jatoi I, Brunt AM. Systematic review of the impact of breast-conserving surgery on cancer outcomes of multiple ipsilateral breast cancers. BJS Open 2018; 2:162-174. [PMID: 30079385 PMCID: PMC6069349 DOI: 10.1002/bjs5.53] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 01/11/2018] [Indexed: 01/16/2023] Open
Abstract
Background The clinical effectiveness of treating ipsilateral multifocal (MF) and multicentric (MC) breast cancers using breast‐conserving surgery (BCS) compared with the standard of mastectomy is uncertain. Inconsistencies relate to definitions, incidence, staging and intertumoral heterogeneity. The primary aim of this systematic review was to compare clinical outcomes after BCS versus mastectomy for MF and MC cancers, collectively defined as multiple ipsilateral breast cancers (MIBC). Methods Comprehensive electronic searches were undertaken to identify complete papers published in English between May 1988 and July 2015, primarily comparing clinical outcomes of BCS and mastectomy for MIBC. All study designs were included, and studies were appraised critically using the Newcastle–Ottawa Scale. The characteristics and results of identified studies were summarized. Results Twenty‐four retrospective studies were included in the review: 17 comparative studies and seven case series. They included 3537 women with MIBC undergoing BCS; breast cancers were defined as MF in 2677 women, MC in 292, and reported as MIBC in 568. Six studies evaluated MIBC treated by BCS or mastectomy, with locoregional recurrence (LRR) rates of 2–23 per cent after BCS at median follow‐up of 59·5 (i.q.r. 56–81) months. BCS and mastectomy showed apparently equivalent rates of LRR (risk ratio 0·94, 95 per cent c.i. 0·65 to 1·36). Thirteen studies compared BCS in women with MIBC versus those with unifocal cancers, reporting LRR rates of 2–40 per cent after BCS at a median follow‐up of 64 (i.q.r. 57–73) months. One high‐quality study reported 10‐year actuarial LRR rates of 5·5 per cent for BCS in 300 women versus 6·5 per cent for mastectomy among 887 women. Conclusion The available studies were mainly of moderate quality, historical and underpowered, with limited follow‐up and biased case selection favouring BCS rather than mastectomy for low‐risk patients. The evidence was inconclusive, weakening support for the St Gallen consensus and supporting a future randomized trial.
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Affiliation(s)
- Z E Winters
- Patient-Reported and Clinical Outcomes Research Group Surgical and Interventional Trials Unit (SITU) London UK
| | - J Horsnell
- Department of Breast Surgery Royal Surrey County Hospital NHS Foundation Trust Guildford UK
| | - K T Elvers
- Patient-Centred and Clinical Outcomes Research Group University of Bristol, Southmead Hospital Bristol UK
| | - A J Maxwell
- Nightingale Centre Wythenshawe Hospital Manchester UK
| | | | - A M Shaaban
- Department of Histopathology Queen Elizabeth Hospital Birmingham and University of Birmingham Birmingham UK
| | - P Schmid
- Centre for Experimental Cancer Medicine, Barts Cancer Institute Queen Mary University of London London UK
| | - N R Williams
- SITU, Division of Surgery and Interventional Science, Faculty of Medical Sciences University College London London UK
| | - A Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School University of Bristol, Southmead Hospital Bristol UK
| | - R Greenwood
- Research Design Service South West University Hospitals Bristol NHS Foundation Trust Bristol UK
| | - J C Ingram
- Research Design Service South West University Hospitals Bristol NHS Foundation Trust Bristol UK
| | - C Saunders
- Division of Surgery, Harry Perkins Institute of Medical Research, Fiona Stanley Hospital University of Western Australia Murdoch Western Australia Australia
| | - J S Vaidya
- SITU, Division of Surgery and Interventional Science, Faculty of Medical Sciences University College London London UK
| | - L Esserman
- University of California San Francisco Carol Franc Buck Breast Care Centre San Francisco California USA
| | - I Jatoi
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery University of Texas Health Science Centre San Antonio Texas USA
| | - A M Brunt
- Cancer Centre University Hospitals of North Midlands and Keele University Stoke-on-Trent UK
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Wang W, Li J, Xing J, Xu M, Shao Q, Fan T, Guo B, Liu S. Analysis of the variability among radiation oncologists in delineation of the postsurgical tumor bed based on 4D-CT. Oncotarget 2018; 7:70516-70523. [PMID: 27655639 PMCID: PMC5342570 DOI: 10.18632/oncotarget.12044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 08/24/2016] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE This study investigated interobserver and intraobserver variability in radiation oncologists' definition of the tumor bed (TB) after breast-conserving surgery (BCS). RESULTS The TB volume, CVS and number of surgical clips were not significantly related to intraobserver variability. Moreover, no correlation was noted between CT slice thickness and interobserver variability (Δinter, DSCinter) in TB delineation, and no significant difference was noted among the three groups. The TB volume was negatively correlated with Δinter. DSCinter improved significantly with increased TB volume and decreased Δinter. DSCinter also increased significantly in patients with a CVS of 3 to 5 compared with patients with a CVS of 1 to 2. DSCinter was thus positively correlated with the CVS, with a correlation coefficient of 0.451. The use of 7 to 9 surgical clips neither decreased Δinter nor increased DSCinter. MATERIALS AND METHODS Five or more surgical clips were placed at the TB during lumpectomy. The TB was delineated on the end expiration scan. The data were stratified based on the cavity visualization score (CVS), CT slice thickness and surgical clip number. The Dice similarity coefficient (DSC) and inter(intra)observer variability (Δinter and Δintra) in different groups were evaluated and compared. CONCLUSIONS Inter(intra)observer variability in TB delineation was decreased for breast cancer patients implanted with 5 or more surgical clips in the cohort with a higher CVS and a larger TB. The use of more than 6 surgical clips did not significantly improve TB delineation, so 5 to 6 surgical clips are likely adequate to delineate the TB.
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Affiliation(s)
- Wei Wang
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Jianbin Li
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Jun Xing
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Min Xu
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Qian Shao
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Tingyong Fan
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Bing Guo
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
| | - Shanshan Liu
- Department of Radiation Oncology, Shandong Cancer Hospital affiliated to Shandong University, Shandong Academy of Medical Sciences, Jinan, Shandong province, China, 250117
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19
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Improvement of consistency in delineating breast lumpectomy cavity using surgical clips. J Surg Res 2018; 221:30-34. [DOI: 10.1016/j.jss.2017.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 07/12/2017] [Accepted: 07/21/2017] [Indexed: 11/22/2022]
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20
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Mondal D, Julka PK, Sharma DN, Jana M, Laviraj MA, Deo SVS, Roy S, Guleria R, Rath GK. Accelerated hypofractionated adjuvant whole breast radiation with simultaneous integrated boost using volumetric modulated arc therapy for early breast cancer: A phase I/II dosimetric and clinical feasibility study from a tertiary cancer care centre of India. J Egypt Natl Canc Inst 2017; 29:39-45. [DOI: 10.1016/j.jnci.2017.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 11/26/2022] Open
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21
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Zhang A, Li J, Wang W, Wang Y, Mu D, Chen Z, Shao Q, Li F. A comparison study between gross tumor volumes defined by preoperative magnetic resonance imaging, postoperative specimens, and tumor bed for radiotherapy after breast-conserving surgery. Medicine (Baltimore) 2017; 96:e5839. [PMID: 28079816 PMCID: PMC5266178 DOI: 10.1097/md.0000000000005839] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The identification and contouring of target volume is important for breast-conserving therapy. The aim of the study was to compare preoperative magnetic resonance imaging (MRI), postoperative pathology, excised specimens' (ES) size, and tumor bed (TB) delineation as methods for determining the gross tumor volume (GTV) for radiotherapy after breast-conserving surgery (BCS). METHODS Thirty-three patients with breast cancer who underwent preoperative MRI and radiotherapy after BCS were enrolled. The GTVs determined by MRI, pathology, and the ES were defined as GTVMRI, GTVPAT, and GTVES, respectively. GTVMRI+1 was defined as a 1.0-cm margin around the GTVMRI. The radiation oncologist delineated GTV of the TB (GTVTB) using planning computed tomography according to ≥5 surgical clips placed in the lumpectomy cavity (LC). RESULTS The median GTVMRI, GTVMRI+1, GTVPAT, GTVES, and GTVTB were 0.97 cm (range, 0.01-6.88), 12.58 cm (range, 3.90-34.13), 0.97 cm (range, 0.01-6.36), 15.46 cm (range, 1.15-70.69), and 19.24 cm (range, 4.72-54.33), respectively. There were no significant differences between GTVMRI and GTVPAT, GTVMRI+1 and GTVES, GTVES and GTVTB (P = 0.188, 0.070, and 0.264, respectively). GTVMRI is positively related with GTVPAT. However, neither GTVES nor GTVTB correlated with GTVMRI (P = 0.071 and 0.378, respectively). Furthermore, neither GTVES nor GTVTB correlated with GTVMRI+1 (P = 0.068 and 0.375, respectively). CONCLUSION When ≥5 surgical clips were placed in the LC for BCS, the volume of TB was consistent with the volume of ES. Neither the volume of TB nor the volume of ES correlated significantly with the volume of tumor defined by preoperative MRI.
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Affiliation(s)
- Aiping Zhang
- Medicine and Life Sciences College of Shandong Academy of Medical Sciences, Jinan University
- Department of Radiation Oncology
| | | | - Wei Wang
- Department of Radiation Oncology
| | | | | | - Zhaoqiu Chen
- Department of Radiology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
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Lee G, Dinniwell R, Liu FF, Fyles A, Han K, Conrad T, Levin W, Marshall A, Purdie TG, Koch CA. Building a New Model of Care for Rapid Breast Radiotherapy Treatment Planning: Evaluation of the Advanced Practice Radiation Therapist in Cavity Delineation. Clin Oncol (R Coll Radiol) 2016; 28:e184-e191. [PMID: 27542573 DOI: 10.1016/j.clon.2016.07.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/22/2016] [Accepted: 06/24/2016] [Indexed: 11/15/2022]
Abstract
AIMS Breast radiotherapy treatment is commonly managed by a multidisciplinary team to ensure optimal delivery of care. We sought a new model of care whereby a clinical specialist radiation therapist (CSRT) delineates the cavity target for whole breast radiotherapy treatment planning and the radiation oncologist validates the contour during final plan review. This study evaluated the radiation oncologist's acceptance of these contours and identified characteristics of cavities suitable for CSRT-directed contouring. MATERIALS AND METHODS Following specialised breast oncology education and training by the radiation oncologist, the CSRT prospectively delineated cavities in 30 tangential breast radiotherapy cases and consulted the radiation oncologist in 'complex' cases but directed 'non-complex' cases for treatment planning. Changes to CSRT contours were evaluated using the conformity index. Breast density, time since surgery and cavity location, size and visualisation score [CVS: range 1 (no visible cavity) to 5 (homogenous cavity)] were captured. RESULTS Of the 30 CSRT delineated cavities contours, the CSRT directed 20 (66.7%) cases for planning without radiation oncology review; 19 were accepted (without changes) by the radiation oncologist upon final plan review and one was changed by the radiation oncologist (conformity index = 0.93) for boost treatment and did not affect the tangential treatment plan. Ten (33.3%) cases, all CVS ≤ 3, were reviewed with the radiation oncologist before planning (conformity index = 0.88 ± 0.12). CVS was inversely correlated with breast density and cavity size (P < 0.01). CONCLUSIONS The CSRT delineated cavities appropriate for clinical radiotherapy treatment planning in women with well-visualised cavities, whereas 'complex' cases with dense breast parenchyma, CVS ≤ 3, and/or cases needing boost radiotherapy treatment required review with the radiation oncologist before planning.
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Affiliation(s)
- G Lee
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada
| | - R Dinniwell
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - F F Liu
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - A Fyles
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - K Han
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - T Conrad
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - W Levin
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - A Marshall
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada
| | - T G Purdie
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - C A Koch
- Radiation Medicine Program, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
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23
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Chandran S, Vaughan R, Jacob A, Hamilton C, Joon DL, Lim K, Tog C, Bhatia K, Aly A, Sweeney T, Efthymiou M. A novel endoscopic marker for radiological localization and image-guided radiotherapy in esophageal and gastric cancers (with video). Gastrointest Endosc 2016; 83:309-17. [PMID: 26239307 DOI: 10.1016/j.gie.2015.06.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/20/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Radiotherapy is an accepted modality in the treatment of esophageal cancers and is currently being evaluated in conjunction with chemotherapy for the neoadjuvant treatment of gastric cancers. Our aim was to assess whether a novel endoscopically inserted marker can be used to improve radiological assessment of the primary cancer and allow for image-guided radiotherapy. METHODS A phase II feasibility study was conducted at a tertiary-care center. Twenty-six consecutive adult patients with esophagogastric cancers underwent endoscopic marking of the tumor margins with a novel radiopaque marker (mixture of lipiodol and n-butyl 2-cyanoacrylate). The main outcome measure was the successful insertion of the marker based on a combination of radiological, endoscopic, and histological assessment. RESULTS A total of 92 markers were inserted in 26 patients. Twenty-two (88%) had follow-up imaging to assess the 81 markers inserted, 79 of which (97.5%) were visible. There were no postprocedural adverse events noted in our cohort. Radiological assessment of tumor size improved such that it was in line with the endoscopic evaluation after marker placement in 18 of 21 patients (85.7%) who had appropriate follow-up radiology imaging. Ten patients (38.5%) from our cohort underwent image-guided radiotherapy (IGRT) by using the endoscopically inserted markers. CONCLUSION Within the limitations of our small pilot study, endoscopic placement of our novel marker was successful in the majority of our cohort without significant adverse events. Marker placement resulted in improved radiological localization in the majority of our cohort and allowed for IGRT. (Australian New Zealand Clinical Trials Registry: ACTRN12613000239763.).
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Affiliation(s)
- Sujievvan Chandran
- Department of Gastroenterology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia; Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Rhys Vaughan
- Department of Gastroenterology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia; Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Antony Jacob
- Department of Gastroenterology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Chris Hamilton
- Department of Radiation Oncology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Daryl Lim Joon
- Department of Radiation Oncology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Kiat Lim
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Chek Tog
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Kiron Bhatia
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Ahmad Aly
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas Sweeney
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Marios Efthymiou
- Department of Gastroenterology, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
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24
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Bittermann G, Ermer M, Voss P, Duttenhoefer F, Zimmerer R, Schmelzeisen R, Metzger MC. Comparison of virtual and titanium clip marking of tumour resection margins for improved radiation planning in head and neck cancer surgery. Int J Oral Maxillofac Surg 2015; 44:1468-73. [PMID: 26265065 DOI: 10.1016/j.ijom.2015.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 06/09/2015] [Accepted: 07/16/2015] [Indexed: 11/30/2022]
Affiliation(s)
- G Bittermann
- Department of Oral and Maxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany.
| | - M Ermer
- Department of Oral and Maxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - P Voss
- Department of Oral and Maxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - F Duttenhoefer
- Department of Oral and Maxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - R Zimmerer
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany
| | - R Schmelzeisen
- Department of Oral and Maxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany
| | - M C Metzger
- Department of Oral and Maxillofacial Surgery, University Medical Centre Freiburg, Freiburg, Germany
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Interobserver variations of target volume delineation in multicatheter partial breast brachytherapy after open cavity surgery. Brachytherapy 2015. [DOI: 10.1016/j.brachy.2015.06.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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DEN Hartogh MD, Philippens MEP, VAN Dam IE, Kleynen CE, Tersteeg RJHA, Kotte ANTJ, VAN Vulpen M, VAN Asselen B, VAN DEN Bongard DHJG. Post-lumpectomy CT-guided tumor bed delineation for breast boost and partial breast irradiation: Can additional pre- and postoperative imaging reduce interobserver variability? Oncol Lett 2015; 10:2795-2801. [PMID: 26722244 PMCID: PMC4665376 DOI: 10.3892/ol.2015.3697] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 04/20/2015] [Indexed: 12/20/2022] Open
Abstract
For breast boost radiotherapy or accelerated partial breast irradiation, the tumor bed (TB) is delineated by the radiation oncologist on a planning computed tomography (CT) scan. The aim of the present study was to investigate whether the interobserver variability (IOV) of the TB delineation is reduced by providing the radiation oncologist with additional magnetic resonance imaging (MRI) or CT scans. A total of 14 T1-T2 breast cancer patients underwent a standard planning CT in the supine treatment position following lumpectomy, as well as additional pre- and postoperative imaging in the same position. Post-lumpectomy TBs were independently delineated by four breast radiation oncologists on standard postoperative CT and on CT registered to an additional imaging modality. The additional imaging modalities used were postoperative MRI, preoperative contrast-enhanced (CE)-CT and preoperative CE-MRI. A cavity visualization score (CVS) was assigned to each standard postoperative CT by each observer. In addition, the conformity index (CI), volume and distance between centers of mass (dCOM) of the TB delineations were calculated. On CT, the median CI was 0.57, with a median volume of 22 cm3 and dCOM of 5.1 mm. The addition of postoperative MRI increased the median TB volume significantly to 28 cm3 (P<0.001), while the CI (P=0.176) and dCOM (P=0.110) were not affected. The addition of preoperative CT or MRI increased the TB volume to 26 and 25 cm3, respectively (both P<0.001), while the CI increased to 0.58 and 0.59 (both P<0.001) and the dCOM decreased to 4.7 mm (P=0.004) and 4.6 mm (P=0.001), respectively. In patients with CVS≤3, the median CI was 0.40 on CT, which was significantly increased by all additional imaging modalities, up to 0.52, and was accompanied by a median volume increase up to 6 cm3. In conclusion, the addition of postoperative MRI, preoperative CE-CT or preoperative CE-MRI did not result in a considerable reduction in the IOV in postoperative CT-guided TB delineation, while target volumes marginally increased. The value of additional imaging may be dependent on CVS.
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Affiliation(s)
- Mariska D DEN Hartogh
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marielle E P Philippens
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Iris E VAN Dam
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Catharina E Kleynen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Robbert J H A Tersteeg
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexis N T J Kotte
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco VAN Vulpen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bram VAN Asselen
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
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Bittermann G, Voss P, Duttenhoefer F, Zimmerer R, Vach K, Metzger MC. The validity of surgical clips as radiographic markers for the tumour resection cavity in head and neck cancer treatment. J Craniomaxillofac Surg 2015; 43:758-62. [DOI: 10.1016/j.jcms.2015.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 03/24/2015] [Accepted: 04/02/2015] [Indexed: 11/16/2022] Open
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Bittermann G, Wiedenmann N, Bunea A, Schwarz SJ, Grosu AL, Schmelzeisen R, Metzger MC. Clipping of tumour resection margins allows accurate target volume delineation in head and neck cancer adjuvant radiation therapy. Radiother Oncol 2015; 116:82-6. [DOI: 10.1016/j.radonc.2015.04.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 04/30/2015] [Accepted: 04/30/2015] [Indexed: 10/23/2022]
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Marking of tumor resection borders for improved radiation planning facilitates reduction of radiation dose to free flap reconstruction in head and neck cancer surgery. J Craniomaxillofac Surg 2015; 43:567-73. [DOI: 10.1016/j.jcms.2015.02.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/25/2015] [Accepted: 02/27/2015] [Indexed: 01/22/2023] Open
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Guo B, Li J, Wang W, Xu M, Shao Q, Zhang Y, Liang C, Guo Y. Interobserver variability in the delineation of the tumour bed using seroma and surgical clips based on 4DCT scan for external-beam partial breast irradiation. Radiat Oncol 2015; 10:66. [PMID: 25889620 PMCID: PMC4363049 DOI: 10.1186/s13014-015-0370-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 02/25/2015] [Indexed: 11/30/2022] Open
Abstract
Background To explore the interobserver variability in the delineation of the tumour bed using seroma and surgical clips based on the four-dimensional computed tomography (4DCT) scan for external-beam partial breast irradiation (EB-PBI) during free breathing. Methods Patients with a seroma clarity score (SCS) 3 ~ 5 and ≥5 surgical clips in the lumpectomy cavity after breast-conserving surgery who were recruited for EB-PBI underwent 4DCT simulation. Based on the ten sets of 4DCT images acquired, the tumour bed formed using the clips, the seroma, and both the clips and seroma (defined as TBC, TBS and TBC+S, respectively) were delineated by five radiation oncologists using specific guidelines. The following parameters were calculated to analyse interobserver variability: volume of the tumour bed (TBC, TBS, TBC+S), coefficient of variation (COVC, COVS, COVC+S), and matching degree (MDC, MDS, MDC+S). Results The interobserver variability for TBC and TBC+S and for COVC and COVC+S were statistically significant (p = 0.021, 0.008, 0.002, 0.015). No significant difference was observed for TBS and COVS (p = 0.867, 0.061). Significant differences in interobserver variability were observed for MDC vs MDS, MDC vs MDC+S, MDS vs MDC+S (p = 0.000, 0.032, 0.008), the interobserver variability of MDS was smaller than that of MDC and MDC+S (MDS > MDC+S > MDC). Conclusions When the SCS was 3 ~ 5 points and the number of surgical clips was ≥5, interobserver variability was minimal for the delineation of the tumour bed based on seroma.
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Affiliation(s)
- Bing Guo
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China. .,Medicine and Life Sciences College of Shandong Academy of Medical Sciences, Jinan University, Jinan, Shandong Province, People's Republic of China.
| | - Jianbin Li
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China.
| | - Wei Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China.
| | - Min Xu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China.
| | - Qian Shao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China.
| | - Yingjie Zhang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China.
| | - Chaoqian Liang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China.
| | - Yanluan Guo
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jiyan Road, Jinan, Shandong Province, 250117, China. .,Medicine and Life Sciences College of Shandong Academy of Medical Sciences, Jinan University, Jinan, Shandong Province, People's Republic of China.
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Hanna GG, Kirby AM. Intraoperative radiotherapy in early stage breast cancer: potential indications and evidence to date. Br J Radiol 2015; 88:20140686. [PMID: 25734489 DOI: 10.1259/bjr.20140686] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Following early results of recent studies of intraoperative radiotherapy (IORT) in the adjuvant treatment of patients with early breast cancer, the clinical utility of IORT is a subject of much recent debate within the breast oncology community. This review describes the intraoperative techniques available, the potential indications and the evidence to date pertaining to local control and toxicity. We also discuss any implications for current practice and future research.
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Affiliation(s)
- G G Hanna
- 1 Department of Clinical Oncology, Centre for Cancer Research and Cell Biology, Queen's University of Belfast, Belfast, UK
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Ippolito E, Trodella L, Silipigni S, D'Angelillo R, Di Donato A, Fiore M, Grasso A, Angelini E, Ramella S, Altomare V. Estimating the Value of Surgical Clips for Target Volume Delineation in External Beam Partial Breast Radiotherapy. Clin Oncol (R Coll Radiol) 2014; 26:677-83. [DOI: 10.1016/j.clon.2014.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 07/15/2014] [Accepted: 07/21/2014] [Indexed: 11/25/2022]
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Chandran S, Vaughan R, Efthymiou M, Sia J, Hamilton C. A pilot study of EUS-guided fiducial insertion for the multidisciplinary management of gastric cancer. Endosc Int Open 2014; 2:E153-9. [PMID: 26134962 PMCID: PMC4440364 DOI: 10.1055/s-0034-1377523] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/03/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The 5-year survival rates for gastric cancer remain poor despite evolving therapies, and fiducial insertion via endoscopic ultrasound (EUS) is novel within this setting. We aimed to assess the feasibility of fiducial insertion for response assessment and anatomic localization in patients with gastric cancer. PATIENTS AND METHODS A prospective phase II feasibility study was undertaken at Austin Health (Victoria, Australia) from February 2011 to November 2012. Consecutive adult patients were enrolled who had primary adenocarcinoma of the stomach with American Joint Committee on Cancer stage T1 - 3,N0 - 1,M0 - 1a and Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1. In addition, the patients were medically suitable for gastrectomy and chemotherapy/chemoradiotherapy. Gold fiducial markers were inserted under EUS guidance into the margins of the gastric cancer primary. The main outcome was successful insertion of the fiducial without complications for response assessment and anatomic localization. RESULTS A total of 15 fiducials were successfully inserted into 7 (88 %) of 8 patients. No immediate or delayed complications were noted. One patient proceeded to image-guided radiotherapy through the use of fiducials and is disease free at 12 months. Fiducials were used to assess treatment response in all patients who underwent computed tomographic imaging after insertion. Follow-up computed tomography with fiducial placement improved anatomic localization and estimation of the gastric cancer primary size in 3 (60 %) of 5 patients. CONCLUSIONS Within the limitations of our small study cohort, fiducials were placed in gastric cancers under EUS guidance without complications, and placement was successful in the majority of our patients. Although potential benefits exist, there remain substantial limitations to the generalization of this technique across our patient population.
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Affiliation(s)
| | - Rhys Vaughan
- Austin Health—Gastroenterology, Melbourne, Victoria,
Australia
| | | | - Joseph Sia
- Austin Health—Radiation Oncology, Melbourne, Victoria,
Australia
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den Hartogh MD, van den Bongard HJGD, Davidson MTM, Kotte ANTJ, Verkooijen HM, Philippens MEP, van Vulpen M, van Asselen B, Pignol JP. Full-thickness closure in breast-conserving surgery: the impact on radiotherapy target definition for boost and partial breast irradiation. A multimodality image evaluation. Ann Surg Oncol 2014; 21:3774-9. [PMID: 24874499 DOI: 10.1245/s10434-014-3801-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND During breast-conserving surgery (BCS), surgeons increasingly perform full-thickness closure (FTC) to prevent seroma formation. This could potentially impair precision of target definition for boost and accelerated partial breast irradiation (APBI). The purpose of this study was to investigate the precision of target volume definition following BCS with FTC among radiation oncologists, using various imaging modalities. METHODS Twenty clinical T1-2N0 patients, scheduled for BCS involving clip placement and FTC, were included in the study. Seven experienced breast radiation oncologists contoured the tumor bed on computed tomography (CT), magnetic resonance imaging (MRI) and fused CT-MRI datasets. A total of 361 observer pairs per image modality were analyzed. A pairwise conformity among the generated contours of the observers and the distance between their centers of mass (dCOM) were calculated. RESULTS On CT, median conformity was 44 % [interquartile range (IQR) 28-58 %] and median dCOM was 6 mm (IQR 3-9 mm). None of the outcome measures improved when MRI or fused CT-MRI were used. In two patients, superficial closure was performed instead of FTC. In these 14 image sets and 42 observer pairs, median conformity increased to 70 %. CONCLUSIONS Localization of the radiotherapy target after FTC is imprecise, on both CT and MRI. This could potentially lead to a geographical miss in patients at increased risk of local recurrence receiving a radiation boost, or for those receiving APBI. These findings highlight the importance for breast surgeons to clearly demarcate the tumor bed when performing FTC.
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Affiliation(s)
- Mariska D den Hartogh
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands,
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Ding Y, Li J, Wang W, Wang S, Wang J, Ma Z, Shao Q, Xu M. A comparative study on the volume and localization of the internal gross target volume defined using the seroma and surgical clips based on 4DCT scan for external-beam partial breast irradiation after breast conserving surgery. Radiat Oncol 2014; 9:76. [PMID: 24646022 PMCID: PMC3994573 DOI: 10.1186/1748-717x-9-76] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 03/09/2014] [Indexed: 11/19/2022] Open
Abstract
Background To explore the volume and localization of the internal gross target volume defined using the seroma and/or surgical clips based on the four-dimensional computed tomography (4DCT) during free-breathing. Methods Fifteen breast cancer patients after breast-conserving surgery (BCS) were recruited for EB-PBI. On the ten sets CT images, the gross target volume formed by the clips, the seroma, both the clips and seroma delineated by one radiation oncologist and defined as GTVc, GTVs and GTVc + s, respectively. The ten GTVc, GTVs and GTVc + s on the ten sets CT images produced the IGTVc, IGTVs, IGTVc + s, respectively. The IGTV volume and the distance between the center of IGTVc, IGTVs, IGTVc + s were all recorded. Conformity index (CI), degree of inclusion (DI) were calculated for IGTV/IGTV, respectively. Results The volume of IGTVc + s were significantly larger than the IGTVc and IGTVs (p < 0.05). There was significant difference between the DIs of IGTVc vs IGTVc + s, the DIs of IGTVs vs IGTVc + s. There was significant difference among the CIs of IGTV/IGTV. The DIs and CIs of IGTV/IGTV were negatively correlated with their centroid distance (r < 0, p < 0.05). Conclusions There were volume difference and spatial mismatch between the IGTVs delineated based on the surgical clips and seroma. The IGTV defined as the seroma and surgical clips provided the best overall representation of the ‘true’ moving GTV.
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Affiliation(s)
| | - Jianbin Li
- Department of Radiation Oncology (Chest section), Shandong Tumor Hospital, Jinan, Shandong Province, 250117, People's Republic of China.
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Kirwan CC, Al Sarakbi W, Loncaster J, Chan HY, Thompson AM, Wishart GC. Tumour bed clip localisation for targeted breast radiotherapy: compliance is proportional to trial-related research activity: tumour bed clip localisation in breast radiotherapy. Eur J Surg Oncol 2013; 40:158-62. [PMID: 24373297 DOI: 10.1016/j.ejso.2013.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 10/24/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND In breast cancer, with the increasing use of intensity-modulated radiotherapy (IMRT), the need for accurate tumour bed localisation is paramount. We determined current practice of clip usage in patients referred to a regional centre for radiotherapy following breast conserving surgery. We also investigated whether participation of surgical units in IMRT trials, where tumour bed clip use is emphasised, was associated with clip insertion. METHODS A retrospective cohort study of consecutive CT planning images (n = 205), of breast cancer patients treated with radiotherapy following breast conserving surgery. Presence and number of clips; referring hospital and referring surgeon of the patient was recorded. This was correlated to previous participation of referring hospital to IMRT trials. RESULTS Of 196 eligible patients, 126 (64%) had clips sited, of which 15 (12%) had two or fewer clips. Five referring hospitals were high recruiters (≥14 patients), and five hospitals were low/non-recruiters (≤1 patient) to IMRT trials. Of patients from low/non-recruiting centres, 29 of 43 (67%) had clips omitted, compared to 41 of 153 (27%) from high-recruiting centres (p < 0.001). Median number of clips used in centres recruiting high numbers of patients was four, compared to zero in low recruiting centres. Ten of 31 referring surgeons routinely omitted clips. CONCLUSION Despite inclusion in national guidelines, clip insertion has not become routine in the UK in patients undergoing breast conserving surgery. However, hospitals involved in breast radiotherapy randomised controlled trials are more compliant with clip usage recommendations. Auditing of clip insertion should be considered as a quality control marker in breast surgery.
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Affiliation(s)
- C C Kirwan
- University of Manchester Department of Academic Surgery, South Manchester University Hospitals Trust, Southmoor Road, Manchester M23 9LT, UK.
| | - W Al Sarakbi
- Department of Surgery, Conquest Hospital, The Ridge, Hastings, East Sussex TN37 9RD, UK.
| | - J Loncaster
- Department of Clinical Oncology, Christie Hospital, Manchester M20 4BX, UK.
| | - H Y Chan
- Department of Surgery, Cheltenham General Hospital, Sandford Road, Cheltenham, Gloucestershire GL53 7AN, UK.
| | - A M Thompson
- Clinical Research Centre, Dundee Cancer Centre, University of Dundee, Dundee DD1 9SY, UK.
| | - G C Wishart
- Faculty of Health, Social Care & Education, Anglia Ruskin University, East Road, Cambridge BB1 1PT, UK.
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Ding Y, Li J, Wang W, Wang S, Fan T, Xu M, Shao Q, Ma Z. Displacement of the lumpectomy cavity defined by surgical clips and seroma based on 4D-CT scan for external-beam partial breast irradiation after breast-conserving surgery: a comparative study. Br J Radiol 2013; 86:20130416. [PMID: 23995875 DOI: 10.1259/bjr.20130416] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the displacements of the lumpectomy cavity delineated by the surgical clips and the seroma based on four-dimensional CT (4D-CT) for external-beam partial breast irradiation (EB-PBI) after breast-conserving surgery (BCS). METHODS 14 breast cancer patients after BCS were recruited for EB-PBI and undertook 4D-CT simulation. On the 10 sets of the 4D-CT images, all the surgical clips in the cavity were delineated. The gross tumour volume (GTV) formed by the clips, the seroma, and both the clips and the seroma were defined as GTVc, GTVs and GTVc+s, respectively. The displacements of the centre of mass (COM) of the clips, GTVc, GTVs, GTVc+s and the selected clips in the three-dimensional (3D) directions were recorded and compared. RESULTS In the left-right, anterior-posterior and superior-inferior directions, the displacements were 2.20, 1.80 and 2.70 mm for the clip COM; 0.90, 1.05 and 1.20 mm for GTVc; 0.80, 1.05 and 0.80 mm for GTVs; and 0.90, 1.20 and 1.40 mm for GTVc+s, respectively. In the 3D directions, the displacements of the clip COM were greater than the GTVc, GTVs, GTVc+s, and the displacements of the clip COM, GTVc+s, GTVc and GTVs were significantly greater than the displacements of the selected clips (p<0.05). CONCLUSION The displacements of the clip COM were greater than that of the GTVc, GTVs, GTVc+s and the four selected clips. The optimal internal target volume should be defined based on the boundary displacements. ADVANCES IN KNOWLEDGE When the GTV was delineated using the clips and/or the seroma, there was displacement difference between the lumpectomy cavity centre and the boundary for the EB-PBI. The optimal internal target volume should be defined based on the boundary displacements of the lumpectomy cavity.
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Affiliation(s)
- Y Ding
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Jinan, China
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