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Choi S, Dreyfuss I, Taswell CS, Cyriac J, Butkus M, Takita C. Proton Beam Therapy for Breast Cancer. Crit Rev Oncog 2024; 29:67-82. [PMID: 38683154 DOI: 10.1615/critrevoncog.2023050319] [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: 05/01/2024]
Abstract
Given the radiobiological and physical properties of the proton, proton beam therapy has the potential to be advantageous for many patients compared with conventional radiotherapy by limiting toxicity and improving patient outcomes in specific breast cancer scenarios.
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Affiliation(s)
- Seraphina Choi
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Isabella Dreyfuss
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Jonathan Cyriac
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Michael Butkus
- Department of Radiation Oncology, University of Miami Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Mutter RW, Giri S, Fruth BF, Remmes NB, Boughey JC, Harless CA, Ruddy KJ, McGee LA, Afzal A, Gao RW, Shumway DA, Vern-Gross TZ, Villarraga HR, Kenison SL, Kang Y, Wong WW, Stish BJ, Merrell KW, Yan ES, Park SS, Corbin KS, Vargas CE. Conventional versus hypofractionated postmastectomy proton radiotherapy in the USA (MC1631): a randomised phase 2 trial. Lancet Oncol 2023; 24:1083-1093. [PMID: 37696281 PMCID: PMC10591844 DOI: 10.1016/s1470-2045(23)00388-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Proton therapy is under investigation in breast cancer as a strategy to reduce radiation exposure to the heart and lungs. So far, studies investigating proton postmastectomy radiotherapy (PMRT) have used conventional fractionation over 25-28 days, but whether hypofractionated proton PMRT is feasible is unclear. We aimed to compare conventional fractionation and hypofractionation in patients with indications for PMRT, including those with immediate breast reconstruction. METHODS We did a randomised phase 2 trial (MC1631) at Mayo Clinic in Rochester (MN, USA) and Mayo Clinic in Arizona (Phoenix, AZ, USA) comparing conventional fractionated (50 Gy in 25 fractions of 2 Gy [relative biological effectiveness of 1·1]) and hypofractionated (40·05 Gy in 15 fractions of 2·67 Gy [relative biological effectiveness of 1·1]) proton PMRT. All patients were treated with pencil-beam scanning. Eligibility criteria included age 18 years or older, an Eastern Cooperative Oncology Group performance status of 0-2, and breast cancer resected by mastectomy with or without immediate reconstruction with indications for PMRT. Patients were randomly assigned (1:1) to either conventional fractionation or hypofractionation, with presence of immediate reconstruction (yes vs no) as a stratification factor, using a biased-coin minimisation algorithm. Any patient who received at least one fraction of protocol treatment was evaluable for the primary endpoint and safety analyses. The primary endpoint was 24-month complication rate from the date of first radiotherapy, defined as grade 3 or worse adverse events occurring from 90 days after last radiotherapy or unplanned surgical interventions in patients with immediate reconstruction. The inferiority of hypofractionation would not be ruled out if the upper bound of the one-sided 95% CI for the difference in 24-month complication rate between the two groups was greater than 10%. This trial is registered with ClinicalTrials.gov, NCT02783690, and is closed to accrual. FINDINGS Between June 2, 2016, and Aug 23, 2018, 88 patients were randomly assigned (44 to each group), of whom 82 received protocol treatment (41 in the conventional fractionation group and 41 in the hypofractionation group; median age of 52 years [IQR 44-64], 79 [96%] patients were White, two [2%] were Black or African American, one [1%] was Asian, and 79 [96%] were not of Hispanic ethnicity). As of data cutoff (Jan 30, 2023), the median follow-up was 39·3 months (IQR 37·5-61·2). The median mean heart dose was 0·54 Gy (IQR 0·30-0·72) for the conventional fractionation group and 0·49 Gy (0·25-0·64) for the hypofractionation group. Within 24 months of first radiotherapy, 14 protocol-defined complications occurred in six (15%) patients in the conventional fractionation group and in eight (20%) patients in the hypofractionation group (absolute difference 4·9% [one-sided 95% CI 18·5], p=0·27). The complications in the conventionally fractionated group were contracture (five [12%] of 41 patients]) and fat necrosis (one [2%] patient) requiring surgical intervention. All eight protocol-defined complications in the hypofractionation group were due to infections, three of which were acute infections that required surgical intervention, and five were late infections, four of which required surgical intervention. All 14 complications were in patients with immediate expander or implant-based reconstruction. INTERPRETATION After a median follow-up of 39·3 months, non-inferiority of the hypofractionation group could not be established. However, given similar tolerability, hypofractionated proton PMRT appears to be worthy of further study in patients with and without immediate reconstruction. FUNDING The Department of Radiation Oncology, Mayo Clinic, Rochester, MN, the Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA, and the US National Cancer Institute.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA.
| | - Sharmila Giri
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Briant F Fruth
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Kathryn J Ruddy
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Arslan Afzal
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Robert W Gao
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Bradley J Stish
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth S Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | | | - Carlos E Vargas
- Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, USA
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Kang Y, Bues M, Halyard MY, McGee LA, Vern-Gross TZ, Wong WW, Keole SR, Vargas C, James SE, Ahmed SK, Archuleta JP, Ridgway AK, Lara PR, Fatyga M. Dose delivery reproducibility for PBS proton treatment of breast cancer patients with and without mask immobilization. Radiat Oncol 2023; 18:157. [PMID: 37736727 PMCID: PMC10515054 DOI: 10.1186/s13014-023-02323-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/10/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Setup reproducibility of the tissue in the proton beam path is critical in maintaining the planned clinical target volume (CTV) dose coverage and sparing the organs at risk (OAR). In this study, we retrospectively evaluated radiation therapy dose reproducibility for proton pencil beam scanning (PBS) treatment of breast cancer patients with and without mask immobilization. METHODS Ninety-four patients treated between January 2019 and September 2022 with at least one verification CT scan (V-CT) in treatment position were included for this study. All patients were set up with arms up using the Orfit AIO patient positioning system, with (69 patients) or without (25 patients) mask immobilization in chin, neck, shoulder, upper arm, and chest areas. Two to three enface or near enface single field uniform dose PBS beams were optimized using a commercial treatment planning system. Prescription doses were 25 to 60 GyRBE in 5 to 45 fractions. Treatment plan doses re-calculated on V-CTs were compared to the corresponding planned doses. Cumulative doses were also calculated for patients with at least 3 V-CTs by deform and weighted sum doses from V-CTs to corresponding P-CTs. CTV D95%, ipsilateral-lung V40%, esophagus D0.01cc, and heart mean dose were evaluated and reported as percentages of prescription doses. Differences were large dose deteriorations (LDD) if: (1) CTV (V-CT/cumulative D95%) - (Planned D95%) < - 5%; or (2) Ipsilateral-lung (V-CT/cumulative V40%) - (Planned V40%) > 5%; or (3) Esophagus (V-CT/cumulative D0.01cc) - (Planned D0.01cc) > 10%; or (4) Heart (V-CT/cumulative mean) - (Planned mean) > 1.5%. RESULTS On average, V-CT/cumulative and planned CTV/OAR dose parameter differences were less than 2.2%/1.7% and 3.4%/3.7% for masked and maskless patients, respectively. The percentages of patients with at least one CTV or OAR V-CT/cumulative dose LDD were 20.3%/25.0% and 72.0%/54.0% for masked and maskless patients, respectively. CONCLUSIONS On average, masked/maskless setups achieved delivered and planned CTV/OAR dose parameters agreed within 2.2%/3.7% for PBS treatment of breast cancer patients in this study. Maskless patients had higher rate of CTV/OAR LDDs compared to masked patients. Dosimetric differences large enough to raise clinical concerns in either group were able to be addressed with replannings.
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Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Michele Y Halyard
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Tamara Z Vern-Gross
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - William W Wong
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sameer R Keole
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Carlos Vargas
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Sarah E James
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - James P Archuleta
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Ana K Ridgway
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Pedro R Lara
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Mirek Fatyga
- Department of Radiation Oncology, Mayo Clinic, 5881 East Mayo Blvd, Phoenix, AZ, 85054, USA
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Ahmed SK, Keole SR. Proton Therapy in the Adolescent and Young Adult Population. Cancers (Basel) 2023; 15:4269. [PMID: 37686545 PMCID: PMC10487250 DOI: 10.3390/cancers15174269] [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: 07/06/2023] [Revised: 08/14/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Adolescent and young adult cancer patients are at high risk of developing radiation-associated side effects after treatment. Proton beam radiation therapy might reduce the risk of these side effects for this population without compromising treatment efficacy. METHODS We review the current literature describing the utility of proton beam radiation therapy in the treatment of central nervous system tumors, sarcomas, breast cancer and Hodgkin lymphoma for the adolescent and young adult cancer population. RESULTS Proton beam radiation therapy has utility for the treatment of certain cancers in the young adult population. Preliminary data suggest reduced radiation dose to normal tissues, which might reduce radiation-associated toxicities. Research is ongoing to further establish the role of proton therapy in this population. CONCLUSION This report highlights the potential utility of proton beam radiation for certain adolescent young adult cancers, especially with reducing radiation doses to organs at risk and thereby potentially lowering risks of certain treatment-associated toxicities.
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Affiliation(s)
- Safia K. Ahmed
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, AZ 85054, USA;
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Kirby AM, Holt F, Taylor CW, Haviland JS, MacKenzie M, Coles CE. Should patients requiring radiotherapy for breast cancer be treated with proton beam therapy? BMJ 2023; 381:e072896. [PMID: 37295798 DOI: 10.1136/bmj-2022-072896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Anna M Kirby
- Royal Marsden NHS Foundation Trust & Institute of Cancer Research, Sutton, UK
| | - Francesca Holt
- Nuffield Department of Population Health, University of Oxford, UK
| | - Carolyn W Taylor
- Nuffield Department of Population Health, University of Oxford, UK
| | - Joanne S Haviland
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, UK
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Cui X, Jee K, Hu M, Bao J, Lu HM. Improvement of proton beam range uncertainty in breast treatment using tissue samples. Phys Med Biol 2022; 67. [PMID: 36379067 DOI: 10.1088/1361-6560/aca315] [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: 06/08/2022] [Accepted: 11/15/2022] [Indexed: 11/16/2022]
Abstract
Objective.Proton therapy after breast-conserving surgery (BCS) can substantially reduce the dose to lung and cardiac structures. However, these dosimetric benefits are subject to beam range uncertainty in patient. The conversion of the CT-Hounsfield unit (HU) into relative stopping power (RSP) is the primary contribution to range uncertainty. Hence, an accurate HU-RSP conversion is essential.Approach.Real tissue samples, including muscle and adipose, were prepared. The water equivalent path length (WEPL) of these samples was measured under homogeneous conditions using a 12-diode detector array of our time-resolvedin vivorange verification system (IRVS). The HU-RSP conversion was improved using the measured WEPL and HU for adipose tissue. The measured WEPL values were compared with the treatment planning calculation results based on the stoichiometric CT-HU calibration technique. The effect was investigated for both with and without adipose tissue in HU-RSP conversion.Main results.The IRVS was calibrated based on the solid water phantom. The relative differences in WEPL (RSP) between measurements and calculations for muscle, adipose, and water was -1.19% (-0.75%), -4.25%(-4%), and -0.23%(-0.07%), respectively. Based on the improved HU-RSP conversion, the relative differences in WEPL was reduced to -0.97%(-0.62%), -1.50%(-1.46%), and -0.22% (0.00%), respectively.Significance.The WEPL deviation of adipose tissue is larger than the testing limit of 3.5% for beam range robustness in current clinical practice. However, the improved HU-RSP conversion reduced this deviation. The main component of breast tissue is adipose. Hence, the proton treatment of BCS can be undershooting if no proper measures are taken against this specific uncertainty.
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Affiliation(s)
- Xiangli Cui
- Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, Anhui, 230031, People's Republic of China.,Hefei Cancer Hospital, Chinese Academy of Sciences, Hefei, Anhui, 230031, People's Republic of China
| | - Kyungwook Jee
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, United States of America
| | - Man Hu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, People's Republic of China
| | - Jie Bao
- Institute of Health and Medical Technology, Hefei Institutes of Physical Science, Chinese Academy of Sciences, Hefei, Anhui, 230031, People's Republic of China
| | - Hsiao-Ming Lu
- Hefei Ion Medical Center, Hefei, Anhui, 230088, People's Republic of China
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Laughlin BS, Bhangoo RS, Niska JR, Thorpe CS, Girardo ME, Anderson JD, Kosiorek HE, McGee LA, Hartsell WF, Chang JH, Rossi CJ, Tsai HK, Choi IJ, Vargas CE. Proton therapy for isolated local regional recurrence of breast cancer after mastectomy alone. Front Oncol 2022; 12:925078. [DOI: 10.3389/fonc.2022.925078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose/ObjectivesTo assess adverse events (AEs) and disease-specific outcomes after proton therapy for isolated local-regional recurrence (LRR) of breast cancer after mastectomy without prior radiotherapy (RT).Materials/MethodsPatients were identified from a multi-institutional prospective registry and included if diagnosed with invasive breast cancer, initially underwent mastectomy without adjuvant RT, experienced an LRR, and subsequently underwent salvage treatment, including proton therapy. Follow-up and cancer outcomes were measured from the date of RT completion.ResultsNineteen patients were included. Seventeen patients were treated with proton therapy to the chest wall and comprehensive regional lymphatics (17/19, 90%). Maximum grade AE was grade 2 in 13 (69%) patients and grade 3 in 4 (21%) patients. All patients with grade 3 AE received > 60 GyE (p=0.04, Spearman correlation coefficient=0.5). At the last follow-up, 90% of patients were alive with no LRR or distant recurrence.ConclusionsFor breast cancer patients with isolated LRR after initial mastectomy without adjuvant RT, proton therapy is well-tolerated in the salvage setting with excellent loco-regional control. All grade 3 AEs occurred in patients receiving > 60 GyE.
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Lin H, Dong L, Jimenez RB. Emerging Technologies in Mitigating the Risks of Cardiac Toxicity From Breast Radiotherapy. Semin Radiat Oncol 2022; 32:270-281. [DOI: 10.1016/j.semradonc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Yehia ZA, Punglia RS, Wong J. Integration of Radiation and Reconstruction After Mastectomy. Semin Radiat Oncol 2022; 32:237-244. [DOI: 10.1016/j.semradonc.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Garda AE, Hunzeker AE, Michel AK, Fattahi S, Shiraishi S, Remmes NB, Schultz HL, Harmsen WS, Shumway DA, Yan ES, Park SS, Mutter RW, Corbin KS. Intensity Modulated Proton Therapy for Bilateral Breast or Chest Wall and Comprehensive Nodal Irradiation for Synchronous Bilateral Breast Cancer: Initial Clinical Experience and Dosimetric Comparison. Adv Radiat Oncol 2022; 7:100901. [PMID: 35647397 PMCID: PMC9133394 DOI: 10.1016/j.adro.2022.100901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/09/2022] [Indexed: 12/14/2022] Open
Abstract
Purpose Synchronous bilateral breast cancer (SBBC) poses distinct challenges for radiation therapy planning. We report our proton therapy experience in treating patients with SBBC. We also provide a dosimetric comparison of intensity modulated proton therapy (IMPT) versus photon therapy. Methods and Materials Patients with SBBC who received IMPT at our institution were retrospectively analyzed. The clinical target volume (CTV) included the breast or chest wall and comprehensive regional lymph nodes, including axilla, supraclavicular fossa, and the internal mammary chain. Intensity modulated proton therapy and volumetric modulated arc therapy (VMAT) plans were generated with the goal that 90% of the CTV would recieve at least 90% of the prescription dose (D90>=90%). Comparisons between modalities were made using the Wilcoxon signed rank test. Physician-reported acute toxic effects and photography were collected at baseline, end of treatment, and each follow-up visit. Results Between 2015 and 2018, 11 patients with SBBC were treated with IMPT. The prescription was 50 Gy in 25 fractions. The median CTV D90 was 99.9% for IMPT and 97.6% for VMAT (P = .001). The mean heart dose was 0.7 Gy versus 7.2 Gy (P = .001), the total lung mean dose was 7.8 Gy versus 17.3 Gy (P = .001), and the total lung volume recieving 20 Gy was 13.0% versus 27.4% (P = .001). The most common acute toxic effects were dermatitis (mostly grade 1-2 with 1 case of grade 3) and grade 1 to 2 fatigue. The most common toxic effects at the last-follow up (median, 32 months) were grade 1 skin hyperpigmentation, superficial fibrosis, and extremity lymphedema. No nondermatologic or nonfatigue adverse events of grade >1 were recorded. Conclusions Bilateral breast and/or chest wall and comprehensive nodal IMPT is technically feasible and associated with low rates of severe acute toxic effects. Treatment with IMPT offered improved target coverage and normal-tissue sparing compared with photon therapy. Long-term follow-up is ongoing to assess efficacy and toxic effects.
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Affiliation(s)
- Allison E. Garda
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | - Ann K. Michel
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sayeh Fattahi
- Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Satomi Shiraishi
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | | | | | - W. Scott Harmsen
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Dean A. Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth S. Yan
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Sean S. Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Robert W. Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Kowalchuk RO, Corbin KS, Jimenez RB. Particle Therapy for Breast Cancer. Cancers (Basel) 2022; 14:cancers14041066. [PMID: 35205814 PMCID: PMC8870138 DOI: 10.3390/cancers14041066] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 02/05/2023] Open
Abstract
Particle therapy has received increasing attention in the treatment of breast cancer due to its unique physical properties that may enhance patient quality of life and reduce the late effects of therapy. In this review, we will examine the rationale for the use of proton and carbon therapy in the treatment of breast cancer and highlight their potential for sparing normal tissue injury. We will discuss the early dosimetric and clinical studies that have been pursued to date in this domain before focusing on the remaining open questions limiting the widespread adoption of particle therapy.
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Affiliation(s)
- Roman O. Kowalchuk
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Kimberly S. Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA; (R.O.K.); (K.S.C.)
| | - Rachel B. Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence:
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Settatree S, Dunlop A, Mohajer J, Brand D, Mooney L, Ross G, Gulliford S, Harris E, Kirby A. What Can Proton Beam Therapy Achieve for Patients with Pectus Excavatum Requiring Left Breast, Axilla and Internal Mammary Nodal Radiotherapy? Clin Oncol (R Coll Radiol) 2021; 33:e570-e577. [PMID: 34226114 DOI: 10.1016/j.clon.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/12/2021] [Accepted: 06/18/2021] [Indexed: 12/25/2022]
Abstract
AIMS Exposure of the heart to radiation increases the risk of ischaemic heart disease, proportionate to the mean heart dose (MHD). Radiotherapy techniques including proton beam therapy (PBT) can reduce MHD. The aims of this study were to quantify the MHD reduction achievable by PBT compared with volumetric modulated arc therapy in breath hold (VMAT-BH) in patients with pectus excavatum (PEx), to identify an anatomical metric from a computed tomography scan that might indicate which patients will achieve the greatest MHD reductions from PBT. MATERIALS AND METHODS Sixteen patients with PEx (Haller Index ≥2.7) were identified from radiotherapy planning computed tomography images. Left breast/chest wall, axilla (I-IV) and internal mammary node (IMN) volumes were delineated. VMAT and PBT plans were prepared, all satisfying target coverage constraints. Signed-rank comparisons of techniques were undertaken for the mean dose to the heart, ipsilateral lung and contralateral breast. Spearman's rho correlations were calculated for anatomical metrics against MHD reduction achieved by PBT. RESULTS The mean MHD for VMAT-BH plans was 4.1 Gy compared with 0.7 Gy for PBT plans. PBT reduced MHD by an average of 3.4 Gy (range 2.8-4.4 Gy) compared with VMAT-BH (P < 0.001). PBT significantly reduced the mean dose to the ipsilateral lung (4.7 Gy, P < 0.001) and contralateral breast (2.7 Gy, P < 0.001). The distance (mm) at the most inferomedial extent of IMN volume (IMN to heart distance) negatively correlated with MHD reduction achieved by PBT (Spearman's rho -0.88 (95% confidence interval -0.96 to -0.67, P < 0.001)). CONCLUSION For patients with PEx requiring left-sided breast and IMN radiotherapy, a clinically significant MHD reduction is achievable using PBT, compared with the optimal photon technique (VMAT-BH). This is a patient group in whom PBT could have the greatest benefit.
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Affiliation(s)
- S Settatree
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK.
| | - A Dunlop
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - J Mohajer
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - D Brand
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - L Mooney
- The Royal Marsden Hospital, London, UK
| | - G Ross
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - S Gulliford
- Department of Radiotherapy Physics, University College London Hospital, UK; Department of Medical Physics and Bioengineering, University College London, UK
| | - E Harris
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
| | - A Kirby
- The Royal Marsden Hospital, London, UK; The Institute of Cancer Research, London, UK
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Zhu M, Langen K, Nichols EM, Lin Y, Flampouri S, Godette KD, Dutta SW, McDonald MW, Patel SA. Intensity Modulated Proton Therapy Treatment Planning for Postmastectomy Patients with Metallic Port Tissue Expanders. Adv Radiat Oncol 2021; 7:100825. [PMID: 34805622 PMCID: PMC8590033 DOI: 10.1016/j.adro.2021.100825] [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: 03/16/2021] [Revised: 09/10/2021] [Accepted: 09/26/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Proton beam therapy can significantly reduce cardiopulmonary radiation exposure compared with photon-based techniques in the postmastectomy setting for locally advanced breast cancer. For patients with metallic port tissue expanders, which are commonly placed in patients undergoing a staged breast reconstruction, dose uncertainties introduced by the high-density material pose challenges for proton therapy. In this report, we describe an intensity modulated proton therapy planning technique for port avoidance through a hybrid single-field optimization/multifield optimization approach. Methods and Materials In this planning technique, 3 beams are utilized. For each beam, no proton spot is placed within or distal to the metal port plus a 5 mm margin. Therefore, precise modeling of the metal port is not required, and various tissue expander manufacturers/models are eligible. The blocked area of 1 beam is dosimetrically covered by 1 or 2 of the remaining beams. Multifield optimization is used in the chest wall target region with blockage of any beam, while single-field optimization is used for remainder of chest wall superior/inferior to the port. Results Using this technique, clinical plans were created for 6 patients. Satisfactory plans were achieved in the 5 patients with port-to-posterior chest wall separations of 1.5 cm or greater, but not in the sixth patient with a 0.7 cm separation. Conclusions We described a planning technique and the results suggest that the metallic port-to-chest wall distance may be a key parameter for optimal plan design.
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Affiliation(s)
- Mingyao Zhu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Katja Langen
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Elizabeth M Nichols
- Department of Radiation Oncology, Maryland University School of Medicine, Baltimore, Maryland
| | - Yuting Lin
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Karen D Godette
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sunil W Dutta
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sagar A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Milligan MG, Zieminski S, Johnson A, Depauw N, Rosado N, Specht MC, Liao EC, Jimenez RB. Target coverage and cardiopulmonary sparing with the updated ESTRO-ACROP contouring guidelines for postmastectomy radiation therapy after breast reconstruction: a treatment planning study using VMAT and proton PBS techniques. Acta Oncol 2021; 60:1440-1451. [PMID: 34313520 DOI: 10.1080/0284186x.2021.1957499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The European Society for Therapeutic Radiology and Oncology Advisory Committee in Radiation Oncology Practice (ESTRO-ACROP) recently released new contouring guidelines for postmastectomy radiation therapy (PMRT) after implant-based reconstruction (IBR). As compared to prior ESTRO guidelines, the new guidelines primarily redefined the chest wall (CW) target to exclude the breast prosthesis. In this study, we assessed the impact of these changes on treatment planning and dosimetric outcomes using volumetric-modulated arc therapy (VMAT) and proton pencil-beam scanning (PBS) therapy. METHODS We performed a treatment planning study of 10 women with left-sided breast cancer who underwent PMRT after IBR. All target structures were delineated first using standard (ESTRO) breast contouring guidelines and then separately using the new (ESTRO-ACROP) guidelines. Standard organs-at-risk (OARs) and cardiac substructures were contoured. Four sets of plans were generated: (1) VMAT using standard ESTRO contours, (2) VMAT using new ESTRO-ACROP contours, (3) PBS using standard contours, and (4) PBS using new contours. RESULTS VMAT plans using the new ESTRO-ACROP guidelines resulted in modest sparing of the left anterior descending coronary artery (LAD) (mean dose: 6.99 Gy standard ESTRO vs. 6.08 Gy new ESTRO-ACROP, p = 0.010) and ipsilateral lung (V20: 21.66% vs 19.45%, p = 0.017), but similar exposure to the heart (mean dose: 4.6 Gy vs. 4.3 Gy, p = 0.513), with a trend toward higher contralateral lung (V5: 31.0% vs 35.3%, p = 0.331) and CW doses (V5: 31.9% vs 35.4%, p = 0.599). PBS plans using the new guidelines resulted in further sparing of the heart (mean dose: 1.05 Gy(RBE) vs. 0.54 Gy(RBE), p < 0.001), nearly all cardiac substructures (LAD mean dose: 2.01 Gy(RBE) vs. 0.66 Gy(RBE), p < 0.001), and ipsilateral lung (V20: 16.22% vs 6.02%, p < 0.001). CONCLUSIONS PMRT after IBR using the new ESTRO-ACROP contouring guidelines with both VMAT and PBS therapy is associated with significant changes in exposure to several cardiopulmonary structures.
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Affiliation(s)
- Michael G. Milligan
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen Zieminski
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew Johnson
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nicolas Depauw
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Nikki Rosado
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michelle C. Specht
- Department of Surgery, Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Eric C. Liao
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel B. Jimenez
- Harvard Radiation Oncology Program, Boston, MA, USA
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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15
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Choi JI, Khan AJ, Powell SN, McCormick B, Lozano AJ, Del Rosario G, Mamary J, Liu H, Fox P, Gillespie E, Braunstein LZ, Mah D, Cahlon O. Proton reirradiation for recurrent or new primary breast cancer in the setting of prior breast irradiation. Radiother Oncol 2021; 165:142-151. [PMID: 34688807 DOI: 10.1016/j.radonc.2021.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Late local recurrences and second primary breast cancers are increasingly common. Proton beam therapy (PBT) reirradiation (reRT) may allow safer delivery of a second definitive radiotherapy (RT) course. We analyzed outcomes of patients with recurrent or new primary breast cancer who underwent reRT. MATERIALS AND METHODS In an IRB-approved retrospective study, patient/tumor characteristics, treatment parameters, outcomes, and toxicities were collected for all consecutive patients with recurrent or new primary non-metastatic breast cancer previously treated with breast or chest wall RT who underwent PBT reRT. RESULTS Forty-six patients received reRT using uniform (70%) or pencil beam (30%) scanning PBT. Median first RT, reRT, and cumulative doses were 60 Gy (range 45-66 Gy), 50.4 Gy(RBE) (40-66.6 Gy(RBE)), and 110 Gy(RBE) (96.6-169.4 Gy(RBE)), respectively. Median follow-up was 21 months. There were no local or regional recurrences; 17% developed distant recurrence. Two-year DMFS and OS were 92.0% and 93.6%, respectively. Nine of 13 (69.2%) patients who underwent implant or flap reconstruction developed capsular contracture, 3 (23.1%) requiring surgical intervention. One (7.7%) patient developed grade 3 breast pain requiring mastectomy after breast conserving surgery. No acute or late grade 4-5 toxicities were seen. Increased body mass index (BMI) was protective of grade ≥ 2 acute toxicity (OR = 0.84, 95%CI = 0.70-1.00). CONCLUSION In the largest series to date of PBT reRT for breast cancer recurrence or new primary after prior definitive breast or chest wall RT, excellent locoregional control and few high-grade toxicities were encountered. PBT reRT may provide a relatively safe and highly effective salvage option. Additional patients and follow-up are needed to correlate composite normal tissue doses with toxicities and assess long-term outcomes.
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Affiliation(s)
- J Isabelle Choi
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA.
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | | | | | | | - Haoyang Liu
- ProCure Proton Therapy Center, Somerset, USA
| | - Pamela Fox
- ProCure Proton Therapy Center, Somerset, USA
| | - Erin Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dennis Mah
- ProCure Proton Therapy Center, Somerset, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, USA; New York Proton Center, New York, USA
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16
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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17
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Kang Y, Shen J, Bues M, Hu Y, Liu W, Ding X. Technical Note: Clinical modeling and validation of breast tissue expander metallic ports in a commercial treatment planning system for proton therapy. Med Phys 2021; 48:7512-7525. [PMID: 34519357 DOI: 10.1002/mp.15225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/20/2021] [Accepted: 09/05/2021] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To validate breast tissue expander metallic port (MP) models in a commercial treatment planning system (TPS) in proton pencil beam scanning (PBS) treatments for breast cancer patients with breast tissue expanders. METHODS AND MATERIALS Three types of MPs taken out of a Mentor CPX4, a Natrelle 133, and a PMT Integra breast tissue expanders and a 650 cc saline filled Mentor CPX4 expander were placed on top of acrylic slabs, and scanned using a Siemens Somatom Definition AS Open RT CT scanner. Structure templates for each of the MPs were designed within Eclipse TPS. The CT numbers for the metallic parts were overridden to reflect measured or calculated relative proton stopping powers (RPSPs). Mock targets were contoured in acrylic to represent postmastectomy chest-wall radiation therapy (PMRT) targets. Plans with different beam incident angles were optimized using the Eclipse TPS to deliver uniform prescription dose to the target using Hitachi Probeat-V PBS beams. Eclipse calculated doses and an in-house Monte Carlo (MC) code calculated doses were compared to the measured Gafchromic EBT3 film doses in acrylic. RESULTS TPS/MC and film dose comparison results showed that (1) 3%/2 mm/10% threshold Gamma pass rates were better than 90.8% in the acrylic target region for all plans; (2) comparing TPS and film doses for the individual beam plans in the MP dose shadow areas, the area with dose difference above 5% ([ΔA] 5%) ranged from 1.1 to 5.0 cm2 , and the maximum dose difference ([ΔD] 0.01 cm2 ) ranged from 12.5% to 25.0%; (3) comparing MC and film doses for the individual beam plans in the MP dose shadow areas, the (ΔA) 5% varied from 1.1 to 2.9 cm2 and (ΔD) 0.01 cm2 varied from 8.5% to 24.2%; (4) for a plan composed of three individual beams treating through the Mentor CPX4 expander, the TPS (ΔA) 5% was less than 0.13 cm2 , and the (ΔD) 0.01 cm2 was less than 6% in the MP dose shadow areas. CONCLUSIONS It is feasible to treat patients with tissue expanders using multiple PBS beams using a structure template with CT number overridden to represent the measured/calculated RPSP for MPs for PBS treatment planning. MC dose was more accurate than analytical dose in the areas with high dose gradient caused by the density heterogeneity of the breast tissue expander MPs.
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Affiliation(s)
- Yixiu Kang
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jiajian Shen
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Martin Bues
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Xiaoning Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
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18
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Loap P, Tkatchenko N, Goudjil F, Ribeiro M, Baron B, Fourquet A, Kirova Y. Cardiac substructure exposure in breast radiotherapy: a comparison between intensity modulated proton therapy and volumetric modulated arc therapy. Acta Oncol 2021; 60:1038-1044. [PMID: 33788665 DOI: 10.1080/0284186x.2021.1907860] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Proton therapy for breast cancer treatment reduces cardiac radiation exposure. Left-sided breast cancer patients with indication for internal mammary chain (IMC) irradiation are most at risk of radiation-induced cardiotoxicity. This study aims to evaluate in this situation the potential dosimetric benefit of intensity modulated proton therapy (IMPT) over volumetric modulated arc therapy (VMAT) at the cardiac substructure level. MATERIALS AND METHODS Cardiac substructures were retrospectively delineated according to ESTRO guidelines on the simulation CT scans of fourteen left-sided breast cancer patients having undergone conserving surgery and adjuvant locoregional free-breathing (FB-) or deep inspiration breath-hold (DIBH-) VMAT with internal mammary chain irradiation. IMPT treatment was re-planned on the simulation CT scans. Mean doses to cardiac substructures were retrieved and compared between VMAT treatment plans and IMPT simulation plans. Pearson correlation coefficients were calculated between mean doses delivered to cardiac substructures using these two techniques. RESULTS Mean doses to all cardiac substructures were significantly lower with IMPT than with VMAT. Regardless of the irradiation technique, the most exposed cardiac substructure was the mid segment of the left anterior descending coronary artery (LADCA). Pearson correlation coefficients between mean doses to cardiac substructures were usually weak and statistically non-significant for IMPT; mean heart dose (MHD) only correlated with mean doses delivered to the right ventricle, to the mid segment of the right coronary artery (RCA) and, to a lesser extent, to the LADCA. CONCLUSION The dosimetric benefit of IMPT over conformal photon therapy was consistently observed for all cardiac substructures. MHD may not be a reliable dosimetric parameter for precise cardiac exposure evaluation when planning IMPT.
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Affiliation(s)
- Pierre Loap
- Institut Curie, Department of Radiation Oncology, Paris, France
| | | | - Farid Goudjil
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Madison Ribeiro
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Brian Baron
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Alain Fourquet
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Youlia Kirova
- Institut Curie, Department of Radiation Oncology, Paris, France
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19
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Musielak M, Suchorska WM, Fundowicz M, Milecki P, Malicki J. Future Perspectives of Proton Therapy in Minimizing the Toxicity of Breast Cancer Radiotherapy. J Pers Med 2021; 11:jpm11050410. [PMID: 34068305 PMCID: PMC8153289 DOI: 10.3390/jpm11050410] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/16/2022] Open
Abstract
The toxicity of radiotherapy is a key issue when analyzing the eligibility criteria for patients with breast cancer. In order to obtain better results, proton therapy is proposed because of the more favorable distribution of the dose in the patient’s body compared with photon radiotherapy. Scientific groups have conducted extensive research into the improved efficacy and lower toxicity of proton therapy for breast cancer. Unfortunately, there is no complete insight into the potential reasons and prospects for avoiding undesirable results. Cardiotoxicity is considered challenging; however, researchers have not presented any realistic prospects for preventing them. We compared the clinical evidence collected over the last 20 years, providing the rationale for the consideration of proton therapy as an effective solution to reduce cardiotoxicity. We analyzed the parameters of the dose distribution (mean dose, Dmax, V5, and V20) in organs at risk, such as the heart, blood vessels, and lungs, using the following two irradiation techniques: whole breast irradiation and accelerated partial breast irradiation. Moreover, we presented the possible causes of side effects, taking into account biological and technical issues. Finally, we collected potential improvements in higher quality predictions of toxic cardiac effects, like biomarkers, and model-based approaches to give the full background of this complex issue.
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Affiliation(s)
- Marika Musielak
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
- Correspondence: ; Tel.: +48-505372290
| | - Wiktoria M. Suchorska
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiobiology Laboratory, Department of Medical Physics, 61-866 Poznan, Poland
| | | | - Piotr Milecki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Radiotherapy Ward I, 61-866 Poznan, Poland;
| | - Julian Malicki
- Electro-Radiology Department, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (W.M.S.); (P.M.); (J.M.)
- Greater Poland Cancer Centre, Medical Physics Department, 61-866 Poznan, Poland
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20
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Bortfeld TR, Viana MFD, Yan S. The societal impact of ion beam therapy. Z Med Phys 2021; 31:102-104. [PMID: 32680688 PMCID: PMC7361098 DOI: 10.1016/j.zemedi.2020.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/14/2020] [Accepted: 06/21/2020] [Indexed: 11/23/2022]
Affiliation(s)
- Thomas R Bortfeld
- Department of Radiation Oncology - Division of Radiation Biophysics. Massachusetts General Hospital and Harvard Medical School 100 Blossom St. Boston, MA 02114, USA.
| | | | - Susu Yan
- Department of Radiation Oncology - Division of Radiation Biophysics. Massachusetts General Hospital and Harvard Medical School 100 Blossom St. Boston, MA 02114, USA
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21
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Marteinsdottir M, Wang CC, McNamara A, Depauw N, Shin J, Paganetti H. The impact of variable relative biological effectiveness in proton therapy for left-sided breast cancer when estimating normal tissue complications in the heart and lung. Phys Med Biol 2021; 66:035023. [PMID: 33522498 DOI: 10.1088/1361-6560/abd230] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The aim of this study was to evaluate the clinical impact of relative biological effectiveness (RBE) variations in proton beam scanning treatment (PBS) for left-sided breast cancer versus the assumption of a fixed RBE of 1.1, particularly in the context of comparisons with photon-based three-dimensional conformal radiotherapy (3DCRT) and volumetric modulated arc therapy (VMAT). Ten patients receiving radiation treatment to the whole breast/chest wall and regional lymph nodes were selected for each modality. For PBS, the dose distributions were re-calculated with both a fixed RBE and a variable RBE using an empirical RBE model. Dosimetric indices based on dose-volume histogram analysis were calculated for the entire heart wall, left anterior descending artery (LAD) and left lung. Furthermore, normal tissue toxicity probabilities for different endpoints were evaluated. The results show that applying a variable RBE significantly increases the RBE-weighted dose and consequently the calculated dosimetric indices increases for all organs compared to a fixed RBE. The mean dose to the heart and the maximum dose to the LAD and the left lung are significantly lower for PBS assuming a fixed RBE compared to 3DCRT. However, no statistically significant difference is seen when a variable RBE is applied. For a fixed RBE, lung toxicities are significantly lower compared to 3DCRT but when applying a variable RBE, no statistically significant differences are noted. A disadvantage is seen for VMAT over both PBS and 3DCRT. One-to-one plan comparison on 8 patients between PBS and 3DCRT shows similar results. We conclude that dosimetric analysis for all organs and toxicity estimation for the left lung might be underestimated when applying a fixed RBE for protons. Potential RBE variations should therefore be considered as uncertainty bands in outcome analysis.
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Affiliation(s)
- Maria Marteinsdottir
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA 02114, United States of America. Faculty of Physical Sciences, University of Iceland, Dunhaga 5, IS-107 Reykjavik, Iceland
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22
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Chang S, Liu G, Zhao L, Dilworth JT, Zheng W, Jawad S, Yan D, Chen P, Stevens C, Kabolizadeh P, Li X, Ding X. Feasibility study: spot-scanning proton arc therapy (SPArc) for left-sided whole breast radiotherapy. Radiat Oncol 2020; 15:232. [PMID: 33028378 PMCID: PMC7542109 DOI: 10.1186/s13014-020-01676-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study investigated the feasibility and potential clinical benefit of utilizing a new proton treatment technique: Spot-scanning proton arc (SPArc) therapy for left-sided whole breast radiotherapy (WBRT) to further reduce radiation dose to healthy tissue and mitigate the probability of normal tissue complications compared to conventional intensity modulated proton therapy (IMPT). METHODS Eight patients diagnosed with left-sided breast cancer and treated with breast-preserving surgery followed by whole breast irradiation without regional nodal irradiation were included in this retrospective planning. Two proton treatment plans were generated for each patient: vertical intensity-modulated proton therapy used for clinical treatment (vIMPT, gantry angle 10°-30°) and SPArc for comparison purpose. Both SPArc and vIMPT plans were optimized using the robust optimization of ± 3.5% range and 5 mm setup uncertainties. Root-mean-square deviation dose (RMSD) volume histograms were used for plan robustness evaluation. All dosimetric results were evaluated based on dose-volume histograms (DVH), and the interplay effect was evaluated based on the accumulation of single-fraction 4D dynamic dose on CT50. The treatment beam delivery time was simulated based on a gantry rotation with energy-layer-switching-time (ELST) from 0.2 to 5 s. RESULTS The average D1 to the heart and LAD were reduced to 53.63 cGy and 82.25 cGy compared with vIMPT 110.38 cGy (p = 0.001) and 170.38 cGy (p = 0.001), respectively. The average V5Gy and V20Gy of ipsilateral lung was reduced to 16.77% and 3.07% compared to vIMPT 25.56% (p = 0.001) and 4.68% (p = 0.003). Skin3mm mean and maximum dose were reduced to 3999.38 cGy and 4395.63 cGy compared to vIMPT 4104.25 cGy (p = 0.039) and 4411.63 cGy (p = 0.043), respectively. A significant relative risk reduction (RNTCP = NTCPSPArc/NTCPvIMPT) for organs at risk (OARs) was obtained with SPArc ranging from 0.61 to 0.86 depending on the clinical endpoint. The RMSD volume histogram (RVH) analysis shows SPArc provided better plan robustness in OARs sparing, including the heart, LAD, ipsilateral lung, and skin. The average estimated treatment beam delivery times were comparable to vIMPT plans when the ELST is about 0.5 s. CONCLUSION SPArc technique can further reduce dose delivered to OARs and the probability of normal tissue complications in patients treated for left-sided WBRT.
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Affiliation(s)
- Sheng Chang
- Department of Radiation Oncology, Renmin Hospital, Wuhan University, Wuhan, 430060, Hubei Province, China.,Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Gang Liu
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA.,Cancer Center, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, 430023, China.,School of Physics and Technology, Wuhan University, Wuhan, 430072, Hubei, China
| | - Lewei Zhao
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Joshua T Dilworth
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Weili Zheng
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Saada Jawad
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Di Yan
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Peter Chen
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Craig Stevens
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Peyman Kabolizadeh
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Xiaoqiang Li
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, MI, 48074, USA.
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Lin Y, Shueng P, Lin H, Tien H, Lai L. An efficient treatment planning approach to reduce the critical organ dose in volumetric modulated arc therapy for synchronous bilateral breast cancer patients. Radiat Phys Chem Oxf Engl 1993 2020. [DOI: 10.1016/j.radphyschem.2020.108957] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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24
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Paganetti H, Depauw N, Johnson A, Forman RB, Lau J, Jimenez R. The risk for developing a secondary cancer after breast radiation therapy: Comparison of photon and proton techniques. Radiother Oncol 2020; 149:212-218. [PMID: 32464163 DOI: 10.1016/j.radonc.2020.05.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE To compare secondary malignancy risks of modern proton and photon therapy techniques for locally advanced breast cancer. METHODS AND MATERIALS We utilized dosimetric data from 34 [10 photon-VMAT, 10 photon-3DCRT, 14 pencil beam scanning proton (PBS)] breast cancer patients who received comprehensive nodal irradiation. Employing a model based on organ equivalent dose to account for both inhomogeneous organ dose distributions and non-linear functional dose relationships, we estimated excess absolute risk, excess relative risk, and lifetime attributable risk (LAR) for secondary malignancies. The model uses dose distribution, number of fractions, age at exposure, attained age, the linear-quadratic dose response relationship for cell survival, repopulation factor, as well as gender specific age dependencies, and initial slopes of dose response curves. RESULTS The LAR for carcinoma at age 70 was estimated to be up to 3.64% for esophagus with an advantage of 3DCRT over PBS and VMAT. For the ipsilateral lung, risks were lowest for PBS (up to 5.56%), followed by 3DCRT (up to 6.54%) and VMAT (up to 7.7%). For the contralateral lung, there is a clear advantage of 3DCRT and PBS techniques (risk <0.86%) over VMAT (up to 4.4%). The risk for the contralateral breast is negligible for 3DCRT and PBS but was estimated as up to 1.2% for VMAT. Risks for the thyroid are overall negligible. Independently performed comparative treatment plans on 10 patients revealed that the risk for the contralateral lung and breast using VMAT can be more than an order of magnitude higher compared to PBS. Sarcoma risks were estimated as well showing similar trends but were overall lower compared to carcinoma. CONCLUSION Conventional (3DCRT) techniques led to the lowest estimated risks of, thyroid and esophageal secondary cancers while PBS demonstrated a benefit for secondary lung and contralateral breast cancer risks, with the highest risks overall associated with VMAT techniques.
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Affiliation(s)
- Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Nicolas Depauw
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Andrew Johnson
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Beth Forman
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Jackson Lau
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Arms positioning in post-mastectomy proton radiation: Feasibility and development of a new arms down contouring atlas. PHYSICS & IMAGING IN RADIATION ONCOLOGY 2020; 14:6-11. [PMID: 33458307 PMCID: PMC7807669 DOI: 10.1016/j.phro.2020.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 11/22/2022]
Abstract
Background and purpose Breast cancer patients receiving radiation are traditionally positioned with both arms up, but this may not be feasible or comfortable for all patients. We evaluated the treatment planning and positioning reproducibility differences between the arms up and arms down positions for patients receiving post-mastectomy radiation therapy (PMRT) using proton pencil beam scanning (PBS). Materials and methods Ten PMRT patients who were scheduled to receive PBS underwent CT-based treatment planning in both an arms down and a standard arms up position. An arms down contouring atlas was developed for consistency in treatment planning. Treatment plans were performed on both scans. A Wilcoxon test was applied to compare arms up and arms down metrics across patients. Five patients received treatment in the arms-down position at our institution while others were treated with the arms up. Residual set-up errors were recorded for each patient's treatment fractions and compared between positions. Results Target structure coverage remained consistent between the arms up and arms down positions. In regard to the OAR, the heart mean and maximum doses were statistically significantly lower in the arms up position versus the arms down position, however, the absolute differences were modest. Patients demonstrated similar setup errors, less than 0.5 mm differences, in all directions. Conclusions PBS for PMRT in the arms down position appeared stable and reproducible compared to the traditional arms up positioning. The degree of OAR sparing in the arms down group was minimally less robust but still far superior to conventional photon therapy.
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Shumway DA, Momoh AO, Sabel MS, Jagsi R. Integration of Breast Reconstruction and Postmastectomy Radiotherapy. J Clin Oncol 2020; 38:2329-2340. [PMID: 32442071 DOI: 10.1200/jco.19.02850] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Dean A Shumway
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
| | - Michael S Sabel
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
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Sun T, Lin X, Tong Y, Liu X, Pan L, Tao C, Duan J, Yin Y. Heart and Cardiac Substructure Dose Sparing in Synchronous Bilateral Breast Radiotherapy: A Dosimetric Study of Proton and Photon Radiation Therapy. Front Oncol 2020; 9:1456. [PMID: 31998635 PMCID: PMC6966409 DOI: 10.3389/fonc.2019.01456] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/05/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Synchronous bilateral breast cancer (SBBC) is rare. The purpose of this study was to compare the dosimetric differences in intensity-modulated radiation therapy (IMRT), volumetric-modulated arc therapy (VMAT), helical tomotherapy (HT), and intensity-modulated proton therapy (IMPT) to find an optimal radiotherapy technique for bilateral breast cancer radiotherapy. Methods: For 11 patients who received synchronous bilateral whole-breast irradiation without local lymph nodal regions, six plans were designed for each patient: IMRT with a single isocenter (IMRT-ISO1), IMRT with two isocenters (IMRT-ISO2), VMAT with a single isocenter (VMAT-ISO1), VMAT with two isocenters (VMAT-ISO2), HT, and IMPT. The differences between the single- and dual-isocentric plans for IMRT and VMAT were compared, and the plan with the better quality was selected for further dosimetric comparisons with IMPT and HT. The plan aimed for a target coverage of at least 95% with the prescription dose of 50 Gy [relative biological effectiveness (RBE)] while minimizing the dose of organs at risk (OARs). Results: IMRT-ISO1 and VMAT-ISO2 plans were adopted for further dosimetric comparisons because of the reduced dose of the heart and/or lungs compared to IMRT-ISO2 and VMAT-ISO1 plans. The dose coverage of the planning target volume (PTV) was significantly higher in IMPT plans than that in all other plans. VMAT and IMPT plans showed the best conformity, whereas IMRT plans showed the worst conformity. Compared to IMRT and VMAT plans, IMPT and HT plans achieved significantly higher dose homogeneity. IMPT plans reduced the mean dose and low dose volume (V5, V10, and V20) of the heart, left anterior descending artery (LAD), and left ventricle (LV). In high-dose volumes of the heart and cardiac substructures, the IMPT, VMAT, and HT techniques showed similar advantages, and IMRT plans increased the values more than other techniques. IMPT plans had the maximal lung and normal tissue sparing but increased the skin dose compared to IMRT and VMAT plans. Conclusions: IMPT plans improve both the target coverage and the OARs sparing, especially for the heart, cardiac substructures (LAD and LV), lungs and normal tissue, in synchronous bilateral breast radiotherapy. VMAT and HT could be selected as suboptimal techniques for SBBC patients.
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Affiliation(s)
- Tao Sun
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xiutong Lin
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Ying Tong
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Xiao Liu
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Lingjing Pan
- Department of Radiation Oncology, Hefei Ion Medical Center, Hefei, China
| | - Cheng Tao
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Jinghao Duan
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
| | - Yong Yin
- Department of Radiation Physics, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, China
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Jimenez RB, Hickey S, DePauw N, Yeap BY, Batin E, Gadd MA, Specht M, Isakoff SJ, Smith BL, Liao EC, Colwell AS, Ho A, Januzzi JL, Passeri J, Neilan TG, Taghian AG, Lu HM, MacDonald SM. Phase II Study of Proton Beam Radiation Therapy for Patients With Breast Cancer Requiring Regional Nodal Irradiation. J Clin Oncol 2019; 37:2778-2785. [PMID: 31449469 PMCID: PMC7351324 DOI: 10.1200/jco.18.02366] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of proton beam radiation therapy (RT) for patients with breast cancer who require regional nodal irradiation. METHODS Patients with nonmetastatic breast cancer who required postoperative RT to the breast/chest wall and regional lymphatics and who were considered suboptimal candidates for conventional RT were eligible. The primary end point was the incidence of grade 3 or higher radiation pneumonitis (RP) or any grade 4 toxicity within 3 months of RT. Secondary end points were 5-year locoregional failure, overall survival, and acute and late toxicities per Common Terminology Criteria for Adverse Events (version 4.0). Strain echocardiography and cardiac biomarkers were obtained before and after RT to assess early cardiac changes. RESULTS Seventy patients completed RT between 2011 and 2016. Median follow-up was 55 months (range, 17 to 82 months). Of 69 evaluable patients, median age was 45 years (range, 24 to 70 years). Sixty-three patients (91%) had left-sided breast cancer, two had bilateral breast cancer, and five had right-sided breast cancer. Sixty-five (94%) had stage II to III breast cancer. Sixty-eight (99%) received systemic chemotherapy. Fifty (72%) underwent immediate reconstruction. Median dose to the chest wall/breast was 49.7 Gy (relative biological effectiveness) and to the internal mammary nodes, 48.8 Gy (relative biological effectiveness), which indicates comprehensive coverage. Among 62 surviving patients, the 5-year rates for locoregional failure and overall survival were 1.5% and 91%, respectively. One patient developed grade 2 RP, and none developed grade 3 RP. No grade 4 toxicities occurred. The unplanned surgical re-intervention rate at 5 years was 33%. No significant changes in echocardiography or cardiac biomarkers after RT were found. CONCLUSION Proton beam RT for breast cancer has low toxicity rates and similar rates of disease control compared with historical data of conventional RT. No early cardiac changes were observed, which paves the way for randomized studies to compare proton beam RT with standard RT.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Alice Ho
- Massachusetts General Hospital, Boston, MA
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Vyfhuis MAL, Zhu M, Agyepong B, Nichols EM. Techniques for Treating Bilateral Breast Cancer Patients Using Pencil Beam Scanning Technology. Int J Part Ther 2019; 6:1-11. [PMID: 31998816 DOI: 10.14338/ijpt-18-00047.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 08/02/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose Patients with bilateral breast cancer (BBC), who require postmastectomy radiation therapy or radiation as part of breast conservation treatment, present a unique technical challenge. Even with modern techniques, such as intensity modulated radiation therapy or volumetric modulated arc therapy (VMAT), adequate target coverage is rarely achieved without the expense of increased integral dose to important organs at risk (OARs), such as the heart and lungs. Therefore, we present several BBC techniques and a treatment algorithm using intensity-modulated proton therapy (IMPT) for patients treated at our center. Materials and Methods We describe 3 different BBC treatment techniques using IMPT on patients treated at our center, with comparison VMAT plans to demonstrate the dosimetric benefit of proton therapy in these patients. Following RADCOMP (Radiation Therapy Oncology Group, Philadelphia, Pennsylvania) guidelines, a single physician approved all target volumes and OARs. Plans were designed so that ≥ 95% of the prescribed dose covered ≥ 95% of all targets. Parameters for dosimetric volume histograms for the clinical targets and OARs are reported for the 2 radiation methods. Results All methods demonstrated acceptable target coverage with 95% of the prescription planning target volume reaching a mean (± SD) of 98.0% (± 0.87%) and 97.5% (± 2.39%), for VMAT and IMPT plans, respectively. Conformity and homogeneity were also similar between the 2 techniques. Proton therapy provided observed improvements in mean heart dose (average heart mean [SD], 9.98 Gy [± 0.87 Gy] versus 2.12 Gy [± 0.96 Gy]) and total lung 5% prescription dose (V5; mean [SD] total lung V5, 97.9% [± 2.84%]), compared with 39.8% [± 9.39%]). All IMPT methods spared critical OARs; however, the single, 0° anterior-posterior plan allowed for the shortest treatment time. Conclusion Both VMAT and all 3 IMPT techniques provided excellent target coverage in patients with BBC; however, proton therapy was superior in decreasing the dose to OARs. A single-field optimization approach should be the IMPT method of choice when feasible.
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Affiliation(s)
- Melissa A L Vyfhuis
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mingyao Zhu
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Benjamin Agyepong
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland Medical Center, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
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30
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De Rose F, Cozzi L, Meattini I, Fogliata A, Franceschini D, Franzese C, Tomatis S, Becherini C, Livi L, Scorsetti M. The Potential Role of Intensity-modulated Proton Therapy in the Regional Nodal Irradiation of Breast Cancer: A Treatment Planning Study. Clin Oncol (R Coll Radiol) 2019; 32:26-34. [PMID: 31377082 DOI: 10.1016/j.clon.2019.07.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/13/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
AIMS To investigate the role of intensity-modulated proton therapy (IMPT) for regional nodal irradiation in patients with breast carcinoma in comparison with volumetric-modulated arc therapy (VMAT). MATERIALS AND METHODS A cohort of 20 patients (10 in the breast-conserving surgery group and 10 post-mastectomy patients with tissue expander implants) was investigated. Proton plans were also computed using robust optimisation methods. Plan quality was assessed by means of dose-volume histograms and scored with conventional metrics. Estimates of the risk of secondary cancer induction (excess absolute risk, EAR) were carried out, taking into account fractionation, repopulation and repair. RESULTS Concerning target coverage, the data proved a substantial equivalence of VMAT and IMPT: for example, coverage for the 50 Gy target, expressed in terms of V98%, was 47.8 ± 0.4, 47.6 ± 0.4, 47.3 ± 0.8, consistent with the objective of 47.5 Gy, for post-mastectomy patients for the three groups of patients. Also, the conformality of the dose distributions was similar for the two techniques, about 1.1, without statistically significant differences. Organ at risk planning aims were achieved for all structures for both techniques. The mean dose to the ipsilateral lung was 10.8 ± 1.1, 6.2 ± 0.8, 7.2 ± 1.0; for the contralateral lung was 3.2 ± 0.7, 0.3 ± 0.2, 0.4 ± 0.2; for the contralateral breast was: 3.1 ± 0.7, 0.3 ± 0.3 and 0.3 ± 0.3, whereas it was 3.9 ± 0.9, 0.4 ± 0.3 and 0.5 ± 0.5, respectively, for the heart for VMAT, IMPT and robust IMPT plans over the whole group of patients. Robust optimisation affected the near-to-maximum dose values for contralateral lung and breast, the mean dose for the heart and ipsilateral lung, with a deterioration ranging from 20 to 40% of the nominal value of IMPT plans (e.g. from 8.1 ± 6.4 to 11.4 ± 8.8 for the heart compared with 16.2 ± 5.2 for the VMAT plans). The numerical values of EAR per 10 000 patient-years were about one order of magnitude higher for VMAT than for IMPT for contralateral structures: 11.66 ± 2.01, 0.89 ± 0.80, 0.98 ± 0.77 for the contralateral breast and the three groups of plans, respectively; 14.31 ± 2.75, 1.42 ± 0.80, 1.78 ± 0.87 for the contralateral lung; and 34.86 ± 2.64, 18.85 ± 2.15, 20.98 ± 2.35 for the ipsilateral lung. CONCLUSION IMPT with or without robust optimisation seems to be a potentially promising approach for the radiation treatment of breast cancer when nodal volumes should be irradiated. This was measured in terms of dosimetric advantage and predicted clinical benefit. In fact, the significant reduction in estimated EAR could add further clinical value to the dosimetric sparing of the organs at risk achievable with IMPT.
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Affiliation(s)
- F De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - L Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy.
| | - I Meattini
- Department of Biomedical Experimental and Clinical Sciences, University of Florence, Florence, Italy; Radiation Oncology Unit, Az. Osp. Careggi, Florence, Italy
| | - A Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - D Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - C Franzese
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - S Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - C Becherini
- Department of Biomedical Experimental and Clinical Sciences, University of Florence, Florence, Italy; Radiation Oncology Unit, Az. Osp. Careggi, Florence, Italy
| | - L Livi
- Department of Biomedical Experimental and Clinical Sciences, University of Florence, Florence, Italy; Radiation Oncology Unit, Az. Osp. Careggi, Florence, Italy
| | - M Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
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Smith NL, Jethwa KR, Viehman JK, Harmsen WS, Gonuguntla K, Elswick SM, Grauberger JN, Amundson AC, Whitaker TJ, Remmes NB, Harless CA, Boughey JC, Nguyen MDT, Park SS, Corbin KS, Mutter RW. Post-mastectomy intensity modulated proton therapy after immediate breast reconstruction: Initial report of reconstruction outcomes and predictors of complications. Radiother Oncol 2019; 140:76-83. [PMID: 31185327 DOI: 10.1016/j.radonc.2019.05.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE To report reconstructive outcomes of patients treated with post-mastectomy intensity modulated proton therapy (IMPT) following immediate breast reconstruction (IBR). MATERIALS AND METHODS Consecutive women with breast cancer who underwent implant-based IBR and post-mastectomy IMPT were included. Clinical characteristics, dosimetry, and acute toxicity were collected prospectively and reconstruction complications retrospectively. RESULTS Fifty-one women were treated between 2015 and 2017. Forty-two had bilateral reconstruction with unilateral IMPT. The non-irradiated contralateral breasts served as controls. Conventional fractionation (median 50 Gy/25 fractions) was administered in 37 (73%) and hypofractionation (median 40.5 Gy/15 fractions) in 14 (27%) patients. Median mean heart, ipsilateral lung V20Gy, and CTV-IMN V95% were 0.6 Gy, 13.9%, and 97.4%. Maximal acute dermatitis grade was 1 in 32 (63%), 2 in 17 (33%), and 3 in 2 (4%) patients. Surgical site infection (hazard ratio [HR] 13.19, 95% confidence interval [CI] 1.67-104.03, p = 0.0012), and unplanned surgical intervention (HR 9.86, 95% CI 1.24-78.67, p = 0.0068) were more common in irradiated breasts. Eight of 51 irradiated breasts and 2 of 42 non-irradiated breasts had reconstruction failure (HR 3.59, 95% CI 0.78-16.41, p = 0.084). Among irradiated breasts, hypofractionation was significantly associated with reconstruction failure (HR 4.99, 95% CI 1.24-20.05, p = 0.024), as was older patient age (HR 1.14, 95% CI 1.05-1.24, p = 0.002). CONCLUSIONS IMPT following IBR spared underlying organs and had low rates of acute toxicity. Reconstruction complications are more common in irradiated breasts, and reconstructive outcomes appear comparable with photon literature. Hypofractionation was associated with higher reconstruction failure rates. Further investigation of optimal dose-fractionation after IBR is needed.
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Affiliation(s)
- Na L Smith
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Jason K Viehman
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | - William S Harmsen
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, USA
| | | | | | | | - Adam C Amundson
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | | | | | | | | | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA
| | | | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, USA.
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Inverse radiotherapy planning in reconstructive surgery for breast cancer. Int J Surg 2019; 63:77-82. [PMID: 30708063 DOI: 10.1016/j.ijsu.2019.01.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/25/2018] [Accepted: 01/24/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Post-mastectomy radiotherapy reduces the risk of local-regional relapse and distant disease, and increases global survival in women with axillary involvement. With the new reconstruction techniques and increasing use of directed external radiotherapy, immediate reconstruction can be performed with good cosmetic results and low complication rates. MATERIALS AND METHODS Observational study with consecutive sampling conducted in patients undergoing reconstructive surgery for breast cancer, between 2010 and 2016, with a 12-months minimum follow-up period. A group of patients radiated after receiving an expander (RT-Expander) were compared with a control group of non-radiated patients (Non-RT), who had been treated with the same surgical technique. We compare general complications, reconstruction failure, aesthetic results and satisfaction degree with software IBM® SPSS® Statistics v. 21 and BREAST-Q scores. RESULTS Reconstruction failure was observed in 15.6% of patients in a similar proportion in both groups. External radiotherapy was not an independent significant factor influencing the occurrence of general complications, capsular contracture grade ≥3 or reconstruction failure. The Kaplan-Meyer curve showed no differences in reconstruction survival between groups. Aesthetic results were excellent-very good in 78.1% of patients. Absence of a contralateral procedure for symmetrization, occurrence of general complications, occurrence of capsular contracture grade ≥3 and reconstruction failure were significantly associated to fair-poor cosmetic results. The satisfaction degree of operated patients was similar in both groups. CONCLUSIONS The evolution of external radiotherapy towards more directed techniques, which modulate the dose administered to the mammary tissue and adjacent structures, allowed us to make immediate reconstruction a reality for most patients, with complication rates, cosmetic results and satisfaction degrees similar to those of non-radiated patients.
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Braunstein LZ, Cahlon O. Potential Morbidity Reduction With Proton Radiation Therapy for Breast Cancer. Semin Radiat Oncol 2018; 28:138-149. [PMID: 29735190 DOI: 10.1016/j.semradonc.2017.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Proton radiotherapy confers significant dosimetric advantages in the treatment of malignancies that arise adjacent to critical radiosensitive structures. To date, these advantages have been most prominent in the treatment of pediatric and central nervous system malignancies, although emerging data support the use of protons among other anatomical sites in which radiotherapy plays an important role. With advances in the overall treatment paradigm for breast cancer, most patients with localized disease now exhibit long-term disease control and, consequently, may manifest the late toxicities of aggressive treatment. As a result, there is increasing emphasis on the mitigation of iatrogenic morbidity, with particular attention to heart and lung exposure in those receiving adjuvant radiotherapy. Indeed, recent landmark analyses have demonstrated an increase in significant cardiac events that is linked directly to low-dose radiation to the heart. Coupled with practice-changing trials that have expanded the indications for comprehensive regional nodal irradiation, there exists significant interest in employing novel technologies to mitigate cardiac dose while improving target volume coverage. Proton radiotherapy enjoys distinct physical advantages over photon-based approaches and, in appropriately selected patients, markedly improves both target coverage and normal tissue sparing. Here, we review the dosimetric evidence that underlies the putative benefits of proton radiotherapy, and further synthesize early clinical evidence that supports the efficacy and feasibility of proton radiation in breast cancer. Landmark, prospective randomized trials are underway and will ultimately define the role for protons in the treatment of this disease.
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Affiliation(s)
- Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY.
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Brownlee Z, Garg R, Listo M, Zavitsanos P, Wazer DE, Huber KE. Late complications of radiation therapy for breast cancer: evolution in techniques and risk over time. Gland Surg 2018; 7:371-378. [PMID: 30175054 DOI: 10.21037/gs.2018.01.05] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Radiation therapy in combination with surgery, chemotherapy, and endocrine therapy as indicated, has led to excellent local and distant control of early stage breast cancers. With the majority of these patients surviving long term, mitigating the probability and severity of late toxicities is vital. Radiation to the breast, with or without additional fields for nodal coverage, has the potential to negatively impact long term cosmetic outcome of the treated breast as well as cause rare, but severe, complications due to incidental dosage to the heart, lungs and contralateral breast. The long-term clinical side-effects of breast radiation have been studied extensively. This review aims to discuss the risk of developing late complications following breast radiation and how modern techniques can be used to diminish these risks.
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Affiliation(s)
- Zachary Brownlee
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Rashi Garg
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Matthew Listo
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Peter Zavitsanos
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - David E Wazer
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA.,Department of Radiation Oncology, Rhode Island Hospital and Brown University School of Medicine, Providence, RI, USA
| | - Kathryn E Huber
- Department of Radiation Oncology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
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Ranger A, Dunlop A, Hutchinson K, Convery H, Maclennan MK, Chantler H, Twyman N, Rose C, McQuaid D, Amos RA, Griffin C, deSouza NM, Donovan E, Harris E, Coles CE, Kirby A. A Dosimetric Comparison of Breast Radiotherapy Techniques to Treat Locoregional Lymph Nodes Including the Internal Mammary Chain. Clin Oncol (R Coll Radiol) 2018; 30:346-353. [PMID: 29483041 DOI: 10.1016/j.clon.2018.01.017] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/02/2018] [Accepted: 01/03/2018] [Indexed: 10/17/2022]
Abstract
AIMS Radiotherapy target volumes in early breast cancer treatment increasingly include the internal mammary chain (IMC). In order to maximise survival benefits of IMC radiotherapy, doses to the heart and lung should be minimised. This dosimetry study compared the ability of three-dimensional conformal radiotherapy, arc therapy and proton beam therapy (PBT) techniques with and without breath-hold to achieve target volume constraints while minimising dose to organs at risk (OARs). MATERIALS AND METHODS In 14 patients' datasets, seven IMC radiotherapy techniques were compared: wide tangent (WT) three-dimensional conformal radiotherapy, volumetric-modulated arc therapy (VMAT) and PBT, each in voluntary deep inspiratory breath-hold (vDIBH) and free breathing (FB), and tomotherapy in FB only. Target volume coverage and OAR doses were measured for each technique. These were compared using a one-way ANOVA with all pairwise comparisons tested using Bonferroni's multiple comparisons test, with adjusted P-values ≤ 0.05 indicating statistical significance. RESULTS One hundred per cent of WT(vDIBH), 43% of WT(FB), 100% of VMAT(vDIBH), 86% of VMAT(FB), 100% of tomotherapy FB and 100% of PBT plans in vDIBH and FB passed all mandatory constraints. However, coverage of the IMC with 90% of the prescribed dose was significantly better than all other techniques using VMAT(vDIBH), PBT(vDIBH) and PBT(FB) (mean IMC coverage ± 1 standard deviation = 96.0% ± 4.3, 99.8% ± 0.3 and 99.0% ± 0.2, respectively). The mean heart dose was significantly reduced in vDIBH compared with FB for both the WT (P < 0.0001) and VMAT (P < 0.0001) techniques. There was no advantage in target volume coverage or OAR doses for PBT(vDIBH) compared with PBT(FB). CONCLUSIONS Simple WT radiotherapy delivered in vDIBH achieves satisfactory coverage of the IMC while meeting heart and lung dose constraints. However, where higher isodose coverage is required, VMAT(vDIBH) is the optimal photon technique. The lowest OAR doses are achieved by PBT, in which the use of vDIBH does not improve dose statistics.
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Affiliation(s)
- A Ranger
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK.
| | - A Dunlop
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - K Hutchinson
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - H Convery
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | | | - H Chantler
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - N Twyman
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - C Rose
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - D McQuaid
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - R A Amos
- University College London, London, UK
| | - C Griffin
- Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - N M deSouza
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - E Donovan
- CVSSP, University of Surrey, Guildford, UK
| | - E Harris
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
| | - C E Coles
- University of Cambridge, Cambridge, UK
| | - A Kirby
- The Royal Marsden NHS Foundation Trust, London, UK; The Institute of Cancer Research, London, UK
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Impact of dose engine algorithm in pencil beam scanning proton therapy for breast cancer. Phys Med 2018; 50:7-12. [DOI: 10.1016/j.ejmp.2018.05.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/04/2018] [Accepted: 05/17/2018] [Indexed: 11/19/2022] Open
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Underwood TSA, Grassberger C, Bass R, MacDonald SM, Meyersohn NM, Yeap BY, Jimenez RB, Paganetti H. Asymptomatic Late-phase Radiographic Changes Among Chest-Wall Patients Are Associated With a Proton RBE Exceeding 1.1. Int J Radiat Oncol Biol Phys 2018; 101:809-819. [PMID: 29976493 DOI: 10.1016/j.ijrobp.2018.03.037] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 02/13/2018] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE Clinical practice assumes a fixed proton relative biological effectiveness (RBE) of 1.1, but in vitro experiments demonstrate higher RBEs at the distal edge of the proton spread-out Bragg peak, that is, in a region that falls within the lung for chest-wall patients. We performed retrospective qualitative and quantitative analyses of lung-density changes-indicative of asymptomatic fibrosis-for chest-wall patients treated with protons or photons. Our null hypothesis was that, assuming a fixed RBE of 1.1, these changes would be the same for the 2 cohorts, supporting current RBE practice. Our alternative hypothesis was that radiographic abnormalities would be greater for the proton cohort, suggesting an RBE > 1.1. METHODS AND MATERIALS We analyzed follow-up computed tomography (CT) scans for 20 proton and photon patients. All were prescribed 50.4 Gy (RBE) in 28 fractions, assuming a fixed RBE of 1.1 for protons and 1 for photons. Deformable registrations enabled us to calculate density changes in the normal lung, specifically (1) median Hounsfield unit (HU) values among posttreatment CT scans and (2) changes in median HU values between pretreatment and posttreatment CT scans, both as a function of grays (RBE). In addition, qualitative abnormality grading was performed by a radiologist. RESULTS Proton patients exhibited higher values of HU/Gy (RBE) (endpoint 1) and ΔHU/Gy (RBE) (endpoint 2): P = .049 and P = .00019, respectively, were obtained (likelihood ratio tests of full linear mixed-effects models against models without "modality"). Furthermore, qualitative radiologic scoring indicated a significant difference between the cohorts (Wilcoxon P = .018; median score, 3 of 9 for protons and 1.5 of 9 for photons). CONCLUSIONS Our data support the hypothesis that the proton RBE for lung-density changes exceeds 1.1. This RBE elevation could be attributable to (1) the late, normal tissue endpoint that we consider or (2) end-of-range proton linear energy transfer elevation-or a combination of the two. Regardless, our results suggest that variations in proton RBE prove important in vivo as well as in vitro.
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Affiliation(s)
- Tracy S A Underwood
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medical Physics and Biomedical Engineering, University College London, London, UK.
| | - Clemens Grassberger
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rhedise Bass
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nandini M Meyersohn
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harald Paganetti
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Corbin KS, Mutter RW. Proton therapy for breast cancer: progress & pitfalls. BREAST CANCER MANAGEMENT 2018. [DOI: 10.2217/bmt-2018-0001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
As the number of patients cured from breast cancer increases with improvements in multidisciplinary care, emphasis on reducing late toxicities of treatment has increased, in order to improve long-term quality of life. Proton beam therapy (PBT) is a form of radiotherapy that uses particles with unique physical properties that enable treatment delivery with minimal dose deposition beyond the treatment target. Therefore, PBT has emerged as an exciting radiotherapy modality for breast cancer due to the ability to minimize exposure to the heart, lungs, muscle, and bone. Herein, we review the rationale for PBT in breast cancer, potential clinical applications, and the available clinical data supporting its use. We also address some of the technical and logistical challenges and areas of ongoing research that will ultimately establish the role for PBT for breast cancer in the years ahead.
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Affiliation(s)
- Kimberly S Corbin
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
| | - Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, USA
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Ho AY, Hu ZI, Mehrara BJ, Wilkins EG. Radiotherapy in the setting of breast reconstruction: types, techniques, and timing. Lancet Oncol 2017; 18:e742-e753. [DOI: 10.1016/s1470-2045(17)30617-4] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/06/2017] [Accepted: 07/17/2017] [Indexed: 11/30/2022]
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Kirk M, Freedman G, Ostrander T, Dong L. Field-Specific Intensity-modulated Proton Therapy Optimization Technique for Breast Cancer Patients with Tissue Expanders Containing Metal Ports. Cureus 2017; 9:e1698. [PMID: 29159005 PMCID: PMC5690468 DOI: 10.7759/cureus.1698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This report aims to propose and present an evaluation of a robust pencil beam scanning proton multi-field optimized treatment planning technique for postmastectomy radiation of breast cancer patients with implanted tissue expanders containing an internal metal port. Field-specific split targets were created for optimization to prevent spots from traveling through the metal port, while providing uniform coverage of the target with the use of a multi-field intensity modulated optimization approach. Two beam angles were strategically selected to provide complementary target coverage and plan robustness. The plan was compared with an independently developed photon plan and evaluated for robustness with respect to isocenter shifts, range shifts, and variation of the water-equivalent thickness of the port. The proton plan resulted in clinically acceptable target coverage and dosage to neighboring normal tissues. The D95% coverage was 95.3% in the nominal proton plan, with a worst-case coverage of 90.1% (when considering 0.3 cm isocenter shifts combined with 3.5% range uncertainty), and the coverage varied less than 1% under a hypothetically extreme variation of the port density. The proton plan had improved dose homogeneity compared with the photon plan, and reduced ipsilateral lung and mean heart doses. We demonstrated that a practical, field-specific intensity-modulated proton therapy (IMPT) optimization technique can be used to deal with the challenge of metal port in breast cancer patients with tissue expanders. The resulting proton plan has superior dosimetric characteristics over the best-case scenario photon plan, and is also robust to setup and proton range uncertainties.
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Affiliation(s)
- Maura Kirk
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | - Gary Freedman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
| | | | - Lei Dong
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania
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Mutter RW, Remmes NB, Kahila MMH, Hoeft KA, Pafundi DH, Zhang Y, Corbin KS, Park SS, Yan ES, Lemaine V, Boughey JC, Beltran CJ. Initial clinical experience of postmastectomy intensity modulated proton therapy in patients with breast expanders with metallic ports. Pract Radiat Oncol 2017; 7:e243-e252. [DOI: 10.1016/j.prro.2016.12.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/07/2016] [Accepted: 12/12/2016] [Indexed: 11/30/2022]
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Patel SA, Lu HM, Nyamwanda JA, Jimenez RB, Taghian AG, MacDonald SM, Depauw N. Postmastectomy radiation therapy technique and cardiopulmonary sparing: A dosimetric comparative analysis between photons and protons with free breathing versus deep inspiration breath hold. Pract Radiat Oncol 2017; 7:e377-e384. [PMID: 28734644 DOI: 10.1016/j.prro.2017.06.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/25/2017] [Accepted: 06/16/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Dosimetric studies have suggested greater cardiopulmonary sparing with protons over photons for left-sided postmastectomy radiation therapy (PMRT). Modern techniques such as deep inspiration breath hold (DIBH) can help spare the heart. This analysis compares photon and proton delivery with and without DIBH. METHODS AND MATERIALS Ten women with left breast cancer referred for PMRT on a prospective clinical trial with unfavorable cardiac anatomy underwent free breathing (FB) and DIBH computed tomography simulation. A partially wide tangent photon (PWTF) during DIBH, passively scattered proton during FB, pencil-beam scanning (PBS) proton during FB, and PBS proton during DIBH plan was completed for each patient. Plans were designed to achieve 95% prescription dose coverage to 95% of chest wall and regional lymphatics while maximally sparing heart and lungs. RESULTS All techniques resulted in similar target coverage, although protons improved homogeneity indices and cardiopulmonary sparing (omnibus P < .0001 for each metric). Heart/lung metrics for PWTF with DIBH, scattered protons with FB, PBS protons with FB, and PBS protons with DIBH, respectively, were as follows: mean heart dose (2.09, 0.39, 0.98, 0.71 Gy relative biological effectiveness [RBE]), mean left ventricle dose (3.72, 0.08, 0.19, 0.21 GyRBE), V20 left ventricle (2.73, 0.03, 0, 0%), maximum left anterior descending artery dose (46.14, 8.28, 4.58, 4.63 GyRBE), mean lung dose (13.30, 5.74, 7.63, 7.49 GyRBE), and V20 lung (26.04, 12.04, 15.18, 14.43 %). Pairwise testing confirmed an improvement in each metric with all proton plans compared with PWTF with DIBH; there were no differences in homogeneity indices or cardiopulmonary sparing between passively scattered and PBS protons, regardless of addition of DIBH. CONCLUSIONS For left-sided PMRT, passively scattered or PBS protons with or without DIBH improves homogeneity and cardiopulmonary sparing without compromise in target coverage compared with PWTF photons with DIBH. Furthermore, the addition of DIBH to proton therapy did not provide a significant dosimetric benefit.
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Affiliation(s)
- Sagar A Patel
- Harvard Radiation Oncology Program, Harvard Medical School, Boston, Massachusetts.
| | - Hsiao-Ming Lu
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicolas Depauw
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Verma V, Iftekaruddin Z, Badar N, Hartsell W, Han-Chih Chang J, Gondi V, Pankuch M, Gao M, Schmidt S, Kaplan D, McGee L. Proton beam radiotherapy as part of comprehensive regional nodal irradiation for locally advanced breast cancer. Radiother Oncol 2017; 123:294-298. [PMID: 28457577 DOI: 10.1016/j.radonc.2017.04.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 04/04/2017] [Accepted: 04/04/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE This study evaluates acute toxicity outcomes in breast cancer patients treated with adjuvant proton beam therapy (PBT). METHODS From 2011 to 2016, 91 patients (93 cancers) were treated with adjuvant PBT targeting the intact breast/chest wall and comprehensive regional nodes including the axilla, supraclavicular fossa, and internal mammary lymph nodes. Toxicity was recorded weekly during treatment, one month following treatment, and then every 6months according to the Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Charts were retrospectively reviewed to verify toxicities, patient parameters, disease and treatment characteristics, and disease-related outcomes. RESULTS Median follow-up was 15.5months. Median PBT dose was 50.4 Gray relative biological effectiveness (GyRBE), with subsequent boost as clinically indicated (N=61, median 10 GyRBE). Chemotherapy, when administered, was given adjuvantly (N=42) or neoadjuvantly (N=46). Grades 1, 2, and 3 dermatitis occurred in 23%, 72%, and 5%, respectively. Eight percent required treatment breaks owing to dermatitis. Median time to resolution of dermatitis was 32days. Grades 1, 2, and 3 esophagitis developed in 31%, 33%, and 0%, respectively. CONCLUSIONS PBT displays acceptable toxicity in the setting of comprehensive regional nodal irradiation.
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Affiliation(s)
- Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, USA
| | - Zaid Iftekaruddin
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - Nida Badar
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - William Hartsell
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | | | - Vinai Gondi
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - Mark Pankuch
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - Ming Gao
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - Stacey Schmidt
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - Darren Kaplan
- Northwestern Medicine Chicago Proton Therapy Center, Warrenville, USA
| | - Lisa McGee
- Department of Radiation Oncology, Mayo Clinic, Phoenix, USA.
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Yu J, Park SS, Herman MG, Langen K, Mehta M, Feigenberg SJ. Free Breathing versus Breath-Hold Scanning Beam Proton Therapy and Cardiac Sparing in Breast Cancer. Int J Part Ther 2017; 3:407-413. [PMID: 31772990 DOI: 10.14338/ijpt-16-00021.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 11/16/2016] [Indexed: 12/25/2022] Open
Abstract
Purpose To assess dose errors caused by the interplay effects of free-breathing (FB) motion and to assess the value of breath-hold (BH) in terms of cardiac dose reduction for scanning beam proton therapy (SBPT). Materials and Methods Three patients with left-sided breast cancer previously treated with photon therapy were included in this dosimetric study: 2 following breast-conserving surgery with 2 hypothetical target volumes (whole breast alone and whole breast plus regional nodes, including supraclavicular, axillary, and internal mammary lymph nodes); and 1 postmastectomy, with the target volume including the chest wall plus regional nodes. SBPT plans were generated with various beam angles that ranged between 2 tangential directions. For treatment with FB, nominal dose and dose with interplay effects considered were calculated based on FB 4-dimensional computed tomography scans. SBPT plans on the BH computed tomography were also calculated for one of the patients, who was selected to be treated with photon therapy with BH. Results Dosimetric differences between nominal and interplay dose were small (average target mean dose, -0.06 Gy; range, -0.23 to 0.06 Gy; average heart mean dose, 0.001 Gy; range, -0.12 to 0.05 Gy). The largest dose deviations occurred in plans calculated with tangential beam arrangements; the smallest was noted with the en face beam. The average value of the mean heart dose with FB was <1 Gy. For the selected patient, the mean heart doses were 0.5 and 0.2 Gy for FB and BH, respectively. Conclusion Dose deviations caused by the interplay effects of respiratory motion during FB do not have a significant impact in SBPT with en face beam arrangement. BH does not significantly reduce cardiac dose. SBPT delivery is feasible with FB and can provide optimal target coverage and maximal sparing of the cardiopulmonary system, which can translate into improved clinical outcomes and a decrease in treatment-related morbidity in left-sided breast cancer patients or those who require internal mammary node coverage.
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Affiliation(s)
- Jen Yu
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Michael G Herman
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Katja Langen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minesh Mehta
- Radiation Oncology Department, Baptist Hospital South Florida, Miami, FL, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
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Kuerer HM, Cordeiro PG, Mutter RW. Optimizing Breast Cancer Adjuvant Radiation and Integration of Breast and Reconstructive Surgery. Am Soc Clin Oncol Educ Book 2017; 37:93-105. [PMID: 28561684 DOI: 10.1200/edbk_175342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Postmastectomy radiotherapy (PMRT) reduces the risk of locoregional and distant recurrence and improves overall survival in women with lymph node-positive breast cancer. Because of stage migration and improvements in systemic therapy and other aspects of breast cancer care, the absolute benefit of PMRT and regional nodal irradiation may be small in some favorable subsets of patients with very low nodal burden, and newer consensus guidelines do not mandate PMRT in all node-positive cases. The use and need for PMRT may considerably complicate breast reconstruction after mastectomy and therefore mandates multidisciplinary input that takes into account patient choice given potential risk of acute and long-term toxicities, benefits, life expectancy, the biology of the tumor, plans for systemic therapy, and actual tumor burden. Management of axillary lymph node metastases is changing with selective use of axillary lymph node dissection for advanced disease, sentinel lymph node biopsy alone for clinically and pathologic node-negative cases receiving mastectomy, and targeted axillary dissection alone among patients with eradication of initial biopsy-proven nodal metastases with neoadjuvant systemic therapy use. In general, when the need for PMRT is anticipated, autologous reconstruction should be delayed. This comprehensive article reviews the current indications and implications regarding integration of breast cancer surgery and timing of reconstruction with optimum radiation delivery to achieve the best possible patient outcomes.
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Affiliation(s)
- Henry M Kuerer
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Peter G Cordeiro
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
| | - Robert W Mutter
- From the Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiation Oncology, Mayo Clinic, Rochester, MN
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Clinical Outcomes and Toxicity of Proton Radiotherapy for Breast Cancer. Clin Breast Cancer 2016; 16:145-54. [DOI: 10.1016/j.clbc.2016.02.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 12/16/2015] [Accepted: 02/03/2016] [Indexed: 12/15/2022]
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Hernandez M, Zhang R, Sanders M, Newhauser W. A treatment planning comparison of volumetric modulated arc therapy and proton therapy for a sample of breast cancer patients treated with post-mastectomy radiotherapy. ACTA ACUST UNITED AC 2016; 1. [PMID: 29104948 DOI: 10.14319/jpt.11.9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Post-mastectomy radiotherapy (PMRT) has been shown to improve disease-free survival and overall survival for locally advanced breast cancer. However, long term survivors may develop life threatening acute and chronic treatment-related toxicities after radiotherapy, like cardiac toxicity and second cancers. The more advanced techniques like volumetric arc therapy (VMAT), and proton therapy have the potential to improve treatment outcome by constraining doses to radiosensitive organs, but evidence from outcome study will not be available until years or decades later. Furthermore, the literature is largely incomplete regarding systematic comparison of potential benefits of advanced technologies for PMRT. The purpose of this study was to compare proton therapy, both passively scattered (PSPT) and intensity modulated (IMPT), to VMAT and develop an evidence-based rationale for selecting a treatment modality for left sided post-mastectomy radiotherapy (PMRT) patients. Eight left-sided PMRT patients previously treated with VMAT were included in this study. Planning target volumes (PTV) included the chest wall and regional lymph nodes. PSPT and IMPT plans were created using a commercial proton treatment planning system. The resulting plans were compared to the corresponding VMAT on the basis of dosimetric and radiobiological endpoints. The uncertainties in risk from proton range, set-up errors, and dose-response models were also evaluated. All modalities produced clinically acceptable treatment plans with nearly 100% tumor control probability. Both proton techniques provided significantly lower normal tissue complication probability values for the heart (p < 0.02) and lung (p < 0.001). Patient-averaged second cancer risk for the contralateral breast and lungs were also significantly lower (p < 0.001) with protons compared to VMAT. The findings of this study were upheld by the uncertainty analysis. All three techniques provided acceptable PMRT treatment plans. Proton therapy showed significant advantages in terms of predicted normal tissue sparing compared to VMAT, taking into account possible uncertainties.
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Affiliation(s)
- Margaret Hernandez
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA
| | - Rui Zhang
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA.,Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Mary Sanders
- Department of Radiation Oncology, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA
| | - Wayne Newhauser
- Department of Physics, Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana, USA.,Department of Physics and Astronomy, Louisiana State University, Baton Rouge, Louisiana, USA
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Assessing radiation exposure of the left anterior descending artery, heart and lung in patients with left breast cancer: A dosimetric comparison between multicatheter accelerated partial breast irradiation and whole breast external beam radiotherapy. Radiother Oncol 2015; 117:459-66. [PMID: 26328940 DOI: 10.1016/j.radonc.2015.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 07/20/2015] [Accepted: 08/09/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND PURPOSE This study aims to quantify dosimetric reduction to the left anterior descending (LAD) artery, heart and lung when comparing whole breast external beam radiotherapy (WBEBRT) with multicatheter accelerated partial breast irradiation (MCABPI) for early stage left breast cancer. MATERIALS AND METHODS Planning CT data sets of 15 patients with left breast cancer receiving multicatheter brachytherapy post breast conserving surgery were used to create two independent treatment plans - WBEBRT prescribed to 50 Gy/25 fractions and MCABPI prescribed to 34 Gy/10 fractions. Dose parameters for (i) LAD artery, (ii) heart, and (iii) ipsilateral lung were calculated and compared between the two treatment modalities. RESULTS After adjusting for Equivalent Dose in 2 Gy fractions(EQD2), and comparing MCAPBI with WBEBRT, the largest dose reduction was for the LAD artery whose mean dose differed by a factor of 7.7, followed by the ipsilateral lung and heart with a factor of 4.6 and 2.6 respectively. Compared to WBEBRT, the mean MCAPBI LAD was significantly lower compared to WBEBRT (6.0 Gy vs 45.9 Gy; p<0.01). Mean MCAPBI heart D(0.1cc) (representing the dose received by the most highly exposed 0.1 cc of the risk organ, i.e. the dose peak) was significantly lower (16.3 Gy vs 50.6 Gy; p<0.01). Likewise, the mean heart dose (MHD) was significantly lower (2.3 Gy vs 6.0 Gy; p<0.01). Peak dose and mean lung dose (MLD) for ipsilateral lung was also lower for MCAPBI compared to WBEBRT (Peak dose: 22.2 Gy vs 52.0 Gy; p<0.01; MLD: 2.3 Gy vs 10.7 Gy; p<0.01). CONCLUSION Compared to WBEBRT, MCAPBI showed a significant reduction in radiation dose for the LAD, heart and lung. This may translate into better cardiac and pulmonary toxicities for patients undergoing MCAPBI.
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Lin LL, Vennarini S, Dimofte A, Ravanelli D, Shillington K, Batra S, Tochner Z, Both S, Freedman G. Proton beam versus photon beam dose to the heart and left anterior descending artery for left-sided breast cancer. Acta Oncol 2015; 54:1032-9. [PMID: 25789715 DOI: 10.3109/0284186x.2015.1011756] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to compare the dose to heart, left anterior descending (LAD) artery and lung between proton and photon beam irradiation for left-sided early stage breast cancer. MATERIAL AND METHODS Ten women with early stage left-sided breast cancer were treated with breast conserving surgery and radiation. Whole breast radiation was delivered for actual treatment via a tangential technique with deep inspiration breath hold (DIBH) utilizing inverse planned intensity-modulated radiation therapy (IMRT). Each patient was replanned on an Institutional Review Board (IRB)-approved prospective study using en face proton beam radiation with both uniform scanning (US) and pencil beam scanning (PBS) techniques. RESULTS Both PBS (0.011 Gy) and US (0.009 Gy) proton plans resulted in a significantly lower mean heart dose compared to IMRT (1.612 Gy) (p < 0.05 for PBS vs. IMRT and US vs. IMRT). The Dmean, Dmin, Dmax, and D0.2cm(3) of the LAD with either proton technique were significantly lower (p = 0.005) compared to IMRT. Both US and PBS reduced the mean dose to the lungs compared to IMRT. The coverage of the breast planning target volume was comparable between photon and proton plans. CONCLUSIONS The dose to whole heart was relatively low in this study of patients treated under conditions of DIBH. However, proton beam radiation was associated with lower minimum, maximum, and dose to 0.2 cm(3) of the LAD, which is the critical structure for late radiation therapy effects, compared to even the most optimized photon beam plan with DIBH and IMRT.
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Affiliation(s)
- Lilie L. Lin
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sabina Vennarini
- Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Andreea Dimofte
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Daniele Ravanelli
- Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Katie Shillington
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sonny Batra
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Zelig Tochner
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan Both
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Gary Freedman
- Radiation Oncology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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