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Jung W, Chung J, Lee J, Kim K. Quantifying radiation-induced breast fibrosis by shear-wave elastography in patients with breast cancer: A 12-months-follow-up data of a prospective study. Clin Transl Radiat Oncol 2024; 46:100773. [PMID: 38590328 PMCID: PMC10999491 DOI: 10.1016/j.ctro.2024.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/17/2024] [Accepted: 03/29/2024] [Indexed: 04/10/2024] Open
Abstract
Purpose To assess radiation-induced fibrosis (RIF) using shear-wave elastography (SWE) in patients with breast cancer who received radiotherapy (RT) after breast conserving surgery. Methods Forty-one patients were enrolled in a prospective study before RT. SWE and B-mode ultrasonography were performed to measure elasticity. For quantitative measurement, the maximum elasticity value was measured in the tumor bed and non-tumor bed of the treated breast, and contralateral breast before RT and at 3, and 12 months after RT. and RIF was recorded using the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Results The mean ± standard deviation elasticity values for the tumor bed, non-tumor bed, and contralateral breast were 71.2 ± 74.9 kPa, 19.4 ± 9.8 kPa and 20.3 ± 10.0 kPa before RT; 28.7 ± 26.3 kPa, 15.1 ± 7.0 kPa, and 14.7 ± 6.3 kPa at 12 months after RT, respectively. The elasticity values for all three measurement areas before and 12 months after RT were significantly different (p < 0.001 for tumor bed, p = 0.002 for non-tumor bed, p = 0.001 for contralateral breast). At 12 months follow-up, the distribution of grades of RIF evaluated by CTCAE grade was grade 0 in 43.9 %, grade 1 in 48.8 %, and grade 2 in 7.3 %. Conclusion We demonstrated that SWE enables the evaluation of tissue stiffness to provide quantified information for the RIF of breast cancer. Further studies with long-term follow-up should provide more quantitative data.
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Affiliation(s)
- Wonguen Jung
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea
| | - Jin Chung
- Department of Radiology, Ewha Womans University College of Medicine, Republic of Korea
| | - Jihae Lee
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Seoul National University Bundang Hospital, Republic of Korea
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Tang C, Yuan J, Guo H, Dai Z, Liu B, Xi H, He J, Niu S. Quantify the Effect of Air Gap Errors on Skin Dose for Breast Cancer Radiotherapy. Technol Cancer Res Treat 2024; 23:15330338241258566. [PMID: 38803305 PMCID: PMC11135118 DOI: 10.1177/15330338241258566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
Purpose: Determining the impact of air gap errors on the skin dose in postoperative breast cancer radiotherapy under dynamic intensity-modulated radiation therapy (IMRT) techniques. Methods: This was a retrospective study that involved 55 patients who underwent postoperative radiotherapy following modified radical mastectomy. All plans employed tangential IMRT, with a prescription dose of 50 Gy, and bolus added solely to the chest wall. Simulated air gap depth errors of 2 mm, 3 mm, and 5 mm were introduced at depression or inframammary fold areas on the skin, resulting in the creation of air gaps named Air2, Air3, and Air5. Utilizing a multivariable GEE, the average dose (Dmean) of the local skin was determined to evaluate its relationship with air gap volume and the lateral beam's average angle (AALB). Additionally, an analysis was conducted on the impact of gaps on local skin. Results: When simulating an air gap depth error of 2 mm, the average Dmean in plan2 increased by 0.46 Gy compared to the initial plan (planO) (p < .001). For the 3-mm air gap, the average Dmean of plan3 was 0.51 Gy higher than that of planO (p < .001). When simulating the air gap as 5 mm, the average Dmean of plan5 significantly increased by 0.59 Gy compared to planO (p < .001). The TCP results showed a similar trend to those of Dmean. As the depth of air gap error increases, NTCP values also gradually rise. The linear regression of the multivariable GEE equation indicates that the volume of air gaps and the AALB are strong predictors of Dmean. Conclusion: With small irregular air gap errors simulated in 55 patients, the values of skin's Dmean, TCP, and NTCP increased. A multivariable linear GEE regression model may effectively explain the impact of air gap volume and AALB on the local skin.
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Affiliation(s)
- Chunbo Tang
- Department of Radiation Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Jiangxi Clinical Research Center for Cancer, Ganzhou, China
| | - Jun Yuan
- Department of Radiation Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Jiangxi Clinical Research Center for Cancer, Ganzhou, China
| | - Hailiang Guo
- Department of Radiation Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Jiangxi Clinical Research Center for Cancer, Ganzhou, China
| | - Zhongyang Dai
- Department of Radiation Oncology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
- Jiangxi Clinical Research Center for Cancer, Ganzhou, China
| | - Biaoshui Liu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Haiyan Xi
- Department of Radiation Oncology, Nanchang People's Hospital, Nanchang, China
| | - Ji He
- School of Biomedical Engineering, Fourth Affiliated Hospital of Guangzhou, Guangzhou Medical University, Guangzhou, China
| | - Shanzhou Niu
- School of Mathematics and Computer Science / Ganzhou Key Laboratory of Computational Imaging, Gannan Normal University, Ganzhou, China
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Jaikuna T, Osorio EV, Azria D, Chang-Claude J, De Santis MC, Gutiérrez-Enríquez S, van Herk M, Hoskin P, Lambrecht M, Lingard Z, Seibold P, Seoane A, Sperk E, Symonds RP, Talbot CJ, Rancati T, Rattay T, Reyes V, Rosenstein BS, de Ruysscher D, Vega A, Veldeman L, Webb A, West CML, Aznar MC. Contouring variation affects estimates of normal tissue complication probability for breast fibrosis after radiotherapy. Breast 2023; 72:103578. [PMID: 37713940 PMCID: PMC10511799 DOI: 10.1016/j.breast.2023.103578] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/25/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Normal tissue complication probability (NTCP) models can be useful to estimate the risk of fibrosis after breast-conserving surgery (BCS) and radiotherapy (RT) to the breast. However, they are subject to uncertainties. We present the impact of contouring variation on the prediction of fibrosis. MATERIALS AND METHODS 280 breast cancer patients treated BCS-RT were included. Nine Clinical Target Volume (CTV) contours were created for each patient: i) CTV_crop (reference), cropped 5 mm from the skin and ii) CTV_skin, uncropped and including the skin, iii) segmenting the 95% isodose (Iso95%) and iv) 3 different auto-contouring atlases generating uncropped and cropped contours (Atlas_skin/Atlas_crop). To illustrate the impact of contour variation on NTCP estimates, we applied two equations predicting fibrosis grade ≥ 2 at 5 years, based on Lyman-Kutcher-Burman (LKB) and Relative Seriality (RS) models, respectively, to each contour. Differences were evaluated using repeated-measures ANOVA. For completeness, the association between observed fibrosis events and NTCP estimates was also evaluated using logistic regression. RESULTS There were minimal differences between contours when the same contouring approach was followed (cropped and uncropped). CTV_skin and Atlas_skin contours had lower NTCP estimates (-3.92%, IQR 4.00, p < 0.05) compared to CTV_crop. No significant difference was observed for Atlas_crop and Iso95% contours compared to CTV_crop. For the whole cohort, NTCP estimates varied between 5.3% and 49.5% (LKB) or 2.2% and 49.6% (RS) depending on the choice of contours. NTCP estimates for individual patients varied by up to a factor of 4. Estimates from "skin" contours showed higher agreement with observed events. CONCLUSION Contour variations can lead to significantly different NTCP estimates for breast fibrosis, highlighting the importance of standardising breast contours before developing and/or applying NTCP models.
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Affiliation(s)
- Tanwiwat Jaikuna
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom; Division of Radiation Oncology, Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Eliana Vasquez Osorio
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom
| | - David Azria
- Department of Radiation Oncology, Montpellier Cancer Institute, Université Montpellier, Inserm, U1194, France
| | - Jenny Chang-Claude
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf, Germany
| | | | - Sara Gutiérrez-Enríquez
- Hereditary Cancer Genetics Group, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron Hospital Campus, Barcelona, Spain
| | - Marcel van Herk
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom
| | - Peter Hoskin
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom
| | | | - Zoe Lingard
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom
| | - Petra Seibold
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alejandro Seoane
- Medical Physics Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Elena Sperk
- Department of Radiation Oncology, Mannheim Cancer Center, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Paul Symonds
- Leicester Cancer Research Centre, University of Leicester, United Kingdom
| | | | - Tiziana Rancati
- Data Science Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Tim Rattay
- Leicester Cancer Research Centre, University of Leicester, United Kingdom
| | - Victoria Reyes
- Radiation Oncology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Barry S Rosenstein
- Department of Radiation Oncology, Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Dirk de Ruysscher
- Maastricht University Medical Center, Department of Radiation Oncology (Maastro Clinic), GROW School for Oncology and Developmental Biology, Maastricht, the Netherlands
| | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica, Grupo de Medicina Xenómica (USC), Santiago de Compostela, Spain; Instituto de Investigación Sanitaria de, Santiago de Compostela, Spain; Biomedical Network on Rare Diseases (CIBERER), Spain
| | - Liv Veldeman
- Ghent University Hospital, Department of Radiation Oncology, Ghent, Belgium
| | - Adam Webb
- Department of Genetics and Genome Biology, University of Leicester, United Kingdom
| | - Catharine M L West
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom
| | - Marianne C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Christie NHS Foundation Trust Hospital, Manchester, United Kingdom.
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Anjidani S, Siavashpour Z, Houshyari M, Haghgoo M, Nazarnejad M, Zayeri F, Alireza Javadinia S. A dosimetric comparative study following RTOG and ESTRO contouring guidelines for breast radiation therapy. Cancer Radiother 2023; 27:413-420. [PMID: 37482461 DOI: 10.1016/j.canrad.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE To compare the dosimetric parameters considering the Radiation Therapy Oncology Group (RTOG) and European Society for Radiotherapy and Oncology (ESTRO) guidelines for breast cancer radiotherapy. Two radiotherapy techniques, intensity-modulated radiation therapy (IMRT) and volumetric-modulated arc therapy (VMAT), were considered. PATIENTS AND METHODS Twenty-eight patients with left-sided medially-located TanyN2M0 tumors were contoured based on RTOG and ESTRO guidelines. 9-field IMRT, 10-field IMRT, 11-field IMRT, and VMAT treatment plans were applied as radiotherapy (RT) techniques for both contouring sets. The dosimetric parameters of the RT plans were extracted and compared. RESULTS Comparing dose-volume histogram (DVH) parameters, equivalent uniform dose (EUD), and normal tissue complication probability (NTCP) of OARs across the contouring guidelines and considering each RT technique showed that the only significant differences were higher Dmax, Dmean, V30, and V45, EUD, and NTCP of the thyroid in all treatment modalities when the RTOG guideline had been adopted. Using the VMAT technique, PTV's EUD and the tumor control probability (TCP) were considerably higher when the ESTRO guideline was adopted. Moreover, the conformity index (CI) of VMAT plans was significantly higher when the ESTRO guideline was used. CONCLUSION Unless having higher doses to thyroid when the RTOG guideline was adopted, the doses to other organs-at-risk (OAR) were similar between the two considering guidelines. Moreover, except for higher EUD, TCP, and CI for VMAT when the ESTRO guideline was used, no other significant differences were obtained between dosimetric parameters of target volumes considering the RT techniques and contouring guidelines.
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Affiliation(s)
- Sh Anjidani
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Z Siavashpour
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - M Houshyari
- Radiotherapy Oncology Department, Shohada-e Tajrish Educational Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Haghgoo
- Department of Control Engineering, School of Electrical and Computer Engineering, Tarbiat Modares University (TMU), Tehran, Iran
| | - M Nazarnejad
- Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - F Zayeri
- Proteomics Research Center and Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Qods Square, Darband Street, Tehran, Iran
| | - S Alireza Javadinia
- Non-Communicable Diseases Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
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5
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Tan D, Mohd Nasir NF, Abdul Manan H, Yahya N. Prediction of toxicity outcomes following radiotherapy using deep learning-based models: A systematic review. Cancer Radiother 2023; 27:398-406. [PMID: 37482464 DOI: 10.1016/j.canrad.2023.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 07/25/2023]
Abstract
PURPOSE This study aims to perform a comprehensive systematic review of deep learning (DL) models in predicting RT-induced toxicity. MATERIALS AND METHODS A literature review was performed following the PRISMA guidelines. Systematic searches were performed in PubMed, Scopus, Cochrane and Embase databases from the earliest record up to September 2022. Related studies on deep learning models for radiotherapy toxicity prediction were selected based on predefined PICOS criteria. RESULTS Fourteen studies of radiotherapy-treated patients on different types of cancer [prostate (n=2), HNC (n=4), liver (n=2), lung (n=4), cervical (n=1), and oesophagus (n=1)] were eligible for inclusion in the systematic review. Information regarding patient characteristics and model development was summarized. Several approaches, such as ensemble learning, data augmentation, and transfer learning, that were utilized by selected studies were discussed. CONCLUSION Deep learning techniques are able to produce a consistent performance for toxicity prediction. Future research using large and diverse datasets and standardization of the study methodologies are required to improve the consistency of the research output.
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Affiliation(s)
- D Tan
- Centre of Diagnostic, Therapeutic and Investigative Sciences (CODTIS). Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300 Malaysia
| | - N F Mohd Nasir
- Centre of Diagnostic, Therapeutic and Investigative Sciences (CODTIS). Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300 Malaysia
| | - H Abdul Manan
- Functional Image Processing Laboratory, Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur 56000, Malaysia
| | - N Yahya
- Centre of Diagnostic, Therapeutic and Investigative Sciences (CODTIS). Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Aziz, Kuala Lumpur 50300 Malaysia.
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6
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Salim N, Popodko A, Tumanova K, Stolbovoy A, Lagkueva I, Ragimov V. Cardiac dose in the treatment of synchronous bilateral breast cancer patients between three different radiotherapy techniques (VMAT, IMRT, and 3D CRT). Discov Oncol 2023; 14:29. [PMID: 36862205 PMCID: PMC9981832 DOI: 10.1007/s12672-023-00636-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
PURPOSE Synchronous bilateral irradiation of both mammary glands and chest wall is a challenging task due to technical difficulties and limited evidence supporting an optimal technique to improve treatment outcomes. We studied and compared the dosimetry data of three radiotherapy techniques to select the most optimal one. METHODS We compared three-dimensional conformal radiation treatment (3D CRT), intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT) during irradiation of synchronous bilateral breast cancer in nine patients followed by examination of dose distribution to the cardiac conduction system (SA node, AV node and Bundle of His), myocardium, lungs, left anterior descending artery (LADA) and right coronary artery (RCA) . RESULTS VMAT is the most sparing technique for SBBC treatment. Even though doses to the SA node, AV node and Bundle of His were higher with VMAT (Dmean were 3.75 ± 0.62, 2.58 ± 0.83 and 3.03 ± 1.18 Gy respectively) compared with 3D CRT (Dmean were 2.61 ± 0.66, 1.52 ± 0.38 and 1.88 ± 0.70 Gy respectively), this difference is statistically insignificant. Doses to the right and left lung (average Dmean = 12.65 ± 3.20 Gy, V20Gy = 24.12 ± 6.25%), myocardium (Dmean = 5.33 ± 1.51 Gy, V10Gy = 9.80 ± 3.83%, V20Gy = 7.19 ± 3.15%, V25Gy = 6.20 ± 2.93%), and LADA (Dmean = 10.04 ± 4.92 Gy, V20Gy = 18.17 ± 13.24% and V25Gy = 15.41 ± 12.19%) were highest with 3D CRT. The highest Dmean in the cardiac conduction system (5.30 ± 2.23, 3.15 ± 1.61 and 3.89 ± 1.85 Gy respectively) was observed with IMRT, and a similar effect was noted in RCA (Dmean = 7.48 ± 2.11 Gy). CONCLUSION VMAT is the optimal and satisfactory radiation therapy technique for sparing organs at risk (OARs). With VMAT, a lower Dmean value was noted in the myocardium, LADA, and lungs. The use of 3D CRT significantly increases the dose of radiation reaching the lungs, myocardium, and LADA, which can subsequently cause cardiovascular and lung complications, but not in the cardiac conduction system.
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Affiliation(s)
- Nidal Salim
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
- Department of Radiation Oncology, Russian Medical Academy of Continuous Medical Education of the Ministry of Health, Moscow, Russia
| | - Alexey Popodko
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
| | - Kristina Tumanova
- Department of Radiation Oncology, European Medical Center, Moscow, Russia.
| | - Alexandr Stolbovoy
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
- Department of Radiation Oncology, Russian Medical Academy of Continuous Medical Education of the Ministry of Health, Moscow, Russia
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7
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Dennstädt F, Medová M, Putora PM, Glatzer M. Parameters of the Lyman Model for Calculation of Normal-Tissue Complication Probability: A Systematic Literature Review. Int J Radiat Oncol Biol Phys 2023; 115:696-706. [PMID: 36029911 DOI: 10.1016/j.ijrobp.2022.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The Lyman model is one of the most used radiobiological models for calculation of normal-tissue complication probability (NTCP). Since its introduction in 1985, many authors have published parameter values for the model based on clinical data of different radiotherapeutic situations. This study attempted to collect the entirety of radiobiological parameter sets published to date and provide an overview of the data basis for different variations of the model. Furthermore, it sought to compare the parameter values and calculated NTCPs for selected endpoints with sufficient data available. METHODS AND MATERIALS A systematic literature analysis was performed, searching for publications that provided parameters for the different variations of the Lyman model in the Medline database using PubMed. Parameter sets were grouped into 13 toxicity-related endpoint groups. For 3 selected endpoint groups (≤25% reduction of saliva 12 months after irradiation of the parotid, symptomatic pneumonitis after irradiation of the lung, and bleeding of grade 2 or less after irradiation of the rectum), parameter values were compared and differences in calculated NTCP values were analyzed. RESULTS A total of 509 parameter sets from 130 publications were identified. Considerable heterogeneities were detected regarding the number of parameters available for different radio-oncological situations. Furthermore, for the 3 selected endpoints, large differences in published parameter values were found. These translated into great variations of calculated NTCPs, with maximum ranges of 35.2% to 93.4% for the saliva endpoint, of 39.4% to 90.4% for the pneumonitis endpoint, and of 5.4% to 99.3% for the rectal bleeding endpoint. CONCLUSIONS The detected heterogeneity of the data as well as the large variations of published radiobiological parameters underline the necessity for careful interpretation when using such parameters for NTCP calculations. Appropriate selection of parameters and validation of values are essential when using the Lyman model.
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Affiliation(s)
- Fabio Dennstädt
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland.
| | - Michaela Medová
- Department of Radiation Oncology, University of Bern, Bern, Switzerland; Department for BioMedical Research, Inselspital Bern, Bern, Switzerland
| | - Paul Martin Putora
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland; Department of Radiation Oncology, University of Bern, Bern, Switzerland
| | - Markus Glatzer
- Department of Radiation Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Hussein FA, Manan HA, Mustapha AWMM, Sidek K, Yahya N. Ultrasonographic Evaluation of Skin Toxicity Following Radiotherapy of Breast Cancer: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13439. [PMID: 36294025 PMCID: PMC9603505 DOI: 10.3390/ijerph192013439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/05/2022] [Accepted: 10/08/2022] [Indexed: 06/16/2023]
Abstract
The present review aimed to systematically review skin toxicity changes following breast cancer radiotherapy (RT) using ultrasound (US). PubMed and Scopus databases were searched according to PRISMA guidelines. The characteristics of the selected studies, measured parameters, US skin findings, and their association with clinical assessments were extracted. Seventeen studies were included with a median sample size of 29 (range 11-166). There were significant US skin changes in the irradiated skin compared to the nonirradiated skin or baseline measurements. The most observed change is skin thickening secondary to radiation-induced oedema, except one study found skin thinning after pure postmastectomy RT. However, eight studies reported skin thickening predated RT attributed to axillary surgery. Four studies used US radiofrequency (RF) signals and found a decrease in the hypodermis's Pearson correlation coefficient (PCC). Three studies reported decreased dermal echogenicity and poor visibility of the dermis-subcutaneous fat boundary (statistically analysed by one report). The present review revealed significant ultrasonographic skin toxicity changes in the irradiated skin most commonly skin thickening. However, further studies with large cohorts, appropriate US protocol, and baseline evaluation are needed. Measuring other US skin parameters and statistically evaluating the degree of the association with clinical assessments are also encouraged.
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Affiliation(s)
- Fatimah Alaa Hussein
- Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), Department of Radiology, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
| | - Hanani Abdul Manan
- Makmal Pemprosesan Imej Kefungsian (Functional Image Processing Laboratory), Department of Radiology, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
- Department of Radiology and Intervensi, Hospital Pakar Kanak-Kanak (Children Specialist Hospital), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
| | - Aida W. M. Mohd Mustapha
- Department of Radiology, Hospital Canselor Tuanku Muhriz, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
| | - Khairiyah Sidek
- Department of Radiotherapy, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia
| | - Noorazrul Yahya
- Diagnostic Imaging & Radiotherapy Program, Faculty of Health Sciences, School of Diagnostic & Applied Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur 50300, Malaysia
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9
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Tevlin R, Longaker MT, Wan DC. Deferoxamine to Minimize Fibrosis During Radiation Therapy. Adv Wound Care (New Rochelle) 2022; 11:548-559. [PMID: 34074152 PMCID: PMC9347384 DOI: 10.1089/wound.2021.0021] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/14/2021] [Indexed: 01/29/2023] Open
Abstract
Significance: By 2030, there will be >4 million radiation-treated cancer survivors living in the United States. Irradiation triggers inflammation, fibroblast activation, and extracellular matrix deposition in addition to reactive oxygen species generation, leading to a chronic inflammatory response. Radiation-induced fibrosis (RIF) is a progressive pathology resulting in skin pigmentation, reduced elasticity, ulceration and dermal thickening, cosmetic deformity, pain, and the need for reconstructive surgery. Recent Advances: Deferoxamine (DFO) is a U.S. Food and Drug Administration (FDA)-approved iron chelator for blood dyscrasia management, which has been found to be proangiogenic, to decrease free radical formation, and reduce cell death. DFO has shown great promise in the treatment and prophylaxis of RIF in preclinical studies. Critical Issues: Systemic DFO has a short half-life and is cumbersome to deliver to patients intravenously. Transdermal DFO delivery is complicated by its high atomic mass and hydrophilicity, preventing stratum corneum penetration. A transdermal drug delivery system was developed to address these challenges, in addition to a strategy for topical administration. Future Directions: DFO has great potential to translate from bench to bedside. An important step in translation of DFO for RIF prophylaxis is to ensure that DFO treatment does not affect the efficacy of radiation therapy. Furthermore, after an initial plethora of studies reporting DFO treatment by intravenous and subcutaneous routes, a significant advantage of recent studies is the success of transdermal and topical delivery. Given the strong foundation of basic scientific research supporting the use of DFO treatment on RIF, clinicians will be closely following the results of the ongoing human studies.
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Affiliation(s)
- Ruth Tevlin
- Division of Plastic and Reconstructive Surgery, and Stanford University School of Medicine, Stanford, California, USA
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- School of Postgraduate Studies, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael T. Longaker
- Division of Plastic and Reconstructive Surgery, and Stanford University School of Medicine, Stanford, California, USA
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Derrick C. Wan
- Division of Plastic and Reconstructive Surgery, and Stanford University School of Medicine, Stanford, California, USA
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
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10
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Stick LB, Jensen MF, Bentzen SM, Kamby C, Lundgaard AY, Maraldo MV, Offersen BV, Yu J, Vogelius IR. Radiation-Induced Toxicity Risks in Photon Versus Proton Therapy for Synchronous Bilateral Breast Cancer. Int J Part Ther 2021; 8:1-13. [PMID: 35530186 PMCID: PMC9009461 DOI: 10.14338/ijpt-21-00023.1] [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: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study compares photon and proton therapy plans for patients with synchronous bilateral early breast cancer and estimates risks of early and late radiation-induced toxicities. Materials and Methods Twenty-four patients with synchronous bilateral early breast cancer receiving adjuvant radiation therapy using photons, 3-dimensional conformal radiation therapy or volumetric modulated arc therapy, were included and competing pencil beam scanning proton therapy plans were created. Risks of dermatitis, pneumonitis, acute esophageal toxicity, lung and breast fibrosis, hypothyroidism, secondary lung and esophageal cancer and coronary artery events were estimated using published dose-response relationships and normal tissue complication probability (NTCP) models. Results The primary clinical target volume V95% and/or nodal clinical target volume V90% were less than 95% in 17 photon therapy plans and none of the proton plans. Median NTCP of radiation dermatitis ≥ grade 2 was 18.3% (range, 5.4-41.7) with photon therapy and 58.4% (range, 31.4-69.7) with proton therapy. Median excess absolute risk (EAR) of secondary lung cancer at age 80 for current and former smokers was 4.8% (range, 0.0-17.0) using photons and 2.7% (range, 0.0-13.6) using protons. Median EAR of coronary event at age 80, assuming all patients have preexisting cardiac risk factors, was 1.0% (range, 0.0-5.6) with photons and 0.2% (range, 0.0-1.3) with protons. Conclusion Proton therapy plans improved target coverage and reduced risk of coronary artery event and secondary lung cancer while increasing the risk of radiation dermatitis.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren M. Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public, Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claus Kamby
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anni Young Lundgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja Vestmø Maraldo
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Vrou Offersen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Nichol A, Narinesingh D, Wade L, Raman S, Gondara L, Speers C, Tran E, Chan EK, Lohrisch CA, Truong P. Breast Tangent Beam Energy, Surgical Bed-to-Skin Distance and Local Recurrence after Breast-Conserving Treatment. Int J Radiat Oncol Biol Phys 2021; 112:671-680. [PMID: 34699929 DOI: 10.1016/j.ijrobp.2021.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/09/2021] [Accepted: 10/15/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Higher energy (>6 MV) photons reduce dose inhomogeneity with breast tangent beams, thereby reducing late breast toxicity, but skin and superficial tissue sparing by higher energy beams raises concerns about local recurrence (LR) risk. This study aimed to determine whether beam energy and surgical bed-to-skin distance affect LR. METHODS AND MATERIALS This population-based study included newly diagnosed invasive breast cancers without skin involvement (pT1-4a, any-N, M0) treated with breast-conserving surgery and adjuvant whole breast radiotherapy without bolus or beam spoilers. The primary endpoint was the cumulative incidence of LR (CILR). A multivariable analysis (MVA) included mean beam energy, age, T-stage, nodal status, overall stage, lymphovascular invasion (LVI), grade, margin status, extensive intraductal component (EIC), breast cancer subtype, hormone therapy and chemotherapy. In a subgroup with contoured surgical beds, another MVA included surgical bed-to-skin distance. RESULTS The cohort consisted of 10,083 women treated from 2002 to 2011, 327 with 4MV, 6,006 with 6 MV, 2,083 with >6-10 MV and 1,667 with >10 MV tangents. The median follow-up time was 11.1 years. The 10-year CILR was 3.1% [95% confidence interval 1.6,5.4] with 4 MV, 2.8% [2.4,3.3] with 6 MV, 4.2% [3.4,5.3] with >6-10 MV and 2.6% [1.9,3.5] with >10 MV. On MVA of the entire cohort, LR risk was increased with positive margins, LVI, EIC, and lack of hormone therapy, but was not associated with beam energy (HR = 1.01 [0.96,1.05], p = 0.8). On MVA of 3,359 patients with contoured surgical beds, LR risk was not associated with surgical bed-to-skin distance (HR = 1.00 [0.99,1.02], p = 0.8). CONCLUSIONS Use of higher breast tangent beam energies is not associated with increased risk of local recurrence, including in cases with surgical beds that are close to the skin.
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Affiliation(s)
- Alan Nichol
- Departments of Radiation Oncology, BC Cancer-Vancouver, Vancouver, Canada.
| | - Dylan Narinesingh
- Departments of Radiation Oncology, BC Cancer-Vancouver, Vancouver, Canada
| | - Louise Wade
- Departments of Radiation Oncology, BC Cancer-Vancouver, Vancouver, Canada
| | - Srinivas Raman
- Departments of Radiation Oncology, BC Cancer-Vancouver, Vancouver, Canada
| | - Lovedeep Gondara
- Departments of Cancer Surveillance and Outcomes, BC Cancer-Vancouver, Vancouver, Canada
| | - Caroline Speers
- Departments of Cancer Surveillance and Outcomes, BC Cancer-Vancouver, Vancouver, Canada
| | - Eric Tran
- Departments of Radiation Oncology, BC Cancer-Vancouver, Vancouver, Canada
| | - Elisa K Chan
- Departments of Radiation Oncology, BC Cancer-Vancouver, Vancouver, Canada
| | | | - Pauline Truong
- Department of Radiation Oncology, BC Cancer-Victoria, Victoria, Canada
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12
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A Cross-Machine Comparison of Shear-Wave Speed Measurements Using 2D Shear-Wave Elastography in the Normal Female Breast. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11209391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Quantitative measures of radiation-induced breast stiffness are required to support clinical studies of novel breast radiotherapy regimens and exploration of personalised therapy, however, variation between shear-wave elastography (SWE) machines may limit the usefulness of shear-wave speed (cs) for this purpose. Mean cs measured in four healthy volunteers’ breasts and a phantom using 2D-SWE machines Acuson S2000 (Siemens Medical Solutions) and Aixplorer (Supersonic Imagine) were compared. Shear-wave speed was measured in the skin region, subcutaneous adipose tissue and parenchyma. cs estimates were on average 2.3% greater when using the Aixplorer compared to S2000 in vitro. In vivo, cs estimates were on average 43.7%, 36.3% and 49.9% significantly greater (p << 0.01) when using the Aixplorer compared to S2000, for skin region, subcutaneous adipose tissue and parenchyma, respectively. In conclusion, despite relatively small differences between machines observed in vitro, large differences in absolute measures of shear wave speed measured were observed in vivo, which may prevent pooling of cross-machine data in clinical studies of the breast.
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13
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Hoekstra N, Habraken S, Swaak-Kragten A, Breedveld S, Pignol JP, Hoogeman M. Reducing the Risk of Secondary Lung Cancer in Treatment Planning of Accelerated Partial Breast Irradiation. Front Oncol 2020; 10:1445. [PMID: 33014782 PMCID: PMC7461936 DOI: 10.3389/fonc.2020.01445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/08/2020] [Indexed: 01/01/2023] Open
Abstract
Purpose: Adjuvant accelerated partial breast irradiation (APBI) results in low local recurrence risks. However, the survival benefit of adjuvant radiotherapy APBI for low-risk breast cancer might partially be offset by the risk of radiation-induced lung cancer. Reducing the lung dose mitigates this risk, but this could result in higher doses to the ipsilateral breast. Different external beam APBI techniques are equally conformal and homogenous, but the intermediate to low dose distribution differs. Thus, the risk of toxicity is different. The purpose of this study is to quantify the trade-off between secondary lung cancer risk and breast dose in treatment planning and to compare an optimal coplanar and non-coplanar technique. Methods: A total of 440 APBI treatment plans were generated using automated treatment planning for a coplanar VMAT beam-setup and a non-coplanar robotic stereotactic radiotherapy beam-setup. This enabled an unbiased comparison of two times 11 Pareto-optimal plans for 20 patients, gradually shifting priority from maximum lung sparing to maximum ipsilateral breast sparing. The excess absolute risks of developing lung cancer and breast fibrosis were calculated using the Schneider model for lung cancer and the Avanzo model for breast fibrosis. Results: Prioritizing lung sparing reduced the mean lung dose from 2.2 Gy to as low as 0.3 Gy for the non-coplanar technique and from 1.9 Gy to 0.4 Gy for the coplanar technique, corresponding to a 7- and 4-fold median reduction of secondary lung cancer risk, respectively, compared to prioritizing breast sparing. The increase in breast dose resulted in a negligible 0.4% increase in fibrosis risk. The use of non-coplanar beams resulted in lower secondary cancer and fibrosis risks (p < 0.001). Lung sparing also reduced the mean heart dose for both techniques. Conclusions: The risk of secondary lung cancer of external beam APBI can be dramatically reduced by prioritizing lung sparing during treatment planning. The associated increase in breast dose did not lead to a relevant increase in fibrosis risk. The use of non-coplanar beams systematically resulted in the lowest risks of secondary lung cancer and fibrosis. Prioritizing lung sparing during treatment planning could increase the overall survival of early-stage breast cancer patients by reducing mortality due to secondary lung cancer and cardiovascular toxicity.
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Affiliation(s)
- Nienke Hoekstra
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Steven Habraken
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Sebastiaan Breedveld
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | | | - Mischa Hoogeman
- Department of Radiation Oncology, Erasmus MC Cancer Institute, Rotterdam, Netherlands
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14
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Borrelli MR, Patel RA, Adem S, Diaz Deleon NM, Shen AH, Sokol J, Yen S, Chang EY, Nazerali R, Nguyen D, Momeni A, Wang KC, Longaker MT, Wan DC. The antifibrotic adipose-derived stromal cell: Grafted fat enriched with CD74+ adipose-derived stromal cells reduces chronic radiation-induced skin fibrosis. Stem Cells Transl Med 2020; 9:1401-1413. [PMID: 32563212 PMCID: PMC7581454 DOI: 10.1002/sctm.19-0317] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 03/04/2020] [Accepted: 03/27/2020] [Indexed: 02/06/2023] Open
Abstract
Fat grafting can reduce radiation‐induced fibrosis. Improved outcomes are found when fat grafts are enriched with adipose‐derived stromal cells (ASCs), implicating ASCs as key drivers of soft tissue regeneration. We have identified a subpopulation of ASCs positive for CD74 with enhanced antifibrotic effects. Compared to CD74− and unsorted (US) ASCs, CD74+ ASCs have increased expression of hepatocyte growth factor, fibroblast growth factor 2, and transforming growth factor β3 (TGF‐β3) and decreased levels of TGF‐β1. Dermal fibroblasts incubated with conditioned media from CD74+ ASCs produced less collagen upon stimulation, compared to fibroblasts incubated with media from CD74− or US ASCs. Upon transplantation, fat grafts enriched with CD74+ ASCs reduced the stiffness, dermal thickness, and collagen content of overlying skin, and decreased the relative proportions of more fibrotic dermal fibroblasts. Improvements in several extracellular matrix components were also appreciated on immunofluorescent staining. Together these findings indicate CD74+ ASCs have antifibrotic qualities and may play an important role in future strategies to address fibrotic remodeling following radiation‐induced fibrosis.
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Affiliation(s)
- Mimi R Borrelli
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Ronak A Patel
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Sandeep Adem
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Nestor M Diaz Deleon
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Abra H Shen
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Jan Sokol
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Sara Yen
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Erin Y Chang
- Program in Epithelial Biology, Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Rahim Nazerali
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Dung Nguyen
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Arash Momeni
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin C Wang
- Program in Epithelial Biology, Department of Dermatology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael T Longaker
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA.,Stanford Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Derrick C Wan
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California, USA
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15
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Avanzo M, Pirrone G, Vinante L, Caroli A, Stancanello J, Drigo A, Massarut S, Mileto M, Urbani M, Trovo M, El Naqa I, De Paoli A, Sartor G. Electron Density and Biologically Effective Dose (BED) Radiomics-Based Machine Learning Models to Predict Late Radiation-Induced Subcutaneous Fibrosis. Front Oncol 2020; 10:490. [PMID: 32373520 PMCID: PMC7186445 DOI: 10.3389/fonc.2020.00490] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/18/2020] [Indexed: 12/24/2022] Open
Abstract
Purpose: to predict the occurrence of late subcutaneous radiation induced fibrosis (RIF) after partial breast irradiation (PBI) for breast carcinoma by using machine learning (ML) models and radiomic features from 3D Biologically Effective Dose (3D-BED) and Relative Electron Density (3D-RED). Methods: 165 patients underwent external PBI following a hypo-fractionation protocol consisting of 40 Gy/10 fractions, 35 Gy/7 fractions, and 28 Gy/4 fractions, for 73, 60, and 32 patients, respectively. Physicians evaluated toxicity at regular intervals by the Common Terminology Adverse Events (CTAE) version 4.0. RIF was assessed every 3 months after the completion of radiation course and scored prospectively. RIF was experienced by 41 (24.8%) patients after average 5 years of follow up. The Hounsfield Units (HU) of the CT-images were converted into relative electron density (3D-RED) and Dose maps into Biologically Effective Dose (3D-BED), respectively. Shape, first-order and textural features of 3D-RED and 3D-BED were calculated in the planning target volume (PTV) and breast. Clinical and demographic variables were also considered (954 features in total). Imbalance of the dataset was addressed by data augmentation using ADASYN technique. A subset of non-redundant features that best predict the data was identified by sequential feature selection. Support Vector Machines (SVM), ensemble machine learning (EML) using various aggregation algorithms and Naive Bayes (NB) classifiers were trained on patient dataset to predict RIF occurrence. Models were assessed using sensitivity and specificity of the ML classifiers and the area under the receiver operator characteristic curve (AUC) of the score functions in repeated 5-fold cross validation on the augmented dataset. Results: The SVM model with seven features was preferred for RIF prediction and scored sensitivity 0.83 (95% CI 0.80-0.86), specificity 0.75 (95% CI 0.71-0.77) and AUC of the score function 0.86 (0.85-0.88) on cross-validation. The selected features included cluster shade and Run Length Non-uniformity of breast 3D-BED, kurtosis and cluster shade from PTV 3D-RED, and 10th percentile of PTV 3D-BED. Conclusion: Textures extracted from 3D-BED and 3D-RED in the breast and PTV can predict late RIF and may help better select patient candidates to exclusive PBI.
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Affiliation(s)
- Michele Avanzo
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Giovanni Pirrone
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Lorenzo Vinante
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Angela Caroli
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | | | - Annalisa Drigo
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Samuele Massarut
- Breast Surgery Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Mario Mileto
- Breast Surgery Unit, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Martina Urbani
- Department of Radiology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Marco Trovo
- Department of Radiation Oncology, Udine General Hospital, Udine, Italy
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, United States
| | - Antonino De Paoli
- Department of Radiation Oncology, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Giovanna Sartor
- Department of Medical Physics, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
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16
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Palma G, Monti S, Conson M, Xu T, Hahn S, Durante M, Mohan R, Liao Z, Cella L. NTCP Models for Severe Radiation Induced Dermatitis After IMRT or Proton Therapy for Thoracic Cancer Patients. Front Oncol 2020; 10:344. [PMID: 32257950 PMCID: PMC7090153 DOI: 10.3389/fonc.2020.00344] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/27/2020] [Indexed: 12/25/2022] Open
Abstract
Radiation therapy (RT) of thoracic cancers may cause severe radiation dermatitis (RD), which impacts on the quality of a patient's life. Aim of this study was to analyze the incidence of acute RD and develop normal tissue complication probability (NTCP) models for severe RD in thoracic cancer patients treated with Intensity-Modulated RT (IMRT) or Passive Scattering Proton Therapy (PSPT). We analyzed 166 Non-Small-Cell Lung Cancer (NSCLC) patients prospectively treated at a single institution with IMRT (103 patients) or PSPT (63 patients). All patients were treated to a prescribed dose of 60 to 74 Gy in conventional daily fractionation with concurrent chemotherapy. RD was scored according to CTCAE v3 scoring system. For each patient, the epidermis structure (skin) was automatically defined by an in house developed segmentation algorithm. The absolute dose-surface histogram (DSH) of the skin were extracted and normalized using the Body Surface Area (BSA) index as scaling factor. Patient and treatment-related characteristics were analyzed. The Lyman-Kutcher-Burman (LKB) NTCP model recast for DSH and the multivariable logistic model were adopted. Models were internally validated by Leave-One-Out method. Model performance was evaluated by the area under the receiver operator characteristic curve, and calibration plot parameters. Fifteen of 166 (9%) patients developed severe dermatitis (grade 3). RT technique did not impact RD incidence. Total gross tumor volume (GTV) size was the only non dosimetric variable significantly correlated with severe RD (p = 0.027). Multivariable logistic modeling resulted in a single variable model including S20Gy, the relative skin surface receiving more than 20 Gy (OR = 31.4). The cut off for S20Gy was 1.1% of the BSA. LKB model parameters were TD50 = 9.5 Gy, m = 0.24, n = 0.62. Both NTCP models showed comparably high prediction and calibration performances. Despite skin toxicity has long been considered a potential limiting factor in the clinical use of PSPT, no significant differences in RD incidence was found between RT modalities. Once externally validated, the availability of NTCP models for prediction of severe RD may advance treatment planning optimization.
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Affiliation(s)
- Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy.,National Institute for Nuclear Physics, (INFN), Naples, Italy
| | - Serena Monti
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Ting Xu
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Stephen Hahn
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Marco Durante
- GSI Helmholtz Centre for Heavy Ion Research, Department of Biophysics, Darmstadt, Germany
| | - Radhe Mohan
- Department of Radiation Physics, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Zhongxing Liao
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Laura Cella
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy.,National Institute for Nuclear Physics, (INFN), Naples, Italy
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17
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Falco M, Masojć B, Rolla M, Czekała A, Milchert-Leszczyńska M, Pietruszewska J, Lewocki M. Analysis of breast cosmetic effects 3 years after breast-conserving surgery and intraoperative radiotherapy with and without adjuvant whole breast irradiation. Breast J 2020; 26:882-887. [PMID: 31997527 DOI: 10.1111/tbj.13767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Intraoperative radiotherapy (IORT) based on low-kV photons may be an option for early breast cancer patients. Following Targit trial results some of those patients should undergo whole breast irradiation (WBRT) additionally. MATERIAL AND METHODS Since April 2010, IORT has been applied to early breast cancer patients. One hundred and fifty patients were prospectively followed up and examined to evaluate the side effects (pain, fibrosis, breast edema, telangiectasias). We present the results 3 years post-treatment. WBRT was given to 82 (54.7%) patients. RESULTS Tumor cavity fibrosis grade II and more was observed in 18 (12%) patients, as grade III only in 2 (1.33%) patients. Breast tissue fibrosis outside tumor cavity grade II was observed only in 2 (1.33%) patients. Breast edema was present in 10 (6.66%) patients. WBRT administration led to increased frequency of higher grade tumor cavity fibrosis (P < .0001), breast fibrosis (P < .0001), breast edema (P = .003), and occurrence of telangiectasias (P = .03), with no influence on pain reported by patients. In case of WBRT, tumor location (P = .026) and size of the irradiated breast (P = .015) were independent risk factors for higher degree of breast fibrosis, as seroma evacuation 6 months post-WBRT (P = .036) was the only independent risk factor for higher level of tumor cavity fibrosis in multiple regression. CONCLUSIONS The cosmetic result after IORT is good and comparable to other accelerated partial breast irradiation techniques. Administration of WBRT post-IORT in breast cancer patients increases the level of fibrotic changes, breast edema and telangiectasias 3 years post-treatment, but with no influence on pain.
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Affiliation(s)
- Michał Falco
- Radiation Oncology Department, West Pomeranian Oncology Center, Szczecin, Poland
| | - Bartłomiej Masojć
- Radiation Oncology Department, West Pomeranian Oncology Center, Szczecin, Poland
| | - Magdalena Rolla
- Radiation Oncology Department, West Pomeranian Oncology Center, Szczecin, Poland
| | - Agnieszka Czekała
- Radiation Oncology Department, West Pomeranian Oncology Center, Szczecin, Poland
| | | | | | - Mirosław Lewocki
- Department of Medical Physics, West Pomeranian Oncology Center, Szczecin, Poland
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18
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Shahbazian H, Bakhshali R, Shamsi A, Bagheri A. Dosimetric analysis of breast cancer tumor bed boost: An interstitial brachytherapy vs. external beam radiation therapy comparison for deeply seated tumors. Brachytherapy 2019; 19:264-274. [PMID: 31787575 DOI: 10.1016/j.brachy.2019.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To dosimetrically compare interstitial brachytherapy (MIBT) vs. EBRT (3DCRT and high-energy electron beams) for deep-seated tumor bed boosts (depth ≥4 cm) in early-stage breast cancer. METHODS AND MATERIALS Planning CTs of fifteen left-side breast cancer patients previously treated with MIBT boost chosen for this study. MIBT, 3DCRT (three-field technique), and enface high-energy electron (15-18 MeV) plans retrospectively generated on these images. To minimize intrapatient target contour inconsistency, due to a technical limitation for transferring identical contours from brachytherapy to EBRT planning system, spherical volumes delineated as hypothetical CTVs (CTV-H) (depth ≥4 cm with considering the geometry of the brachytherapy implant) instead of original lumpectomy cavities (which had irregular contours). In EBRT, PTV-H=CTV-H+5 mm. To account for beam penumbra, additional PTV-H to beam-edge margins added (3DCRT = 5 mm; electron = 10 mm). Included organs at risk (OARs) were ipsilateral breast, skin, ribs, lung, and heart. Prescribed dose-fractionations were 12 Gy/3fractions (MIBT) and 16 Gy/8fractions (EBRT) (BED = 24 Gy, breast cancer Alpha/Beta = 4 Gy). Biologically equivalent DVH parameters for all techniques compared. RESULTS Mean CTV-H depth was 6 cm. Normal breast V25%-V100%; skin V10%-V90%; rib V25%-V75%; lung V5%-V25%; heart V10%; mean lung dose; ribs/lung Dmax were lower in MIBT vs. 3CDRT. MIBT reduced breast V25%-V125%; skin V25%-V125%; rib V25%-V75% and V100%; lung V25%-V90%; heart V10%-V50%; skin/ribs/lung Dmax compared to electrons. In contrast, breast V125%-V250% and V175%-V250% were increased in MIBT vs. 3DCRT and electron plans, respectively. Electron plans had the minimum mean heart dose. CONCLUSIONS From a dosimetric point of view, in deeply-seated lumpectomy beds, MIBT boost better protects OARs from exposure to medium and high doses of radiation compared to 3DCRT and high energy electron beams (except more ipsilateral breast hot spots).
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Affiliation(s)
- Hodjatollah Shahbazian
- Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Roksana Bakhshali
- Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Azin Shamsi
- Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Bagheri
- Interventional Radiotherapy Ward, Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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19
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Lin JY, Yang X, Serra M, Miller AH, Godette KD, Kahn ST, Henry S, Brown G, Liu T, Torres MA. Full axillary lymph node dissection and increased breast epidermal thickness 1 year after radiation therapy for breast cancer. J Surg Oncol 2019; 120:1397-1403. [PMID: 31705561 DOI: 10.1002/jso.25757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 10/30/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND We previously reported a prospective study showing axillary lymph node dissection (ALND) is associated with increased breast skin thickening during and 6 weeks post-radiation therapy (RT), and now report ALND's long-term impact at 1 year. METHODS Among 66 women who received whole breast RT after lumpectomy, objective ultrasound measurements of epidermal thickness over four quadrants of the treated breast were measured at five time points: before RT, week 6 of RT, and 6 weeks, 6 months, and 1 year post-RT. Skin thickness ratio (STRA) was generated by normalizing for corresponding measurements of the contralateral breast. RESULTS A total of 2,436 ultrasound images were obtained. Among 63 women with evaluable data at 1 year, mean STRA significantly increased at 6 months (absolute mean increase of 65%, SD 0.054), and remained elevated at 1 year post-RT (absolute mean increase of 44%, SD 0.048). In multivariable analysis, ALND compared to sentinel lymph node biopsy, longer interval between surgery and RT, increased baseline STRA, and Caucasian race predicted for more severe changes in STRA at 1 year compared to baseline (all P < .05). CONCLUSIONS In the setting of whole breast RT, our findings suggest that ALND has long-term repercussions on breast skin thickening.
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Affiliation(s)
- Jolinta Y Lin
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Xiaofeng Yang
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Monica Serra
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Andrew H Miller
- Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Karen D Godette
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shannon T Kahn
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Simone Henry
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Gabrielle Brown
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mylin A Torres
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia.,Winship Cancer Institute, Emory University, Atlanta, Georgia
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20
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Borrelli MR, Shen AH, Lee GK, Momeni A, Longaker MT, Wan DC. Radiation-Induced Skin Fibrosis: Pathogenesis, Current Treatment Options, and Emerging Therapeutics. Ann Plast Surg 2019; 83:S59-S64. [PMID: 31513068 PMCID: PMC6746243 DOI: 10.1097/sap.0000000000002098] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Radiotherapy (RT) has become an indispensable part of oncologic treatment protocols for a range of malignancies. However, a serious adverse effect of RT is radiodermatitis; almost 95% of patients develop moderate to severe skin reactions following radiation treatment. In the acute setting, these can be erythema, desquamation, ulceration, and pain. Chronically, soft tissue atrophy, alopecia, and stiffness can be noted. Radiodermatitis can delay oncologic treatment protocols and significantly impair quality of life. There is currently a paucity of effective treatment options and prevention strategies for radiodermatitis. Importantly, recent preclinical and clinical studies have suggested that fat grafting may be of therapeutic benefit, reversing detrimental changes to soft tissue following RT. This review outlines the damaging effects of RT on the skin and soft tissue as well as discusses available treatment options for radiodermatitis. Emerging strategies to mitigate detrimental, chronic radiation-induced changes are also presented.
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Affiliation(s)
- Mimi R. Borrelli
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California
| | - Abra H. Shen
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California
| | - Gordon K. Lee
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, California
| | - Michael T. Longaker
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, California
| | - Derrick C. Wan
- Hagey Laboratory for Pediatric Regenerative Medicine, Department of Surgery, Division of Plastic Surgery, Stanford University School of Medicine, Stanford, California
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21
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Poodt IGM, Walstra CJEF, Vugts G, Maaskant-Braat AJG, Voogd AC, Schipper RJ, Nieuwenhuijzen GAP. Low Risk of Development of a Regional Recurrence After an Unsuccessful Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence. Ann Surg Oncol 2019; 26:2417-2427. [PMID: 30850903 DOI: 10.1245/s10434-019-07272-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Unlike sentinel lymph node biopsy (SLNB) in the primary setting, the repeat SLNB (rSLNB) in patients with ipsilateral breast tumor recurrence (IBTR) is challenging, because it is difficult to visualize and/or harvest a sentinel lymph node in every patient. Regional treatments options and safety in terms of regional disease control after such an unsuccessful rSLNB remain unclear. This study assesses factors associated with the performance of axillary lymph node dissection (ALND) after unsuccessful rSLNB and evaluates the occurrence of regional recurrences. METHODS Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 239 patients, the rSLNB was unsuccessful, of whom 60 patients underwent ipsilateral ALND. RESULTS A shorter time interval between primary treatment and IBTR, and a primary negative SLNB were significantly associated with a higher probability to be treated with ALND after unsuccessful rSLNB (P < 0.001). The 5-year regional-recurrence rate was 0.0% in the ALND group compared with 3.7% in the group treated without ALND (P = 0.113). Of the 179 patients treated without ALND, after a median follow-up of 5.1 years (range 0.3-13.2), 7 (3.9%) developed a regional recurrence as first event after unsuccessful rSLNB. None of the seven recurrences occurred in the ipsilateral axilla. Univariable analysis showed no factors associated with regional recurrence as first event after unsuccessful rSLNB (P > 0.05). CONCLUSIONS The present study demonstrates that the risk of regional recurrence in patients with an IBTR and an unsuccessful rSLNB is negligible, irrespective of the use of ALND. This suggests that there is no need for additional treatment of the axilla after an unsuccessful rSLNB.
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Affiliation(s)
- Ingrid G M Poodt
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ, Eindhoven, The Netherlands.
| | - Coco J E F Walstra
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ, Eindhoven, The Netherlands
| | - Guusje Vugts
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ, Eindhoven, The Netherlands
| | | | - Adri C Voogd
- Department of Epidemiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert-Jan Schipper
- Department of Surgery, Catharina Hospital Eindhoven, 5623 EJ, Eindhoven, The Netherlands
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22
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Palma G, Cella L. A new formalism of Dose Surface Histograms for robust modeling of skin toxicity in radiation therapy. Phys Med 2019; 59:75-78. [PMID: 30928068 DOI: 10.1016/j.ejmp.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/09/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE To present a new formalism for a robust computation of Dose-Surface Histograms (DSHs) to be exploited in the analysis of surface effects in radiation induced toxicity phenomena. METHODS A new formal recipe for the DSH extraction is described. It is based on the computation of the Dose-Volume Histogram (DVH) on a 3D structure in the limit of vanishing thickness to approach the two-dimensional organ manifold. The theory is customized for the application to skin description. RESULTS The derived formalism resulted in a redefinition of the generalized equivalent uniform dose (gEUD) and, accordingly, in an extension of the scope of the classical Lyman-Kutcher-Burman (LKB) Normal Tissue Complication Probability (NTCP) to a DSH-based toxicity modeling. CONCLUSIONS Our approach properly fits the intrinsic 3D nature of the DSH computation issue, and guarantees the rotational invariance and the robustness of the results. The proposed formalism can be easily implemented in treatment planning systems for dose optimization and potentially paves the way to a consistent analysis of radiation-induced morbidity endpoints related to surface effects in hollow organs.
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Affiliation(s)
- Giuseppe Palma
- Institute of Biostructures and Bioimaging, Italian National Research Council, Napoli, Italy.
| | - Laura Cella
- Institute of Biostructures and Bioimaging, Italian National Research Council, Napoli, Italy
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23
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Predictors for poor cosmetic outcome in patients with early stage breast cancer treated with breast conserving therapy: Results of the Young boost trial. Radiother Oncol 2018; 128:434-441. [DOI: 10.1016/j.radonc.2018.06.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/27/2018] [Accepted: 06/12/2018] [Indexed: 11/21/2022]
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24
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Kindts I, Defraene G, Laenen A, Petillion S, Van Limbergen E, Depuydt T, Weltens C. Development of a normal tissue complication probability model for late unfavourable aesthetic outcome after breast-conserving therapy. Acta Oncol 2018; 57:916-923. [PMID: 29652212 DOI: 10.1080/0284186x.2018.1461926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE/OBJECTIVES To develop a normal tissue complication probability (NTCP) model for late unfavourable aesthetic outcome (AO) after breast-conserving therapy. MATERIAL AND METHODS The BCCT.core software evaluated the AO using standardized photographs of patients treated between 2009 and 2014. Dose maps in 2 Gy equivalents were calculated assuming α/β = 3.6 Gy. Uni- and multivariable logistic regression analysis was performed to study the predictive value of clinicopathological and dosimetric variables for unfavourable AO. The Lyman Kutcher Burman (LKB) model was fit to the data with dose modifying factors (dmf). Model performance was assessed with the area under the curve (AUC) of the receiver operating characteristic curve and bootstrap sampling. RESULTS Forty-four of the 121 analysed patients (36%) developed unfavourable AO. In the optimal multivariable logistic regression model, a larger breast volume receiving ≥55 Gy (V55), a seroma and an axillary lymph node dissection (ALND) were independently associated with an unfavourable AO, AUC = 0.75 (95%CI 0.64;0.85). Beta-estimates were -2.68 for β0, 0.057 for V55, 1.55 for seroma and 1.20 for ALND. The optimal LKB model parameters were EUD3.6(50) = 63.3 Gy, n = 1.00, m = 0.23, dmf(seroma) = 0.83 and dmf(ALND) = 0.84, AUC = 0.74 (95%CI 0.61;0.83). CONCLUSIONS An NTCP model for late unfavourable AO after breast-conserving therapy was developed including seroma, axillary lymphadenectomy and V55.
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Affiliation(s)
- Isabelle Kindts
- Department of Oncology, Experimental Radiation Oncology, KU Leuven – University of Leuven, Leuven, Belgium
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Gilles Defraene
- Department of Oncology, Experimental Radiation Oncology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-Biostat), KU Leuven University, Leuven, Belgium
| | - Saskia Petillion
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Erik Van Limbergen
- Department of Oncology, Experimental Radiation Oncology, KU Leuven – University of Leuven, Leuven, Belgium
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Tom Depuydt
- Department of Oncology, Experimental Radiation Oncology, KU Leuven – University of Leuven, Leuven, Belgium
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Caroline Weltens
- Department of Oncology, Experimental Radiation Oncology, KU Leuven – University of Leuven, Leuven, Belgium
- Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
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25
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Acute toxicity of intraoperative radiotherapy and external beam-accelerated partial breast irradiation in elderly breast cancer patients. Breast Cancer Res Treat 2018; 169:549-559. [PMID: 29460031 PMCID: PMC5953978 DOI: 10.1007/s10549-018-4712-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/03/2018] [Indexed: 12/27/2022]
Abstract
Background and purpose We investigated the acute toxicity of accelerated partial breast irradiation using external beam (EB-APBI) or intraoperative radiotherapy (IORT) techniques in elderly breast cancer patients. Materials and methods Women ≥ 60 years with unifocal breast tumors of ≤ 30 mm were eligible for this prospective multi-center cohort study. IORT was applied with electrons following lumpectomy (23.3 Gy). EB-APBI was delivered using 3D-CRT or IMRT in 10 daily fractions of 3.85 Gy within 6 weeks after surgery. Acute toxicity was scored using the CTCAE v3.0 at 3 months after treatment. Patient-reported symptoms were analyzed using visual analogue scales (VAS) for pain and fatigue (scale 0–10), and single items from the EORTC QLQ-C30 and Breast Cancer questionnaires. Results In total, 267 (IORT) and 206 (EB-APBI) patients were available for toxicity analysis. More patients experienced ≥ grade 2 CTCAE acute toxicity in the IORT group (10.4% IORT and 4.9% EB-APBI; p = 0.03); grade 3 toxicity was low (3.3% IORT and 1.5% EB-APBI; ns); and no grade 4 toxicity occurred. EB-APBI patients experienced less fatigue direct postoperatively (EORTC p < 0.00, VAS p < 0.00). After 3 months only pain, according to the VAS scale, was significantly worse in the EB-APBI group (p < 0.00). Conclusion Acute toxicity after IORT and EB-APBI treatment is acceptable.
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26
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Which simultaneous-integrated boost (SIB) intensity-modulated radiotherapy (IMRT) technique is dosimetrically superior in the treatment of breast cancer; volumetric-modulated arc therapy (VMAT) or fixed field (ff) IMRT? JOURNAL OF RADIOTHERAPY IN PRACTICE 2017. [DOI: 10.1017/s1460396917000164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground and purposeTo determine which concomitant boost technique is dosimetrically superior in the treatment of breast cancer; volumetric-modulated arc therapy (VMAT) or fixed field intensity-modulated radiotherapy (ff-IMRT).Materials and methodsIn total, 30 breast patients were re-planned with both VMAT and fixed field concomitant boost intensity-modulated radiotherapy techniques. A hybrid technique was used delivering 80% of the dose through tangential beams and 20% through an integrated boost. A two-tailed t-test sample for means was used to compare the dosimetric differences between the techniques.ResultsMaximum dose was statistically lower for VMAT; 103·2 versus 103·7% for ff-IMRT along with statistically lower V2 Gy doses to the contralateral lung (0·7 versus 1·6%) and heart for both left- (19·0%/22·6%), and right- (5·5%/8·8%) sided patients, respectively. ff-IMRT boasted significantly lower ipsilateral lung V20, V18 and V10 Gy (7·9/8·6/13·1 versus 8·1/8·8/13·4%) than VMAT, respectively. No differences were found with minimum coverage, mean dose and V5 Gy to all organs at risk (OARs).ConclusionVMAT and ff-IMRT techniques demonstrate excellent target coverage and OAR sparing facilitated by the hybrid planning technique and deep inspiration breath hold. There is no obvious dosimetrically superior option between the two techniques. Reduced treatment times with VMAT make it more desirable to implement clinically.
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27
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Basaula D, Quinn A, Walker A, Batumalai V, Kumar S, Delaney GP, Holloway L. Risks and benefits of reducing target volume margins in breast tangent radiotherapy. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2017; 40:305-315. [PMID: 28243923 DOI: 10.1007/s13246-017-0529-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 01/27/2017] [Indexed: 12/25/2022]
Abstract
This study investigates the potential benefits of planning target volume (PTV) margin reduction for whole breast radiotherapy in relation to dose received by organs at risk (OARs), as well as reductions in radiation-induced secondary cancer risk. Such benefits were compared to the increased radiation-induced secondary cancer risk attributed from increased ionizing radiation imaging doses. Ten retrospective patients' computed tomography datasets were considered. Three computerized treatment plans with varied PTV margins (0, 5 and 10 mm) were created for each patient complying with the Radiation Therapy Oncology Group (RTOG) 1005 protocol requirements. The BEIR VII lifetime attributable risk (LAR) model was used to estimate secondary cancer risk to OARs. The LAR was assessed for all treatment plans considering (a) doses from PTV margin variation and (b) doses from two (daily and weekly) kilovoltage cone beam computed tomography (kV CBCT) imaging protocols during the course of treatment. We found PTV margins from largest to smallest resulted in a mean OAR relative dose reduction of 31% (heart), 28% (lung) and 23% (contralateral breast) and the risk of radiation-induced secondary cancer by a relative 23% (contralateral breast) and 22% (contralateral lung). Daily image-guidance using kV CBCT increased the risk of radiation induced secondary cancer to the contralateral breast and contralateral lung by a relative 1.6-1.9% and 1.9-2.5% respectively. Despite the additional dose from kV CBCT for the two considered imaging protocols, smaller PTV margins would still result in an overall reduction in secondary cancer risk.
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Affiliation(s)
- Deepak Basaula
- Department of Medical Physics and Radiation Engineering, The Canberra Hospital, Garran, Australia. .,Ingham Institute of Applied Medical Research, Sydney, Australia.
| | - Alexandra Quinn
- Northern Sydney Cancer Therapy Centre, Royal North Shore Hospital, Sydney, Australia
| | - Amy Walker
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
| | - Vikneswary Batumalai
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Shivani Kumar
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Geoff P Delaney
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia
| | - Lois Holloway
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, Australia.,Ingham Institute of Applied Medical Research, Sydney, Australia.,University of New South Wales, Sydney, Australia.,Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia.,Institute of Medical Physics, University of Sydney, Sydney, Australia
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28
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Strigari L, Ferrero V, Visonà G, Dalmasso F, Gobbato A, Cerello P, Visentin S, Attili A. Targeted dose enhancement in radiotherapy for breast cancer using gold nanoparticles, part 2: A treatment planning study. Med Phys 2017; 44:1993-2001. [PMID: 28236658 DOI: 10.1002/mp.12178] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/15/2016] [Accepted: 02/13/2017] [Indexed: 12/22/2022] Open
Abstract
PURPOSE In recent years, there has been growing interest in the use of gold nanoparticles (GNPs) combined with radiotherapy to improve tumor control. However, the complex interplay between GNP uptake and dose distribution in realistic clinical treatment are still somewhat unknown. METHODS The effects of different concentrations of 2 nm diameter GNP, ranging from 0 to 5×105 nanoparticles per tumoral cell, were theoretically investigated. A parametrization of the GNP distribution outside the target was carried out using a Gaussian standard deviation σ, from a zero value, relative to a selective concentration of GNPs inside the tumor volume alone, to 50mm, when GNPs are spatially distributed also in the healthy tissues surrounding the tumor. Treatment simulations of five patients with breast cancer were performed with 6 and 15 MV photons assuming a partial breast irradiation. A closed analytical reformulation of the Local Effect Model coupled with the estimation of local dose deposited around a GNP was validated using an in vitro study for MDA-MB-231 tumoral cells. The expected treatment outcome was quantified in terms of tumor control probability (TCP) and normal tissue complication probability (NTCP) as a function of the spatially varying gold uptake. RESULTS Breast cancer treatment planning simulations show improved treatment outcomes when GNPs are selectively concentrated in the tumor volume (i.e., σ = 0 mm). In particular, the TCP increases up to 18% for 5×105 nanoparticles per cell in the tumor region depending on the treatment schedules, whereas an improvement of the therapeutic index is observed only for concentrations of about 105 GNPs per tumoral cell and limited spatial distribution in the normal tissue. CONCLUSIONS The model provides a useful framework to estimate the nanoparticle-driven radiosensitivity in breast cancer treatment irradiation, accounting for the complex interplay between dose and GNP uptake distributions.
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Affiliation(s)
- Lidia Strigari
- Laboratory of Medical Physics and Expert Systems, National Cancer Institute Regina Elena, Roma, Italy
| | - Veronica Ferrero
- Physics Department, Università degli Studi di Torino, Torino, Italy.,Istituto Nazionale di Fisica Nucleare (INFN), Torino, Italy
| | - Giovanni Visonà
- Physics Department, Università degli Studi di Torino, Torino, Italy
| | - Federico Dalmasso
- Physics Department, Università degli Studi di Torino, Torino, Italy.,Istituto Nazionale di Fisica Nucleare (INFN), Torino, Italy
| | - Andrea Gobbato
- Physics Department, Università degli Studi di Torino, Torino, Italy.,Istituto Nazionale di Fisica Nucleare (INFN), Torino, Italy
| | | | - Sonja Visentin
- Istituto Nazionale di Fisica Nucleare (INFN), Torino, Italy.,Molecular Biotechnology and Health Sciences Department, Università degli Studi di Torino, Torino, Italy
| | - Andrea Attili
- Istituto Nazionale di Fisica Nucleare (INFN), Torino, Italy
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29
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Herskind C, Ma L, Liu Q, Zhang B, Schneider F, Veldwijk MR, Wenz F. Biology of high single doses of IORT: RBE, 5 R's, and other biological aspects. Radiat Oncol 2017; 12:24. [PMID: 28107823 PMCID: PMC5251326 DOI: 10.1186/s13014-016-0750-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 12/21/2016] [Indexed: 01/14/2023] Open
Abstract
Intraoperative radiotherapy differs from conventional, fractionated radiotherapy in several aspects that may influence its biological effect. The radiation quality influences the relative biologic effectiveness (RBE), and the role of the five R’s of radiotherapy (reassortment, repair, reoxygenation, repopulation, radiosensitivity) is different. Furthermore, putative special biological effects and the small volume receiving a high single dose may be important. The present review focuses on RBE, repair, and repopulation, and gives an overview of the other factors that potentially contribute to the efficacy. The increased RBE should be taken into account for low-energy X-rays while evidence of RBE < 1 for high-energy electrons at higher doses is presented. Various evidence supports a hypothesis that saturation of the primary DNA double-strand break (DSB) repair mechanisms leads to increasing use of an error-prone backup repair system leading to genomic instability that may contribute to inactivate tumour cells at high single doses. Furthermore, the elimination of repopulation of residual tumour cells in the tumour bed implies that some patients are likely to have very few residual tumour cells which may be cured even by low doses to the tumour bed. The highly localised dose distribution of IORT has the potential to inactivate tumour cells while sparing normal tissue by minimising the volume exposed to high doses. Whether special effects of high single doses also contribute to the efficacy will require further experimental and clinical studies.
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Affiliation(s)
- Carsten Herskind
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Lin Ma
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Present Address: Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Qi Liu
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Present Address: Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Bo Zhang
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.,Present Address: Department of Oncology at No. 2 Hospital Anhui Medical University, and School of Life Sciences, Anhui Medical University, Hefei, Anhui, China
| | - Frank Schneider
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Marlon R Veldwijk
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Radiation-induced fibrosis in the boost area after three-dimensional conformal radiotherapy with a simultaneous integrated boost technique for early-stage breast cancer: A multivariable prediction model. Radiother Oncol 2017; 122:45-49. [DOI: 10.1016/j.radonc.2016.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 09/22/2016] [Accepted: 10/02/2016] [Indexed: 01/19/2023]
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Teguh DN, Bol Raap R, Struikmans H, Verhoef C, Koppert LB, Koole A, Huang Y, van Hulst RA. Hyperbaric oxygen therapy for late radiation-induced tissue toxicity: prospectively patient-reported outcome measures in breast cancer patients. Radiat Oncol 2016; 11:130. [PMID: 27682427 PMCID: PMC5041335 DOI: 10.1186/s13014-016-0700-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 09/13/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction This study examines patient reported outcome measures of women undergoing hyperbaric oxygen treatment (HBOT) after breast-conserving therapy. Method Included were 57 women treated with HBOT for late radiation-induced tissue toxicity (LRITT) referred in the period January 2014-December 2015. HBOT consisted of (on average) 47 sessions. In total, 80 min of 100 % O2 was administered under increased pressure of 2.4 ATA. Quality of life was assessed before and after treatment using the European Organization for Research and Treatment of Cancer (EORTC) QLQ-BR23, and a NRS pain score. Results Fifty-seven women were available for evaluation before and after treatment. Before HBOT, patients had severe complaints of pain in the arm/shoulder (46 %), swollen arm/hand (14 %), difficulty to raise arm or move it sideways (45 %), pain in the area of the affected breast (67 %), swollen area of the affected breast (45 %), oversensitivity of the affected breast (54 %), and skin problems on/in the area of the affected breast (32 %); post HBOT, severe complaints were still experienced in 17, 7, 22, 15, 13, 15, and 11 % of the women, respectively. Differences were all significant. The NRS pain score improved at least 1 point (range 0–10) in 81 % of the patients (p < 0.05). Conclusion In these breast cancer patients treated with HBOT for LRITT, the patient-reported outcomes were positive and improvements were observed. HBOT was a well-tolerated treatment for LRITT and its side-effects were both minimal and reversible.
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Affiliation(s)
- David N Teguh
- Hyperbaar Geneeskundig Centrum Rijswijk, Treubstraat 5a, 2288 EG, Rijswijk, The Netherlands. .,Department of Surgery/Hyperbaric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - René Bol Raap
- Hyperbaar Geneeskundig Centrum Rijswijk, Treubstraat 5a, 2288 EG, Rijswijk, The Netherlands
| | - Henk Struikmans
- Department of Radiation Oncology, Leiden University Medical Centre, Leiden, The Netherlands.,Radiotherapy Centre West, Medical Centre Haaglanden, The Hague, The Netherlands
| | - Cees Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Arne Koole
- Hyperbaar Geneeskundig Centrum Rijswijk, Treubstraat 5a, 2288 EG, Rijswijk, The Netherlands
| | - Yadi Huang
- University of Leuven, Leuven, The Netherlands
| | - Rob A van Hulst
- Hyperbaar Geneeskundig Centrum Rijswijk, Treubstraat 5a, 2288 EG, Rijswijk, The Netherlands.,Department of Anesthesiology/Hyperbaric Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Torres MA, Yang X, Noreen S, Chen H, Han T, Henry S, Mister D, Andic F, Long Q, Liu T. The Impact of Axillary Lymph Node Surgery on Breast Skin Thickening During and After Radiation Therapy for Breast Cancer. Int J Radiat Oncol Biol Phys 2016; 95:590-6. [PMID: 27055397 DOI: 10.1016/j.ijrobp.2016.01.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/04/2016] [Accepted: 01/18/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE This prospective study was conducted to determine predictors of epidermal thickening during and after whole-breast radiation therapy (XRT) using objective measurements acquired with ultrasound. METHODS AND MATERIALS After breast-conserving surgery, 70 women received a definitive course of whole-breast XRT (50 Gy plus boost). Prior to XRT, at week 6 of XRT, and 6 weeks after XRT, patients underwent objective ultrasound measurements of epidermal thickness over the lumpectomy cavity and all 4 quadrants of the treated breast. A skin thickness ratio (STRA) was then generated normalizing for corresponding measurements taken of the untreated breast. RESULTS Baseline measurements indicated that 87% of patients had skin thickening in the treated versus untreated breast (mean increase, 27%; SD, 0.29) prior to XRT. The STRA increased significantly by week 6 of XRT (mean, 25%; SD, 0.46) and continued to increase significantly 6 weeks after XRT (mean, 33%; SD, 0.46) above baseline measurements (P<.001 for both time points). On multivariate analysis, breast volume (P=.003) and surgical evaluation of the axilla with full lymph node dissection (P<.05) predicted for more severe changes in the STRA 6 weeks after XRT compared with baseline. STRA measurements correlated with physician ratings of skin toxicity according to Radiation Therapy Oncology Group grading criteria. CONCLUSIONS This is one of the first studies to objectively document that lymph node surgery affects XRT-induced skin thickening in patients with breast cancer. Surgical evaluation of the axilla with complete lymph node dissection was associated with the most severe XRT-induced skin changes after XRT completion. These results may inform future studies aimed at minimizing side effects of XRT and surgery, particularly when surgical lymph node assessments may not alter breast cancer management or outcome.
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Affiliation(s)
- Mylin A Torres
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia.
| | - Xiaofeng Yang
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Samantha Noreen
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Hao Chen
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia; Provision Center for Proton Therapy, Knoxville, Tennessee
| | - Tatiana Han
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Simone Henry
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Donna Mister
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Fundagal Andic
- Department of Radiation Oncology, Cukurova University School of Medicine, Adana, Turkey
| | - Qi Long
- Winship Cancer Institute, Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University, Atlanta, Georgia
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Kindts I, Laenen A, Peeters S, Janssen H, Depuydt T, Neven P, Van Limbergen E, Weltens C. Evaluation of a breast cancer nomogram to predict ipsilateral breast relapse after breast-conserving therapy. Radiother Oncol 2016; 119:45-51. [PMID: 26879286 DOI: 10.1016/j.radonc.2016.01.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE A nomogram to predict for the 10-year ipsilateral breast relapse (IBR) after breast-conserving therapy (BCT) for breast cancer (BC) was developed based on the 'boost-no-boost'-trial with a concordance probability estimate (CPE) of 0.68. The aim of our study was to validate that algorithm. MATERIAL AND METHODS We retrospectively identified 1787 BC cases, treated with BCT and radiotherapy at the University Hospitals Leuven from 2000 to 2007, without missing data of the nomogram variables. Clinicopathologic factors were assessed. Validity of the prediction model was tested in terms of discrimination and calibration. RESULTS Median follow-up time was 10.75years. The validation cohort differed with respect to the administration of a radiation boost, chemo- or hormonal therapy, age, tumour diameter or grade, ductal carcinoma in situ and hormone receptor positivity. On multivariable analysis, the omission of the boost was a significant prognosticator of IBR (p<0.01). The 10-year IBR-rate was 1.4%. The nomogram demonstrated suboptimal discrimination (CPE 0.54) and calibration, with an overestimation of the IBR-risk in general. CONCLUSIONS The predictive model for IBR in BC is imperfect in this more recent study population.
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Affiliation(s)
- Isabelle Kindts
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Radiation Oncology, Belgium.
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-Biostat), KU Leuven University, Belgium
| | - Stephanie Peeters
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Radiation Oncology, Belgium
| | - Hilde Janssen
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Radiation Oncology, Belgium
| | - Tom Depuydt
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Radiation Oncology, Belgium
| | - Patrick Neven
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Obstetrics and Gynaecology, Belgium
| | - Erik Van Limbergen
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Radiation Oncology, Belgium
| | - Caroline Weltens
- KU Leuven - University of Leuven, Department of Oncology, Belgium; University Hospitals Leuven, Department of Radiation Oncology, Belgium.
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Pastore F, Conson M, D’Avino V, Palma G, Liuzzi R, Solla R, Farella A, Salvatore M, Cella L, Pacelli R. Dose-surface analysis for prediction of severe acute radio-induced skin toxicity in breast cancer patients. Acta Oncol 2015; 55:466-73. [PMID: 26623532 DOI: 10.3109/0284186x.2015.1110253] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Severe acute radiation-induced skin toxicity (RIST) after breast irradiation is a side effect impacting the quality of life in breast cancer (BC) patients. The aim of the present study was to develop normal tissue complication probability (NTCP) models of severe acute RIST in BC patients. PATIENTS AND METHODS We evaluated 140 consecutive BC patients undergoing conventional three-dimensional conformal radiotherapy (3D-CRT) after breast conserving surgery in a prospective study assessing acute RIST. The acute RIST was classified according to the RTOG scoring system. Dose-surface histograms (DSHs) of the body structure in the breast region were extracted as representative of skin irradiation. Patient, disease, and treatment-related characteristics were analyzed along with DSHs. NTCP modeling by Lyman-Kutcher-Burman (LKB) and by multivariate logistic regression using bootstrap resampling techniques was performed. Models were evaluated by Spearman's Rs coefficient and ROC area. RESULTS By the end of radiotherapy, 139 (99%) patients developed any degree of acute RIST. G3 RIST was found in 11 of 140 (8%) patients. Mild-moderate (G1-G2) RIST was still present at 40 days after treatment in six (4%) patients. Using DSHs for LKB modeling of acute RIST severity (RTOG G3 vs. G0-2), parameter estimates were TD50=39 Gy, n=0.38 and m=0.14 [Rs = 0.25, area under the curve (AUC) = 0.77, p = 0.003]. On multivariate analysis, the most predictive model of acute RIST severity was a two-variable model including the skin receiving ≥30 Gy (S30) and psoriasis [Rs = 0.32, AUC = 0.84, p < 0.001]. CONCLUSIONS Using body DSH as representative of skin dose, the LKB n parameter was consistent with a surface effect for the skin. A good prediction performance was obtained using a data-driven multivariate model including S30 and a pre-existing skin disease (psoriasis) as a clinical factor.
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Affiliation(s)
- Francesco Pastore
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Manuel Conson
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Vittoria D’Avino
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Giuseppe Palma
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Raffaele Liuzzi
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Raffaele Solla
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Antonio Farella
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Marco Salvatore
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
| | - Laura Cella
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
| | - Roberto Pacelli
- Department of Advanced Biomedical Sciences, Federico II University School of Medicine, Naples, Italy
- Institute of Biostructures and Bioimaging, National Research Council (CNR), Naples, Italy
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Harris EJ, Mukesh MB, Donovan EM, Kirby AM, Haviland JS, Jena R, Yarnold J, Baker A, Dean J, Eagle S, Mayles H, Griffin C, Perry R, Poynter A, Coles CE, Evans PM. A multicentre study of the evidence for customized margins in photon breast boost radiotherapy. Br J Radiol 2015; 89:20150603. [PMID: 26585543 PMCID: PMC4985208 DOI: 10.1259/bjr.20150603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/10/2015] [Accepted: 11/19/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine if subsets of patients may benefit from smaller or larger margins when using laser setup and bony anatomy verification of breast tumour bed (TB) boost radiotherapy (RT). METHODS Verification imaging data acquired using cone-beam CT, megavoltage CT or two-dimensional kilovoltage imaging on 218 patients were used (1574 images). TB setup errors for laser-only setup (dlaser) and for bony anatomy verification (dbone) were determined using clips implanted into the TB as a gold standard for the TB position. Cases were grouped by centre-, patient- and treatment-related factors, including breast volume, TB position, seroma visibility and surgical technique. Systematic (Σ) and random (σ) TB setup errors were compared between groups, and TB planning target volume margins (MTB) were calculated. RESULTS For the study population, Σlaser was between 2.8 and 3.4 mm, and Σbone was between 2.2 and 2.6 mm, respectively. Females with larger breasts (p = 0.03), easily visible seroma (p ≤ 0.02) and open surgical technique (p ≤ 0.04) had larger Σlaser. Σbone was larger for females with larger breasts (p = 0.02) and lateral tumours (p = 0.04). Females with medial tumours (p < 0.01) had smaller Σbone. CONCLUSION If clips are not used, margins should be 8 and 10 mm for bony anatomy verification and laser setup, respectively. Individualization of TB margins may be considered based on breast volume, TB and seroma visibility. ADVANCES IN KNOWLEDGE Setup accuracy using lasers and bony anatomy is influenced by patient and treatment factors. Some patients may benefit from clip-based image guidance more than others.
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Affiliation(s)
- Emma J Harris
- Radiotherapy and Imaging, Institute of Cancer Research Sutton, UK
| | - Mukesh B Mukesh
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Oncology Centre, Colchester Hospital University NHS Trust, Colchester, UK
| | - Ellen M Donovan
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Anna M Kirby
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Joanne S Haviland
- ICR-CTSU, Institute of Cancer Research, Sutton, UK
- Macmillan Survivorship Research Group, Faculty of Health Sciences, University of Southampton, UK
| | - Raj Jena
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - John Yarnold
- Radiotherapy and Imaging, Institute of Cancer Research Sutton, UK
| | - Angela Baker
- Department of Physics, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | - June Dean
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Sally Eagle
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
| | - Helen Mayles
- Department of Physics, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
| | | | - Rosalind Perry
- Department of Radiotherapy, Ipswich Hospital NHS Trust, Ipswich, UK
| | | | - Charlotte E Coles
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | | | - On behalf of the IMPORT high trialists
- Radiotherapy and Imaging, Institute of Cancer Research Sutton, UK
- Oncology Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Oncology Centre, Colchester Hospital University NHS Trust, Colchester, UK
- The Breast Unit, Royal Marsden Hospital NHS Foundation Trust, Sutton, UK
- ICR-CTSU, Institute of Cancer Research, Sutton, UK
- Macmillan Survivorship Research Group, Faculty of Health Sciences, University of Southampton, UK
- Department of Physics, The Clatterbridge Cancer Centre NHS Foundation Trust, Wirral, UK
- Department of Radiotherapy, Ipswich Hospital NHS Trust, Ipswich, UK
- Radiotherapy Department, Peterborough City Hospital, UK
- CVSSP, University of Surrey, Guildford, UK
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Avanzo M, Trovo M, Stancanello J, Jena R, Roncadin M, Toffoli G, Zuiani C, Capra E. Hypofractionation of partial breast irradiation using radiobiological models. Phys Med 2015; 31:1022-1028. [PMID: 26508014 DOI: 10.1016/j.ejmp.2015.08.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/10/2015] [Accepted: 08/03/2015] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To reduce the fraction number in Partial Breast Irradiation (PBI) with initial prescription of 40 Gy in 10 fractions using radiobiological models with specific focus on risk of moderate/severe radiation-induced fibrosis (RIF) and report clinical results. METHODS AND MATERIALS 68 patients (patient group A) were treated with 40 Gy in 10 fractions delivered by field-in-field, forward-planned IMRT. Isotoxic regimens with decreasing number of fractions were calculated using Biological Effective Dose (BED) to the breast. Risk for RIF in hypofractionated treatment was predicted by calculating NTCP from DVHs of group A rescaled to fractions and dose of novel regimens. Moderate/severe RIF was prospectively scored during follow-up. Various NTCP models, with and without incomplete repair correction, were assessed from difference to observed incidence of RIF. In order to verify the value for α/β of 3 Gy assumed for breast, we fitted α/β to observed incidences of moderate/severe RIF. RESULTS Treatments with 35 Gy/7f and 28 Gy/4f were selected for the fraction reduction protocol. 75 patients (group B) were treated in 35 Gy/7f. Incidence of moderate/severe RIF was 5.9% in group A, 5.3% in group B. The NTCP model with correction for incomplete repair had lowest difference from observed RIF. The α/β obtained from fitting was 2.8 (95%CIs 1.1-10.7) Gy. CONCLUSIONS The hypofractionated regimen was well tolerated. The model for NTCP corrected for incomplete repair was the most accurate and an assumed α/β value of 3 Gy is consistent with our patient data. The hypofractionation protocol is continuing with patients treated with 28 Gy/4f.
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Affiliation(s)
- Michele Avanzo
- Medical Physics Department, CRO Aviano, 33081 Aviano, Italy.
| | - Marco Trovo
- Radiation Oncology Department, CRO Aviano, 33081 Aviano, Italy
| | | | - Rajesh Jena
- Department of Oncology, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Mario Roncadin
- Radiation Oncology Department, CRO Aviano, 33081 Aviano, Italy
| | - Giulia Toffoli
- Institute of Diagnostic Radiology, Department of Medical and Biological Sciences, University of Udine, 33100 Udine, Italy
| | - Chiara Zuiani
- Institute of Diagnostic Radiology, Department of Medical and Biological Sciences, University of Udine, 33100 Udine, Italy
| | - Elvira Capra
- Medical Physics Department, CRO Aviano, 33081 Aviano, Italy
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Vugts G, Maaskant-Braat AJG, Voogd AC, van Riet YEA, Luiten EJT, Rutgers EJT, Rutten HJT, Roumen RMH, Nieuwenhuijzen GAP. Repeat sentinel node biopsy should be considered in patients with locally recurrent breast cancer. Breast Cancer Res Treat 2015; 153:549-56. [DOI: 10.1007/s10549-015-3571-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 09/07/2015] [Indexed: 10/23/2022]
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Pignol JP, Janus C. The evaluation of innovation in radiation oncology--what can we do and what should we do? Acta Oncol 2015. [PMID: 26198659 DOI: 10.3109/0284186x.2015.1067719] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jean-Philippe Pignol
- a Radiation Oncology Department, Erasmus MC Cancer Institute , Rotterdam , The Netherlands
| | - Cecile Janus
- a Radiation Oncology Department, Erasmus MC Cancer Institute , Rotterdam , The Netherlands
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Seppälä J, Heikkilä J, Myllyoja K, Koskela K. Volumetric modulated arc therapy for synchronous bilateral whole breast irradiation - A case study. Rep Pract Oncol Radiother 2015; 20:398-402. [PMID: 26549999 DOI: 10.1016/j.rpor.2015.05.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 02/13/2015] [Accepted: 05/24/2015] [Indexed: 01/08/2023] Open
Abstract
PURPOSE The treatment planning of bilateral breast irradiation (BBI) is a challenging task. The overlapping of tangential fields is usually unavoidable without compromising the target coverage. The purpose of this study was to investigate the technical feasibility and benefits of a single isocentre volumetric modulated arc therapy (VMAT) in BBI. METHODS AND MATERIALS Two women with bilateral breast cancer were included in this case study. The first patient (Pat#1) underwent a bilateral breast-conserving surgery and sentinel lymph node biopsy. The second patient (Pat#2) underwent a bilateral ablation and axillary lymph node dissection. Planning target volumes (PTV) and organs at risk were delineated on CT images. VMAT plans were created with four (two for both sides, Pat#1) or two (one for each breast, Pat#2) separate VMAT fields. Subsequently, traditional tangential field plans were generated for each patient and the dosimetric parameters were compared. RESULTS The treatment times of the patients with VMAT were less than 15 min with daily CBCT imaging. When compared to the standard tangential field technique, the VMAT plans improved the PTV dose coverage and dose homogeneity with improved sparing of lungs and heart. With traditional field arrangement, the overlapping of the tangential fields was inevitable without significantly compromising the target coverage, whereas with VMAT the hotspots were avoided. The patients were treated with the VMAT technique and no acute skin toxicity was observed with either of the patients. CONCLUSIONS A single isocentre VMAT technique has been implemented clinically for BBI. With the VMAT techniques, the dose delivery was quick and the hotspots in the field overlapping areas were avoided. The PTV dose coverage was superior in VMAT plans when compared with conventional tangential technique plans.
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Affiliation(s)
- Jan Seppälä
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Janne Heikkilä
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Kimmo Myllyoja
- Cancer Center, Kuopio University Hospital, Kuopio, Finland
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Virén T, Heikkilä J, Myllyoja K, Koskela K, Lahtinen T, Seppälä J. Tangential volumetric modulated arc therapy technique for left-sided breast cancer radiotherapy. Radiat Oncol 2015; 10:79. [PMID: 25888866 PMCID: PMC4404692 DOI: 10.1186/s13014-015-0392-x] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 03/25/2015] [Indexed: 11/24/2022] Open
Abstract
Background The aim of the present study was to introduce a new restricted tangential volumetric modulated arc therapy (tVMAT) technique for whole breast irradiation and compare its dosimetric properties to other currently used breast cancer radiotherapy techniques. Method Ten consecutive women with left-sided breast cancer were enrolled in this retrospective study. Four treatment plans were generated for each patient: 1) standard tangential field-in-field (FinF), 2) tangential intensity modulated radiotherapy (tIMRT), 3) tangential VMAT (tVMAT) with two dual arcs of 50-60° and 4) continuous VMAT (cVMAT) with a dual arc of 240°. The plans were created with Monaco® (tIMRT, tVMAT and cVMAT) and Oncentra® (FinF) treatment planning systems. Results With both VMAT techniques significantly higher cardiac avoidance, dose coverage and dose homogenity were achieved when compared with FinF or tIMRT techniques (p < 0.01). VMAT techniques also decreased the high dose areas (above 20 Gy) of ipsilateral lung. There were no significant differences in the mean dose of contralateral breast between the tVMAT, tIMRT and FinF techniques. The dose coverage (V47.5 Gy) was greatest with cVMAT. However, with cVMAT the increase of contralateral breast dose was significant. Conclusions The present results support the hypothesis that the introduced tVMAT technique is feasible for treatment of left-sided breast cancer. With tVMAT dose to heart and ipsilateral lung can be reduced and the dose homogeneity can be improved without increasing the dose to contralateral breast or lung.
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Affiliation(s)
- Tuomas Virén
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
| | - Janne Heikkilä
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
| | - Kimmo Myllyoja
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
| | - Kristiina Koskela
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
| | - Tapani Lahtinen
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
| | - Jan Seppälä
- Cancer Center, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland.
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Donovan EM, Harris EJ, Mukesh MB, Haviland JS, Titley J, Griffin C, Coles CE, Evans PM. The IMPORT HIGH image-guided radiotherapy study: a model for assessing image-guided radiotherapy. Clin Oncol (R Coll Radiol) 2015; 27:3-5. [PMID: 25445551 DOI: 10.1016/j.clon.2014.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 09/23/2014] [Indexed: 11/30/2022]
Affiliation(s)
- E M Donovan
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - E J Harris
- Joint Department of Physics at The Royal Marsden NHS Foundation Trust and Institute of Cancer Research, London, UK
| | - M B Mukesh
- Oncology Centre, Colchester Hospital University NHS Trust, Colchester, UK
| | - J S Haviland
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - J Titley
- ICR-CTSU, Institute of Cancer Research, Sutton, UK
| | - C Griffin
- ICR-CTSU, Institute of Cancer Research, Sutton, UK
| | - C E Coles
- Oncology Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - P M Evans
- Centre for Vision Speech and Signal Processing, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, UK.
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