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Karius A, Leifeld LM, Strnad V, Fietkau R, Bert C. First implementation of an innovative infra-red camera system integrated into a mobile CBCT scanner for applicator tracking in brachytherapy-Initial performance characterization. J Appl Clin Med Phys 2024; 25:e14364. [PMID: 38626753 PMCID: PMC11244686 DOI: 10.1002/acm2.14364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/24/2024] [Accepted: 03/28/2024] [Indexed: 04/18/2024] Open
Abstract
PURPOSE To enable a real-time applicator guidance for brachytherapy, we used for the first time infra-red tracking cameras (OptiTrack, USA) integrated into a mobile cone-beam computed tomography (CBCT) scanner (medPhoton, Austria). We provide the first description of this prototype and its performance evaluation. METHODS We performed assessments of camera calibration and camera-CBCT registration using a geometric calibration phantom. For this purpose, we first evaluated the effects of intrinsic parameters such as camera temperature or gantry rotations on the tracked marker positions. Afterward, calibrations with various settings (sample number, field of view coverage, calibration directions, calibration distances, and lighting conditions) were performed to identify the requirements for achieving maximum tracking accuracy based on an in-house phantom. The corresponding effects on camera-CBCT registration were determined as well by comparing tracked marker positions to the positions determined via CBCT. Long-term stability was assessed by comparing tracking and a ground-truth on a weekly basis for 6 weeks. RESULTS Robust tracking with positional drifts of 0.02 ± 0.01 mm was feasible using the system after a warm-up period of 90 min. However, gantry rotations affected the tracking and led to inaccuracies of up to 0.70 mm. We identified that 4000 samples and full coverage were required to ensure a robust determination of marker positions and camera-CBCT registration with geometric deviations of 0.18 ± 0.03 mm and 0.42 ± 0.07 mm, respectively. Long-term stability showed deviations of more than two standard deviations from the initial calibration after 3 weeks. CONCLUSION We implemented for the first time a standalone combined camera-CBCT system for tracking in brachytherapy. The system showed high potential for establishing corresponding workflows.
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Affiliation(s)
- Andre Karius
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Lisa Marie Leifeld
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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2
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Moore-Palhares D, Chen H, Khan BM, McCann C, Bosnic S, Hahn E, Soliman H, Czarnota G, Karam I, Rakovitch E, Lee J, Vesprini D. Locoregional Ablative Radiation Therapy for Patients With Breast Cancer Unsuitable for Surgical Resection. Pract Radiat Oncol 2024; 14:316-327. [PMID: 38154688 DOI: 10.1016/j.prro.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/23/2023] [Accepted: 12/01/2023] [Indexed: 12/30/2023]
Abstract
PURPOSE Patients with breast cancer who are unsuitable for surgical resection are typically managed with palliative systemic therapy alone. We report outcomes of 5-fraction ablative radiation therapy for nonresected breast cancers. METHODS AND MATERIALS This is a retrospective analysis of an institutional registry of patients with breast cancer who were unsuitable for resection and underwent 35 to 40 Gy/5 fractions to the primary breast tumor or regional lymph nodes from 2014 to 2021. Primary outcomes were cumulative incidence of local failure and grade ≥3 toxicity (Common Terminology Criteria for Adverse Events, version 5.0). RESULTS We reviewed 57 patients who received 61 treatment courses (median age of 81 years; range, 38-99). Unresectable tumor (10%), patient refusal (18%), medical inoperability (35%), and metastatic disease (37%) were the causes of not having surgery. Five patients (8%) had previously undergone adjuvant locoregional radiation therapy. Fifty-four percent (n = 33/61) of treatment courses targeted the breast only, 31% (n = 19/61) both the breast and lymph nodes, and 15% (n = 9/61) the lymph nodes only. Sixty-seven percent (n = 35/52) of the courses that targeted the breast were delivered with partial breast irradiation and 33% (n = 17/52) with whole breast radiation therapy (median dose of 25 Gy in 5 fractions) ± simultaneous integrated boost to the primary tumor. Most primary tumors (65%, n = 34/52) and target lymph nodes (61%, n = 17/28) were treated with a dose of 35 Gy in 5 fractions. Most treatments (52%) were delivered with intensity modulated radiation therapy (IMRT). Radiation therapy was delivered daily (20%), every other day (18%), twice weekly (36%), or weekly (26%). The 2-year cumulative incidence of local failure was 11.4% and grade≥3 toxicity was 15.1%. The grade ≥3 toxicity was 6.5% for IMRT treatments, versus 7.7% for non-IMRT treatments targeting partial breast or lymph nodes (hazard ratio, 1.13, P = .92), versus 38.9% for non-IMRT treatments targeting the entire breast (hazard ratio, 6.91, P = .023). All grade ≥3 toxicity cases were radiation dermatitis. No cases of brachial plexopathy were observed. CONCLUSIONS Thirty-five to 40 Gy in 5 fractions is a safe and effective breast stereotactic body radiation therapy (SBRT) regimen and may be an attractive option for patients who are not surgical candidates. Highly conformal techniques (ie, IMRT or partial breast irradiation) were associated with a reduced risk of toxicity and should be the preferred treatment approaches.
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Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Benazir Mir Khan
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Claire McCann
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sandi Bosnic
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ezra Hahn
- Department of Radiation Oncology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Gregory Czarnota
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Irene Karam
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eileen Rakovitch
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Justin Lee
- Department of Radiation Oncology, Juravinski Cancer Centre, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Danny Vesprini
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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3
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Díaz-Gavela AA, Cerro Peñalver ED, Sanchez-Garcia S, Pardo-Perez E, Thuissard-Vasallo IJ, Andreu-Vázquez C, Molina López MY, Pena Huertas M, Guerrero-Gómez LL, Sanz-Rosa D, Lorenzo FC. Hypofractionated whole breast IMRT with HDR brachytherapy boost in early-stage breast cancer: Long-term results from a single-center. Brachytherapy 2024; 23:342-354. [PMID: 38522961 DOI: 10.1016/j.brachy.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 02/18/2024] [Accepted: 02/24/2024] [Indexed: 03/26/2024]
Abstract
INTRODUCTION/OBJECTIVES The addition of a boost to the lumpectomy bed after whole-breast (WB) radiotherapy plays a key role in the treatment of patients with breast cancer (BC). The clinical benefits of a boost with high-dose-rate brachytherapy (HDR-BT) after conventional fractionation is supported by a large body of evidence. However, few studies have described its outcomes after a hypofractionated scheme. MATERIALS AND METHODS We included all patients treated with adjuvant WB-IMRT in 15 sessions followed by a single-session HDR-BT boost with local anesthesia on an outpatient basis. RESULTS Between 2009 and 2017, 638 patients with early-stage BC were treated according to the aforementioned protocol after breast-conserving surgery. Median follow-up was 6 years (4-11). Despite the low incidence of side effects and their slightness, we did identify an impact of breast volume on the risk of acute radiodermatitis, fibrosis, pain and edema. However, we did not identify any relationship between the volume in cubic centimeters of the BT-implant with acute or long-term side effects. 2.2% patients had an actual local relapse, 2.4% a 2nd primary in the same breast and 2.39% were diagnosed with contralateral BC. Event-free survival at 11 years was 85.5% with an overall survival of 95.7%. CONCLUSION Adjuvant hypofractionated whole-breast IMRT followed by a single dose HDR-BT boost has a low incidence of acute and chronic toxicity and excellent oncological outcomes. However, it may be worthwhile to intensify self-care protocols and surveillance in women with large breasts who may be at increased risk of side effects.
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Affiliation(s)
- Ana Aurora Díaz-Gavela
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain; Radiation Therapy Department, Quironsalud La Luz Hospital, Madrid, Spain.
| | - Elia Del Cerro Peñalver
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain; Radiation Therapy Department, Quironsalud La Luz Hospital, Madrid, Spain
| | | | - Eduardo Pardo-Perez
- Radiophysics Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain
| | - Israel John Thuissard-Vasallo
- Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - Cristina Andreu-Vázquez
- Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | - Marina Pena Huertas
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | | | - David Sanz-Rosa
- Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain
| | - Felipe Counago Lorenzo
- Radiation Therapy Department, Quironsalud Madrid University Hospital, Pozuelo de Alarcón, Madrid, Spain; Medicine Department, School of Biomedical Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, Madrid, Spain; Radiation Therapy Department, Quironsalud La Luz Hospital, Madrid, Spain; Present address: Department of Radiation Oncology, San Francisco de Asís Hospital, Madrid, Spain; Department of Radiation Oncology, La Milagrosa Hospital, Madrid, Spain
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4
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Hannoun-Levi JM, Gimeno Morales M, Gal J, Anchuelo J, Guinot JL, Gaztañaga M, Meszaros N, Polgar C, Strnad V, Schiappa R, Gutierrez C. Very accelerated partial breast irradiation in 1 or 2 days: Late toxicity and early oncological outcome of the GEC-ESTRO VAPBI cohort. Radiother Oncol 2024; 194:110217. [PMID: 38460552 DOI: 10.1016/j.radonc.2024.110217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/05/2024] [Accepted: 03/05/2024] [Indexed: 03/11/2024]
Abstract
PURPOSE To analyze late toxicity after very accelerated partial breast irradiation (VAPBI) for low-risk breast cancer. MATERIALS Methods: In this retrospective, observational, international multicenter study (HDH F20220713143949), patients with low-risk breast cancer underwent lumpectomy + vAPBI (high-dose rate multicatheter interstitial brachytherapy-MIBT). VAPBI was performed with 4(4x6.2 Gy/2d), 3(3x7.45 Gy/2d) or 1 fraction (1x16Gy or 1x18Gy/1d). Primary endpoint was late toxicity. Secondary endpoints were cumulative incidence of breast cancer local relapse (LR) and distant metastatic relapse (DMR) and specific (SS) and overall (OS) survivals. Prognostic factors for late toxicity were analyzed. RESULTS From 01/2012 to 06/2022, 516 pts with early breast cancer were enrolled. Median follow-up was 44 months [95 %CI 39-46]. Median age was 71 years [40-100]. Median tumor size was 12 mm [1-35]. VAPBI delivered 1, 3 and 4 fractions for 205pts (39.7 %), 167pts (32.4 %) and 144pts (28 %) respectively. 221 late toxicity events were observed in 168pts (32.6 %) (Fibrosis, dyschromia, pain and telangiectasia). Grade 2 and 3 late toxicities were observed in 7.2 and 0.6 % respectively (no G4) with no difference between 1 and ≥ 2 treatment days. CTV > 50 cc (p = 0.007) and V150 > 40 % (p = 0.027) were prognostic factors for G ≥ 2 late toxicity. Four-year cumulative incidence rates of LR and DMR were 2 % [95 %CI 0-3] and 1 % [95 %CI 0-2] respectively. CONCLUSIONS VAPBI based on 1 or ≥ 2 days of MIBT represents an attractive de-escalation of irradiation approach for low-risk breast cancer. Late toxicity profile appears acceptable while early oncological outcome shows encouraging local control. Longer follow-up is warranted in order to confirm these preliminary results.
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Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center, University Côte d'Azur, 33 avenue Valombrose, 06189 Nice Cedex 2, Nice, France.
| | - Marta Gimeno Morales
- Department of Radiation Oncology, Clínica Universidad de Navarra, Pamplona, Spain
| | - Jocelyn Gal
- Department of Statistics, Antoine Lacassagne Cancer Center - University of Côte d'Azur, Nice, France
| | - Javier Anchuelo
- Department of Radiation Oncology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Jose-Luis Guinot
- Department of Radiation Oncology, Instituto Valenciano de Oncologia, Valencia, Spain
| | - Miren Gaztañaga
- Department of Radiation Oncology, Hospital Clínico San Carlos, Madrid, Spain
| | - Norbert Meszaros
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Csaba Polgar
- National Institute of Oncology and National Tumor Biology Laboratory, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
| | - Renaud Schiappa
- Department of Statistics, Antoine Lacassagne Cancer Center - University of Côte d'Azur, Nice, France
| | - Cristina Gutierrez
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
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Quetin S, Bahoric B, Maleki F, Enger SA. Deep learning for high-resolution dose prediction in high dose rate brachytherapy for breast cancer treatment. Phys Med Biol 2024; 69:105011. [PMID: 38604185 DOI: 10.1088/1361-6560/ad3dbd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/11/2024] [Indexed: 04/13/2024]
Abstract
Objective.Monte Carlo (MC) simulations are the benchmark for accurate radiotherapy dose calculations, notably in patient-specific high dose rate brachytherapy (HDR BT), in cases where considering tissue heterogeneities is critical. However, the lengthy computational time limits the practical application of MC simulations. Prior research used deep learning (DL) for dose prediction as an alternative to MC simulations. While accurate dose predictions akin to MC were attained, graphics processing unit limitations constrained these predictions to large voxels of 3 mm × 3 mm × 3 mm. This study aimed to enable dose predictions as accurate as MC simulations in 1 mm × 1 mm × 1 mm voxels within a clinically acceptable timeframe.Approach.Computed tomography scans of 98 breast cancer patients treated with Iridium-192-based HDR BT were used: 70 for training, 14 for validation, and 14 for testing. A new cropping strategy based on the distance to the seed was devised to reduce the volume size, enabling efficient training of 3D DL models using 1 mm × 1 mm × 1 mm dose grids. Additionally, novel DL architecture with layer-level fusion were proposed to predict MC simulated dose to medium-in-medium (Dm,m). These architectures fuse information from TG-43 dose to water-in-water (Dw,w) with patient tissue composition at the layer-level. Different inputs describing patient body composition were investigated.Main results.The proposed approach demonstrated state-of-the-art performance, on par with the MCDm,mmaps, but 300 times faster. The mean absolute percent error for dosimetric indices between the MC and DL-predicted complete treatment plans was 0.17% ± 0.15% for the planning target volumeV100, 0.30% ± 0.32% for the skinD2cc, 0.82% ± 0.79% for the lungD2cc, 0.34% ± 0.29% for the chest wallD2ccand 1.08% ± 0.98% for the heartD2cc.Significance.Unlike the time-consuming MC simulations, the proposed novel strategy efficiently converts TG-43Dw,wmaps into preciseDm,mmaps at high resolution, enabling clinical integration.
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Affiliation(s)
- Sébastien Quetin
- Medical Physics Unit, Department of Oncology, McGill University, Montreal, QC, Canada
- Montreal Institute for Learning Algorithms, Mila, Montreal, QC, Canada
| | - Boris Bahoric
- Department of Radiation Oncology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Farhad Maleki
- Department of Computer Science, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Radiology, McGill University, Montreal, QC, Canada
- Department of Radiology, University of Florida, Gainesville, FL, United States of America
| | - Shirin A Enger
- Medical Physics Unit, Department of Oncology, McGill University, Montreal, QC, Canada
- Montreal Institute for Learning Algorithms, Mila, Montreal, QC, Canada
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
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De Brabandere M, Placidi E, Siebert FA, Carlsson Tedgren Å, Slocker Escarpa A, Tagliaferri L, Andrássy M, Schulz C, Fog LS. GEC-ESTRO survey of 106Ru eye applicator practice for ocular melanoma - Physicist survey. Radiother Oncol 2024; 193:110114. [PMID: 38309583 DOI: 10.1016/j.radonc.2024.110114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/16/2024] [Accepted: 01/27/2024] [Indexed: 02/05/2024]
Abstract
AIM 106Ru eye plaque brachytherapy (BT, interventional radiotherapy) is an eye-preserving treatment for uveal melanoma performed in about 100 clinics worldwide. Despite this relatively low number, there is a considerable variation in clinical practice. In 2022, the BRAPHYQS and Head & Neck and Skin GEC-ESTRO working groups conducted a survey to map the current clinical practice. The survey consisted of a physicist and a physician part. This paper describes the physicist results. However, three physician questions with overlapping interest are included here as well. MATERIALS AND METHODS The survey questions pertained to commissioning and quality control (QC) of the plaques, treatment planning, radiobiological correction, as well as more general questions on practice improvement. The questions overlapping with the physician survey were related to dose prescription and margins. RESULTS Sixty-five physicist responses were included. A majority of the centres do not perform an independent measurement of the absorbed dose at reference depth, percentage depth dose (PDD) and off-axis data. A lack of calibration services and suitable equipment are the main reasons. About one third of the centres indicated that they do image based treatment planning. The use of margins and dose prescription showed a large variability, despite the availability of guidelines [1]. Many respondents expressed a strong wish for improvement in a wide range of aspects of clinical practice. CONCLUSION The physics survey showed a wide variability regarding quality control of the 106Ru sources and treatment planning practice.
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Affiliation(s)
| | - Elisa Placidi
- UOC Physics for Life Sciences, Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Frank-André Siebert
- Clinic of Radiotherapy (Radiooncology), University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Åsa Carlsson Tedgren
- Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology Pathology, Karolinska Institute, Stockholm, Sweden
| | | | - Luca Tagliaferri
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Gemelli ART (Advanced Radiation Therapy), Interventional Oncology Center (IOC), Rome, Italy
| | - Michael Andrássy
- Eckert & Ziegler BEBIG GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany
| | - Carmen Schulz
- Eckert & Ziegler BEBIG GmbH, Robert-Rössle-Straße 10, 13125 Berlin, Germany
| | - Lotte S Fog
- Ocular oncology unit, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Alfred Health Radiation Oncology, Melbourne, VIC, Australia
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7
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Lo Faro L, Fogliata A, Franceschini D, Spoto R, Dominici L, Bertolini A, Stefanini S, Vernier V, Ilieva MB, Scorsetti M. Adjuvant Hypofractionated Whole Breast Irradiation (WBI) vs. Accelerated Partial Breast Irradiation (APBI) in Postmenopausal Women with Early Stage Breast Cancer: 5Years Update of the HYPAB Trial. Clin Breast Cancer 2024; 24:253-260. [PMID: 38220538 DOI: 10.1016/j.clbc.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/06/2023] [Accepted: 12/31/2023] [Indexed: 01/16/2024]
Abstract
Therapeutical strategies in breast cancer are continuously updating. Recent researches assessed the possibility of irradiating only the surgical bed in selected patients (Partial Breast Irradiation, PBI). In 2014 we designed a study to evaluate toxicity and cosmesis of APBI using Volumetric Modulated Arc Therapy-Rapid Arc compared with hypofractionated whole breast irradiation (WBI). We present here the 5-years updated data. HYPAB was a single-institution randomized trial that recruited 172 patients from 2015 to 2018. Patients underwent conserving surgery and were randomized to either adjuvant WBI (40.5Gy/15 fractions with simultaneous boost to 48 Gy to tumoral bed) or APBI (30Gy/5 fractions), both delivered with VMAT-RA technique. Clinical evaluation was performed during the first visit, once a week during radiotherapy and during follow up. Cosmesis was assessed using the Harvard Scale for Breast Cosmesis. At the time of the analysis 161 patients were eligible, 53% in the WBI and 47% in the APBI group, with a median follow-up of 67 months. Most common late skin toxicities were G1 fibrosis (32%) and oedema (28%) and were higher in the WBI group; no G3 toxicities were observed. Cosmesis was rated poor in only 6 cases. 147 patients had no evidence of disease at the last follow-up, and no patients died of the disease. Mature results confirm the safety and efficacy of APBI in selected early stage breast cancer patients. Late toxicity is improved in the APBI arm at the cost of a slight increase in local relapse. Further studies are ongoing to better elucidate the use of APBI as a de-escalation approach.
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Affiliation(s)
- L Lo Faro
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy.
| | - A Fogliata
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - D Franceschini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - R Spoto
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - L Dominici
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - A Bertolini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - S Stefanini
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - V Vernier
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - M B Ilieva
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
| | - M Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
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8
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Hannoun-Lévi JM, Savignoni A, Féron JG, Malhaire C, Ezzili C, Brédart A, Loap P, Kirova Y. Management of second ipsilateral breast tumor event: An advocacy for a randomized trial. Cancer Radiother 2024; 28:188-194. [PMID: 38216433 DOI: 10.1016/j.canrad.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 01/14/2024]
Abstract
For a second ipsilateral breast tumor event, salvage mastectomy is the standard of care while second conservative treatment is a possible option. However, level 1 proofs are missing, leading to perform salvage mastectomy for patients who could receive second conservative treatment and consequently avoid psychological/quality of life salvage mastectomy deleterious impacts. A phase 3 randomized trial comparing salvage mastectomy to second conservative treatment is needed. Here we discuss what would be to us the optimal design of such trial to confirm the non-inferiority between the two salvage options, with a focus on methodological aspects in terms of patient characteristics and statistical issues.
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Affiliation(s)
- J-M Hannoun-Lévi
- Department of Radiation Oncology, centre Antoine-Lacassagne, université Côte d'Azur, Nice, France.
| | - A Savignoni
- Department of Biostatistics, institut Curie, Paris, France
| | - J-G Féron
- Department of Breast Surgery, institut Curie, Paris, France
| | - C Malhaire
- Department of Medical Imaging, institut Curie, Paris, France
| | - C Ezzili
- Department of Clinical Research, institut Curie, Paris, France
| | - A Brédart
- Psycho-Oncology Unit, institut Curie, Paris, France
| | - P Loap
- Department of Radiation Oncology, institut Curie, Paris, France
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, Paris, France
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
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Burkon P, Selingerova I, Slavik M, Holanek M, Vrzal M, Coufal O, Polachova K, Muller P, Slampa P, Kazda T. Toxicity of external beam accelerated partial-breast irradiation (APBI) in adjuvant therapy of early-stage breast cancer: prospective randomized study. Radiat Oncol 2024; 19:17. [PMID: 38310249 PMCID: PMC10837889 DOI: 10.1186/s13014-024-02412-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/29/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) is an alternative breast-conserving therapy approach where radiation is delivered in less time compared to whole breast irradiation (WBI), resulting in improved patient convenience, less toxicity, and cost savings. This prospective randomized study compares the external beam APBI with commonly used moderate hypofractionated WBI in terms of feasibility, safety, tolerance, and cosmetic effects. METHODS Early breast cancer patients after partial mastectomy were equally randomized into two arms- external APBI and moderate hypofractionated WBI. External beam technique using available technical innovations commonly used in targeted hypofractionated radiotherapy to minimize irradiated volumes was used (cone beam computed tomography navigation to clips in the tumor bed, deep inspiration breath hold technique, volumetric modulated arc therapy dose application, using flattening filter free beams and the six degrees of freedom robotic treatment couch). Cosmetics results and toxicity were evaluated using questionnaires, CTCAE criteria, and photo documentation. RESULTS The analysis of 84 patients with a median age of 64 years showed significantly fewer acute adverse events in the APBI arm regarding skin reactions, local and general symptoms during a median follow-up of 37 months (range 21-45 months). A significant difference in favor of the APBI arm in grade ≥ 2 late skin toxicity was observed (p = 0.026). Late toxicity in the breast area (deformation, edema, fibrosis, and pain), affecting the quality of life and cosmetic effect, occurred in 61% and 17% of patients in WBI and APBI arms, respectively. The cosmetic effect was more favorable in the APBI arm, especially 6 to 12 months after the radiotherapy. CONCLUSION External APBI demonstrated better feasibility and less toxicity than the standard regimen in the adjuvant setting for treating early breast cancer patients. The presented study confirmed the level of evidence for establishing the external APBI in daily clinical practice. TRIAL REGISTRATION NCT06007118.
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Affiliation(s)
- Petr Burkon
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Iveta Selingerova
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic.
- Department of Mathematics and Statistics, Faculty of Science, Masaryk University, Brno, Czech Republic.
| | - Marek Slavik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milos Holanek
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Oldrich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Katerina Polachova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Muller
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic
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11
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Karius A, Strnad V, Lotter M, Kreppner S, Fietkau R, Bert C. Investigating the impact of breast positioning control on physical treatment parameters in multi-catheter breast brachytherapy. Strahlenther Onkol 2024; 200:49-59. [PMID: 37676482 PMCID: PMC10784386 DOI: 10.1007/s00066-023-02127-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/16/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE To assess the effects of a workflow for reproducible patient and breast positioning on implant stability during high-dose-rate multi-catheter breast brachytherapy. METHODS Thirty patients were treated with our new positioning control workflow. Implant stability was evaluated based on a comparison of planning-CTs to control-CTs acquired halfway through the treatment. To assess geometric stability, button-button distance variations as well as Euclidean dwell position deviations were evaluated. The latter were also quantified within various separated regions within the breast to investigate the location-dependency of implant alterations. Furthermore, dosimetric variations to target volume and organs at risk (ribs, skin) as well as isodose volume changes were analyzed. Results were compared to a previously treated cohort of 100 patients. RESULTS With the introduced workflow, the patient fraction affected by button-button distance variations > 5 mm and by dwell position deviations > 7 mm were reduced from 37% to 10% and from 30% to 6.6%, respectively. Implant stability improved the most in the lateral to medial breast regions. Only small stability enhancements were observed regarding target volume dosimetry, but the stability of organ at risk exposure became substantially higher. D0.2ccm skin dose variations > 12.4% and D0.1ccm rib dose variations > 6.7% were reduced from 11% to 0% and from 16% to 3.3% of all patients, respectively. CONCLUSION Breast positioning control improved geometric and dosimetric implant stability for individual patients, and thus enhanced physical plan validity in these cases.
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Affiliation(s)
- Andre Karius
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Germany.
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Stephan Kreppner
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstr. 27, 91054, Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Novikov SN, Krivorotko P, Bryantseva Z, Akulova I, Emelyanov A, Mortada V, Ponomareva O, Krzhivitskiy P, Kanaev S. Different approaches to target volume definition and boost delivery in surgery de-escalation clinical trial in breast cancer patients with pathological complete response. Radiat Oncol J 2023; 41:267-273. [PMID: 38185931 PMCID: PMC10772592 DOI: 10.3857/roj.2023.00528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/06/2023] [Accepted: 09/12/2023] [Indexed: 01/09/2024] Open
Abstract
PURPOSE We evaluate various approaches to target volume definition and boost delivery in patients with complete response to neoadjuvant systemic therapy (NST) who were treated by radiotherapy without a surgery. MATERIALS AND METHODS A pathological complete response (pCR) was diagnosed in 21 of 27 patients included in "surgery de-escalation" prospective observation study. Clips were placed in the primary tumor volume (PrTV) before NST and during the vacuum aspiration biopsy. Twenty patients with pCR underwent the whole breast irradiation and a boost to the PrTV. High-dose rate brachytherapy (HDRB) was the basic technique for boost delivery. Finally, we identified the value of fused images (computed tomography [CT] before NST with simulation CT), clips and their combination for an accurate boost delivery. RESULTS A complete overlap between PrTV on pre-treatment CT with the localization of the clips on simulation CT was mentioned in 10, partial mismatch in three patients. In 12 of these 13 women, HDRB was successfully used for the boost delivery. In five cases we mentioned a marked discrepancy between the PrTV on fused images and the topography of the clips. In other two women we did not find clips on simulation CT. The fused images in five of these seven patients showed anatomical landmarks (scar, fibrosis) used for identification of the gross tumor volume. In all 20 women with pCR (average follow-up of 16.6 months), there were no locoregional recurrences. CONCLUSION Combination of the clips with fusion of pre-NST and simulation CTs is important for an accurate boost delivery.
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Affiliation(s)
- Sergey Nikolaevich Novikov
- Department of Radiation Oncology and Nuclear Medicine, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Petr Krivorotko
- Department of Breast Surgery, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Zhanna Bryantseva
- Department of Radiation Oncology and Nuclear Medicine, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Irina Akulova
- Department of Radiation Oncology and Nuclear Medicine, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Alexander Emelyanov
- Department of Breast Surgery, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Viktoria Mortada
- Department of Breast Surgery, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Olga Ponomareva
- Department of Radiation Oncology and Nuclear Medicine, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Pavel Krzhivitskiy
- Department of Radiation Oncology and Nuclear Medicine, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
| | - Sergey Kanaev
- Department of Radiation Oncology and Nuclear Medicine, N.N. Petrov National Medical Research Center of Oncology, St. Petersburg, Russia
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Hannoun-Levi JM, Gal J, Polgar C, Strnad V, Loessl K, Polat B, Kauer-Domer D, Schiappa R, Gutierrez C. Second Conservative Treatment for Local Recurrence Breast Cancer: A GEC-ESTRO Oncological Outcome and Prognostic Factor Analysis. Int J Radiat Oncol Biol Phys 2023; 117:1200-1210. [PMID: 37459998 DOI: 10.1016/j.ijrobp.2023.06.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 08/03/2023]
Abstract
PURPOSE For second ipsilateral breast tumor event (2nd IBTE), second conservative treatment (2nd CT) combining lumpectomy plus accelerated partial breast reirradiation (APBrI) represents a curative option. The aim of this study was to analyze oncological prognostic factors for patients with a 2nd IBTE treated with 2nd CT. METHODS AND MATERIALS An analysis of clinical practices was conducted across 7 academic hospitals/cancer centers in 6 European countries based on the GEC-ESTRO database. Patients presenting a 2nd IBTE occurring after conservative surgery (lumpectomy + axillary evaluation) and irradiation performed for the primary tumor underwent a 2nd CT with brachytherapy-based APBrI. The main outcome was 5-year cumulative incidence (CI) rate of second local relapse. All analyzed patients were classified according to risk groups for Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) accelerated partial breast irradiation (APBI) and molecular classification and time interval between first and second breast surgery (TIS1S2). Finally, we combined GEC-ESTRO APBI, molecular, and TIS1S2 risk groups, leading to the definition of a new score (named TAM: score based on the combination of time interval [T] between first and second surgery and APBI [A] and molecular [M] classifications) specifically designed for 2nd IBTE oncological outcome analysis. RESULTS From July 1994 to January 2021, a total of 508 patients received a 2nd CT. At the time of 2nd IBTE, median age was 64.6 years (range, 56.2-72.6). With a median follow-up of 60.9 months (56.2-72.6), the 5-year second local relapse CI rate was 4% (95% confidence interval [95% CI], 2%-6%). The 5-year distant metastasis disease CI rate was 7% (95% CI, 4%-10%). Five-year disease-free and overall survival rates were 89% (95% CI, 86%-93%) and 91% (95% CI, 88%-94%), respectively. In multivariate analysis, TAM score was an independent prognostic factor for all the oncological items (P < .001) except disease-specific survival (P = .07) and overall survival (P = .09). The grade ≥3 late toxicity rate was 12.1%. CONCLUSIONS This analysis of 2nd CT combining lumpectomy with APBrI for 2nd IBTE confirmed the excellent oncological results obtained after 2nd CT. Furthermore, the GEC-ESTRO TAM score appears to be an important prognostic factor, assisting patients and physicians in the decision-making process.
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Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University Cote d'Azur, Nice, France.
| | - Jocelyn Gal
- Department of Epidemiology/Biostatistics, Antoine Lacassagne Cancer Centre, University Cote d'Azur, Nice, France
| | - Csaba Polgar
- Department of Oncology, Semmelweis University, Budapest, Hungary; Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
| | - Kristina Loessl
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Bulent Polat
- Department of Radiation Oncology, Wurzburg University, Wurzburg, Germany
| | - Daniela Kauer-Domer
- Department of Radiation Oncology, Medical University of Vienna, Vienna, Austria
| | - Renaud Schiappa
- Department of Epidemiology/Biostatistics, Antoine Lacassagne Cancer Centre, University Cote d'Azur, Nice, France
| | - Crisitna Gutierrez
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
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14
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Dürrbeck C, Schuster S, Sauer BC, Abu-Hossin N, Strnad V, Fietkau R, Bert C. Localization of reference points in electromagnetic tracking data and their application for treatment error detection in interstitial breast brachytherapy. Med Phys 2023; 50:5772-5783. [PMID: 37458615 DOI: 10.1002/mp.16629] [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: 03/02/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 09/11/2023] Open
Abstract
BACKGROUND Electromagnetic tracking (EMT) is a promising technology that holds great potential to advance patient-specific pre-treatment verification in interstitial brachytherapy (iBT). It allows easy determination of the implant geometry without line-of-sight restrictions and without dose exposure to the patient. What it cannot provide, however, is a link to anatomical landmarks, such as the exit points of catheters or needles on the skin surface. These landmarks are required for the registration of EMT data with other imaging modalities and for the detection of treatment errors such as incorrect indexer lengths, and catheter or needle shifts. PURPOSE To develop an easily applicable method to detect reference points in the positional data of the trajectory of an EMT sensor, specifically the exit points of catheters in breast iBT, and to apply the approach to pre-treatment error detection. METHODS Small metal objects were attached to catheter fixation buttons that rest against the breast surface to intentionally induce a local, spatially limited perturbation of the magnetic field on which the working principle of EMT relies. This perturbation can be sensed by the EMT sensor as it passes by, allowing it to localize the metal object and thus the catheter exit point. For the proof-of-concept, different small metal objects (magnets, washers, and bushes) and EMT sensor drive speeds were used to find the optimal parameters. The approach was then applied to treatment error detection and validated in-vitro on a phantom. Lastly, the in-vivo feasibility of the approach was tested on a patient cohort of four patients to assess the impact on the clinical workflow. RESULTS All investigated metal objects were able to measurably perturb the magnetic field, which resulted in missing sensor readings, that is two data gaps, one for the sensor moving towards the tip end and one when retracting from there. The size of the resulting data gaps varied depending on the choice of gap points used for calculation of the gap size; it was found that the start points of the gaps in both directions showed the smallest variability. The median size of data gaps was ⩽8 mm for all tested materials and sensor drive speeds. The variability of the determined object position was ⩽0.5 mm at a speed of 1.0 cm/s and ⩽0.7 mm at 2.5 cm/s, with an increase up to 2.3 mm at 5.0 cm/s. The in-vitro validation of the error detection yielded a 100% detection rate for catheter shifts of ≥2.2 mm. All simulated wrong indexer lengths were correctly identified. The in-vivo feasibility assessment showed that the metal objects did not interfere with the routine clinical workflow. CONCLUSIONS The developed approach was able to successfully detect reference points in EMT data, which can be used for registration to other imaging modalities, but also for treatment error detection. It can thus advance the automation of patient-specific, pre-treatment quality assurance in iBT.
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Affiliation(s)
- Christopher Dürrbeck
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Sabrina Schuster
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Birte Christina Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Nadin Abu-Hossin
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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15
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Dürrbeck C, Schulz M, Pflaum L, Kallis K, Geimer T, Abu-Hossin N, Strnad V, Maier A, Fietkau R, Bert C. Estimating follow-up CTs from geometric deformations of catheter implants in interstitial breast brachytherapy: A feasibility study using electromagnetic tracking. Med Phys 2023; 50:5793-5805. [PMID: 37540071 DOI: 10.1002/mp.16659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 06/20/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Electromagnetic tracking (EMT) systems have been shown to provide valuable information on the geometry of catheter implants in breast cancer patients undergoing interstitial brachytherapy (iBT). In the context of an extended patient-specific, pre-treatment verification, EMT can play a key role in determining the potential need and, if applicable, the appropriate time for treatment adaptation. To detect dosimetric shortcomings the relative position between catheters, and target volume and critical structures must be known. Since EMT cannot provide the anatomical context and standard imaging techniques such as cone-beam CT are not yet available in most brachytherapy suites, it is not possible to detect anatomic changes on a daily or fraction basis, so the need for adaptive planning cannot be identified. PURPOSE The aim of this feasibility study is to develop and evaluate a technique capable of estimating follow-up CTs at any time based on the initial treatment planning CT (PCT) and surrogate information about changes of the implant geometry from an EMT system. METHODS A deformation vector field is calculated from two different implant reconstructions acquired in treatment position through EMT, the first immediately after the PCT and the second at another time point during the course of treatment. The calculation is based on discrete displacement vectors of pairs of control and target points. These are extrapolated by means of different radial basis functions in order to cover the entire CT volume. The adequate parameters for the calculation of the deformation field were identified. By warping the PCT according to the deformation field, one obtains an estimated CT (ECT) that reflects the geometric changes. For the proof of concept, ECTs were computed for the time point of the clinical follow-up CT (FCT) that is embedded in the treatment workflow after the fourth fraction. RESULTS ECT and clinical FCTs of 20 patients were compared to each other quantitatively in terms of absolute Hounsfield unit differences in the planning target volume (PTV) and in a convex hull (CH) enclosing the catheters. The median differences were 31.2 and 29.5 HU for the CH and the PTV, respectively. CONCLUSION The proposed ECT approach was able to approximate the "anatomy of the day" and therefore, in principle, allows a dosimetric appraisal of the treatment plan quality before each fraction. In this way, it can contribute to a more detailed patient-specific quality assurance in iBT of the breast and help to identify the timing for a potential treatment adaptation.
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Affiliation(s)
- Christopher Dürrbeck
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Moritz Schulz
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Leonie Pflaum
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
- Pattern Recognition Lab, FAU, Erlangen, Germany
| | - Karoline Kallis
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Tobias Geimer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Pattern Recognition Lab, FAU, Erlangen, Germany
| | - Nadin Abu-Hossin
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | | | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Mittal P, Chopra S, Kamrava M, Vashistha R, Konrad S, Senapati S, Pradhan S, Reddy VA, Sharma DN, Engineer R, Sarin R, Budrukkar A, Ghoshal S, Shrivastava SK, Agarwal JP, Sturdza AE. Brachytherapy training in India: Results from the GEC-ESTRO-India survey. Brachytherapy 2023; 22:562-569. [PMID: 37193616 DOI: 10.1016/j.brachy.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/30/2023] [Accepted: 04/07/2023] [Indexed: 05/18/2023]
Abstract
INTRODUCTION Brachytherapy (BT) is integral in treatment of gynecological malignancies and is also an option for many other cancers. Data on training and proficiency levels of early career oncologists is limited. Like other continents a survey was conducted for early career oncologists in India. METHODS AND MATERIALS An online survey was conducted from November 2019 to February 2020, through Association of Radiation Oncologists of India (AROI) for early career radiation oncologists expected to be within 6 years of training. The survey used a 22 item questionnaire that was also used for European survey. Responses to individual statements were recorded on a 1-5 Likert-type scale. Descriptive statistics were used to describe proportions. RESULTS One-hundred twenty-four (17%) of 700 recipients responded to the survey. Majority of the respondents (88%) stated that being able to perform BT at the end of their training was important. Two-thirds of the respondents (81/124) had performed >10 intracavitary procedure and 22.5% had performed >10 intracavitary-interstitial implants. Many respondents had not performed nongynecological procedure- breast (64%), prostate(82%), gastro-intestinal (47%). Respondents predicted that in next 10 years, the role of BT is likely to increase. Lack of dedicated curriculum and training was perceived as the greatest barriers to achieving independence in BT (58%). Respondents suggested that BT training should be prioritized during conferences (73%) and online teaching modules (56%), along with development of BT skills labs (65%). CONCLUSION This survey identified a lack of proficiency in gynecological intracavitary-interstitial brachytherapy and non-gynecological brachytherapy, despite BT training being regarded as highly important. Dedicated programs, including standardized curriculum and assessment need to be developed for training early- career radiation oncologists in BT.
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Affiliation(s)
- Prachi Mittal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Supriya Chopra
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rajesh Vashistha
- Department of Radiation Oncology, Max Super-Specialty Hospital, Bathinda, India
| | - Stefan Konrad
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Surendra Senapati
- Department of Radiation Oncology, Acharya Harihara Regional Cancer Centre, Cuttack, Odisha, India
| | - Satyajit Pradhan
- Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malaviya Cancer Centre, Varanasi, India
| | - Vijay Anand Reddy
- Department of Radiation Oncology, Apollo Hospitals, Hyderabad, India
| | - Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Reena Engineer
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Rajiv Sarin
- Department of Radiation Oncology, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Ashwini Budrukkar
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sushmita Ghoshal
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Jai Prakash Agarwal
- Department of Radiation Oncology and Medical Physics, Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Alina Emiliana Sturdza
- Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria.
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17
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Hannoun-Levi JM, Gautier M, Rizzi Y, Razzouk K. Workflow optimization of brachytherapy-based very accelerated partial breast irradiation. Brachytherapy 2023; 22:491-495. [PMID: 37164824 DOI: 10.1016/j.brachy.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE For low-risk breast cancer, accelerated partial breast irradiation (APBI) is a level 1 evidence procedure. Brachytherapy based very APBI (vAPBI) makes it possible to perform adjuvant irradiation in 4 to 1 fraction. However, vAPBI organization is critical. The aim of this technical note is to report on its optimization. METHODS AND MATERIALS To offer to low-risk breast cancer patient an efficient, simple, rapid adjuvant irradiation with a reduced number of hospital visits, a new organization of vAPBI based on a single fraction was established, merging all the different steps (from first consultation to irradiation) into a 4-5-consecutive-hour period. This therapeutic program was developed in strong collaboration with radiation oncologists, medical physicists, radiation therapists, and the medical secretary. RESULTS After the validation of adjuvant breast irradiation, the patient was offered a telemedicine consultation with the radiation oncologist. Then, the day of vAPBI, the patient arrived at the brachytherapy unit at 08:00 AM for an in-person consultation followed by a preimplant CT scan (defining catheter number and position). After breast local anesthesia, catheter placement was performed followed by a postimplant CT scan for planning purposes. A total dose of 16 Gy in 1 fraction was delivered before removing the catheters. The patient was discharged from the brachytherapy unit around 12:30 PM with an upcoming surveillance consultation date. CONCLUSIONS VAPBI organization optimization makes it possible to propose a short 5-h procedure from medical consultation to treatment with only one round trip. Strict organization among staff is required.
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Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University Cote d'Azur, Nice, France.
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University Cote d'Azur, Nice, France
| | - Yassine Rizzi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University Cote d'Azur, Nice, France
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18
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Dzhugashvili M, Veldeman L, Kirby AM. The role of the radiation therapy breast boost in the 2020s. Breast 2023; 69:299-305. [PMID: 36958070 PMCID: PMC10068257 DOI: 10.1016/j.breast.2023.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/19/2023] Open
Abstract
Given that most local relapses of breast cancer occur proximal to the original location of the primary, the delivery of additional radiation dose to breast tissue that contained the original primary cancer (known as a "boost") has been a standard of care for some decades. In the context of falling relapse rates, however, it is an appropriate time to re-evaluate the role of the boost. This article reviews the evolution of the radiotherapy boost in breast cancer, discussing who to boost and how to boost in the 2020s, and arguing that, in both cases, less is more.
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Affiliation(s)
| | - L Veldeman
- Ghent University/Ghent University Hospital, Ghent, Belgium.
| | - A M Kirby
- Royal Marsden Hospital NHS Foundation Trust & Institute of Cancer Research, UK.
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McDonald F, Belka C, Hurkmans C, Alicja Jereczek-Fossa B, Poortmans P, van de Kamer JB, Azizaj E, Franco P. Introducing the ESTRO Guidelines Committee, driving force for the new generation of ESTRO guidelines. Radiother Oncol 2023:109724. [PMID: 37244357 DOI: 10.1016/j.radonc.2023.109724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Fiona McDonald
- Lung Unit, Royal Marsden Hospital, London, United Kingdom; Division of Radiotherapy & Imaging, The Institute of Cancer Research, London, United Kingdom
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich; German Cancer Consortium (DKTK), partner site Munich; Bavarian Cancer Research Center (BZKF), Munich, Germany
| | - Coen Hurkmans
- Department of Radiation Oncology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Barbara Alicja Jereczek-Fossa
- Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Department of Radiation Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Jeroen B van de Kamer
- Department of Radiation Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Eralda Azizaj
- European Society for Radiotherapy and Oncology, Brussels, Belgium
| | - Pierfrancesco Franco
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, Novara, Italy; Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy.
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20
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Berger D, Van Dyk S, Beaulieu L, Major T, Kron T. Modern Tools for Modern Brachytherapy. Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00182-6. [PMID: 37217434 DOI: 10.1016/j.clon.2023.05.003] [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: 10/14/2022] [Revised: 03/28/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
This review aims to showcase the brachytherapy tools and technologies that have emerged during the last 10 years. Soft-tissue contrast using magnetic resonance and ultrasound imaging has seen enormous growth in use to plan all forms of brachytherapy. The era of image-guided brachytherapy has encouraged the development of advanced applicators and given rise to the growth of individualised 3D printing to achieve reproducible and predictable implants. These advances increase the quality of implants to better direct radiation to target volumes while sparing normal tissue. Applicator reconstruction has moved beyond manual digitising, to drag and drop of three-dimensional applicator models with embedded pre-defined source pathways, ready for auto-recognition and automation. The simplified TG-43 dose calculation formalism directly linked to reference air kerma rate of high-energy sources in the medium water remains clinically robust. Model-based dose calculation algorithms accounting for tissue heterogeneity and applicator material will advance the field of brachytherapy dosimetry to become more clinically accurate. Improved dose-optimising toolkits contribute to the real-time and adaptive planning portfolio that harmonises and expedites the entire image-guided brachytherapy process. Traditional planning strategies remain relevant to validate emerging technologies and should continue to be incorporated in practice, particularly for cervical cancer. Overall, technological developments need commissioning and validation to make the best use of the advanced features by understanding their strengths and limitations. Brachytherapy has become high-tech and modern by respecting tradition and remaining accessible to all.
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Affiliation(s)
- D Berger
- International Atomic Energy Agency, Vienna International Centre, Vienna, Austria.
| | - S Van Dyk
- Radiation Therapy Services, Division of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - L Beaulieu
- Service de Physique Médicale et Radioprotection, et Axe Oncologie du Centre de Recherche du CHU de Québec, CHU de Québec, Québec, Canada; Département de Physique, de Génie Physique et d'Optique et Centre de Recherche sur le Cancer, Université Laval, Québec, Canada
| | - T Major
- Radiotherapy Centre, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - T Kron
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, Australia
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21
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Cheng HS, Hung CC, Wang KC, Tsai IC, Lin JF, Yeh HL. Preliminary outcomes of accelerated partial breast irradiation by interstitial multicatheter brachytherapy with intraoperative free-hand catheter implantation in early breast cancer. J Chin Med Assoc 2023; 86:381-387. [PMID: 36854132 DOI: 10.1097/jcma.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND To evaluate the clinical feasibility of interstitial brachytherapy by intraoperative free-hand catheter implantation in the treatment of early breast cancer after breast-conserving surgery (BCS). METHODS Between January 2018 and December 2019, 44 patients with early breast cancer after BCS who met the inclusion criteria ≥45 years old, invasive carcinoma ≤3 cm or ductal carcinoma in situ <2.5 cm, estrogen receptor positive, lymph node negative, surgical margin negative, no distant metastasis, and an ECOG performance score ≤1 were enrolled in this phase II single-arm study. The postoperative irradiation field includes the tumor bed plus 2-cm margin in all directions, except in the anterior-posterior direction. The total prescribed tumor dose was 3400 cGy delivered in 10 fractions twice daily at 6-hour intervals. The primary endpoints were acute side effects, late treatment-related toxicity, and cosmetic outcome. The secondary endpoints were local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS), and overall survival (OS). RESULTS The median follow-up time was 33.5 months (mean, 32.9 months; range, 20-43 months). The cosmetic results were good to very good in 92.3% of the questionnaire respondents. The acute toxicities were mild, and no acute grade 3-4 toxicity was noted. Wound infection was noted in two patients (4.5%). There was only one event of regional lymph node recurrence in one patient. The 3-year LRFS, DMFS, and OS were 100%, and RRFS was 94.7%. For two patients who had a positive lymph node based on their final pathology reports, postoperative irradiation, including whole breast and regional lymph nodes, was added. CONCLUSION Accelerated partial breast irradiation using interstitial brachytherapy with the intraoperative free-hand catheter implantation technique provides an alternative method of postoperative radiotherapy for selected patients with early breast cancer after BCS with acceptable toxicities.
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Affiliation(s)
- Hao-Shen Cheng
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chih-Chiang Hung
- Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Kuo-Chung Wang
- Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - I-Chen Tsai
- Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Jia-Fu Lin
- Department of Radiation Physics, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Hui-Ling Yeh
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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22
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Karius A, Szkitsak J, Strnad V, Lotter M, Kreppner S, Schubert P, Fietkau R, Bert C. On the implant stability in adaptive multi-catheter breast brachytherapy: Establishment of a decision-tree for treatment re-planning. Radiother Oncol 2023; 183:109597. [PMID: 36870607 DOI: 10.1016/j.radonc.2023.109597] [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: 01/20/2023] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND AND PURPOSE To assess implant stability and identify causes of implant variations during high-dose-rate multi-catheter breast brachytherapy. MATERIALS AND METHODS Planning-CTs were compared to control-CTs acquired halfway through the treatment for 100 patients. For assessing geometric stability, Fréchet-distance and button-to-button distance changes of all catheters as well as variations of Euclidean distances and convex hulls of all dwell positions were determined. The CTs were inspected to identify the causes of geometric changes. Dosimetric effects were evaluated by target volume transfers and re-contouring of organs at risk. The dose non-uniformity ratio (DNR), 100% and 150% isodose volumes (V100 and V150), coverage index (CI), and organ doses were calculated. Correlations between the examined geometric and dosimetric parameters were assessed. RESULTS Fréchet-distance and dwell position deviations >2.5 mm as well as button-to-button distance changes >5 mm were detected for 5%, 2%, and 6.3% of catheters, but for 32, 17, and 37 patients, respectively. Variations occurred enhanced in the lateral breast and close to the ribs, e.g. due to different arm positions. Only small dosimetric effects with median DNR, V100, and CI variations of -0.01 ± 0.02, (-0.5 ± 1.3)ccm, and (-1.4 ± 1.8)% were observed in general. Skin dose exceeded recommended levels for 12 of 100 patients. Various correlations between geometric and dosimetric implant stability were found, based on which decision-tree regarding treatment re-planning was established. CONCLUSION Multi-catheter breast brachytherapy shows a high implant stability in general, but considering skin dose changes is important. To increase implant stability for individual patients, we plan to investigate patient immobilization aids during treatments.
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Affiliation(s)
- Andre Karius
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany.
| | - Juliane Szkitsak
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Stephan Kreppner
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Philipp Schubert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Universitätsstraße 27, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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23
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Strnad V, Polgár C, Ott OJ, Hildebrandt G, Kauer-Dorner D, Knauerhase H, Major T, Łyczek J, Guinot JL, Gutierrez Miguelez C, Slampa P, Allgäuer M, Lössl K, Polat B, Fietkau R, Schlamann A, Resch A, Kulik A, Arribas L, Niehoff P, Guedea F, Dunst J, Gall C, Uter W. Accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy compared with whole-breast irradiation with boost for early breast cancer: 10-year results of a GEC-ESTRO randomised, phase 3, non-inferiority trial. Lancet Oncol 2023; 24:262-272. [PMID: 36738756 DOI: 10.1016/s1470-2045(23)00018-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several randomised, phase 3 trials have investigated the value of different techniques of accelerated partial breast irradiation (APBI) for patients with early breast cancer after breast-conserving surgery compared with whole-breast irradiation. In a phase 3 randomised trial, we evaluated whether APBI using multicatheter brachytherapy is non-inferior compared with whole-breast irradiation. Here, we present the 10-year follow-up results. METHODS We did a randomised, phase 3, non-inferiority trial at 16 hospitals and medical centres in Austria, Czech Republic, Germany, Hungary, Poland, Spain, and Switzerland. Patients aged 40 years or older with early invasive breast cancer or ductal carcinoma in situ treated with breast-conserving surgery were centrally randomly assigned (1:1) to receive either whole-breast irradiation or APBI using multicatheter brachytherapy. Whole-breast irradiation was delivered in 25 daily fractions of 50 Gy over 5 weeks, with a supplemental boost of 10 Gy to the tumour bed, and APBI was delivered as 30·1 Gy (seven fractions) and 32·0 Gy (eight fractions) of high-dose-rate brachytherapy in 5 days or as 50 Gy of pulsed-dose-rate brachytherapy over 5 treatment days. Neither patients nor investigators were masked to treatment allocation. The primary endpoint was ipsilateral local recurrence, analysed in the as-treated population; the non-inferiority margin for the recurrence rate difference (defined for 5-year results) was 3 percentage points. The trial is registered with ClinicalTrials.gov, NCT00402519; the trial is complete. FINDINGS Between April 20, 2004, and July 30, 2009, 1328 female patients were randomly assigned to whole breast irradiation (n=673) or APBI (n=655), of whom 551 in the whole-breast irradiation group and 633 in the APBI group were eligible for analysis. At a median follow-up of 10·36 years (IQR 9·12-11·28), the 10-year local recurrence rates were 1·58% (95% CI 0·37 to 2·8) in the whole-breast irradiation group and 3·51% (1·99 to 5·03) in the APBI group. The difference in 10-year rates between the groups was 1·93% (95% CI -0·018 to 3·87; p=0·074). Adverse events were mostly grade 1 and 2, in 234 (60%) of 393 participants in the whole-breast irradiation group and 314 (67%) of 470 participants in the APBI group, at 7·5-year or 10-year follow-up, or both. Patients in the APBI group had a significantly lower incidence of treatment-related grade 3 late side-effects than those in the whole-breast irradiation group (17 [4%] of 393 for whole-breast irradiation vs seven [1%] of 470 for APBI; p=0·021; at 7·5-year or 10-year follow-up, or both). At 10 years, the most common type of grade 3 adverse event in both treatment groups was fibrosis (six [2%] of 313 patients for whole-breast irradiation and three [1%] of 375 patients for APBI, p=0·56). No grade 4 adverse events or treatment-related deaths have been observed. INTERPRETATION Postoperative APBI using multicatheter brachytherapy after breast-conserving surgery in patients with early breast cancer is a valuable alternative to whole-breast irradiation in terms of treatment efficacy and is associated with fewer late side-effects. FUNDING German Cancer Aid, Germany.
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Affiliation(s)
- Vratislav Strnad
- Department of Radiation Oncology, University Hospital Erlangen and Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany.
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Oliver J Ott
- Department of Radiation Oncology, University Hospital Erlangen and Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Guido Hildebrandt
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | | | - Hellen Knauerhase
- Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Jarosław Łyczek
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skł odowskej, Warsaw, Poland; Podkarpacki Hospital Cancer Center Brzozów, Brzozów, Poland
| | - Jose Luis Guinot
- Department of Radiation Oncology, Valencian Institute of Oncology Valencia, Valencia, Spain
| | | | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Michael Allgäuer
- Department of Radiation Oncology, Hospital Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Kristina Lössl
- Department of Radiation Oncology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Würzburg, Würzburg, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen and Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany; Department of Radiation Oncology, University Hospital Rostock, Rostock, Germany
| | - Annika Schlamann
- Department of Radiation Oncology, University Hospital Leipzig, Leipzig, Germany
| | - Alexandra Resch
- Department of Radiation Oncology, University Hospital AKH Wien, Vienna, Austria
| | - Anna Kulik
- Brachytherapy Department, Centrum Onkologii-Instytut im Marii Skł odowskej, Warsaw, Poland
| | - Leo Arribas
- Department of Radiation Oncology, Valencian Institute of Oncology Valencia, Valencia, Spain
| | - Peter Niehoff
- Department of Radiation Oncology, University Hospital Kiel, Kiel, Germany; Department of Radiotherapy, Sana Clinic, Offenbach, Germany
| | - Ferran Guedea
- Department of Radiation Oncology, Catalan Institute of Oncology, Barcelona, Spain
| | - Jürgen Dunst
- Department of Radiation Oncology, University Hospital Kiel, Kiel, Germany
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Nuremberg, Germany
| | - Wolfgang Uter
- Department of Medical Informatics, Biometry and Epidemiology, University Erlangen-Nuremberg, Nuremberg, Germany
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Anderson B, Vicini F, Wazer D, Arthur D. Breast brachytherapy: Building a bright future on the foundation of a rich history of advancement in technology, technique, and patient-centered care. Brachytherapy 2023; 22:368-380. [PMID: 36740541 DOI: 10.1016/j.brachy.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 02/05/2023]
Abstract
For over 20 years, the concept of accelerated partial breast irradiation (APBI) has received considerable attention. Initially concentrating on the appropriateness of APBI as an alternative treatment to whole breast radiotherapy, investigation and innovation evolved towards dose delivery and technique appropriateness. The purpose of this article is to review the pertinent literature that supports the role brachytherapy serves in delivering APBI and the recognized brachytherapy techniques for dose delivery. Publications establishing techniques utilizing multicatheter brachytherapy, single-entry brachytherapy applicators, permanent breast seed implantation brachytherapy, noninvasive breast brachytherapy and electronic brachytherapy are described. The use of brachytherapy for repeat breast conservation therapy is additionally reviewed. A historical perspective and potential direction of future investigation and innovation are presented.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
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Dohlmar F, Morén B, Sandborg M, Smedby Ö, Valdman A, Larsson T, Carlsson Tedgren Å. Validation of automated post-adjustments of HDR prostate brachytherapy treatment plans by quantitative measures and oncologist observer study. Brachytherapy 2023; 22:407-415. [PMID: 36739222 DOI: 10.1016/j.brachy.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 12/09/2022] [Accepted: 12/09/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim was to evaluate a postprocessing optimization algorithm's ability to improve the spatial properties of a clinical treatment plan while preserving the target coverage and the dose to the organs at risk. The goal was to obtain a more homogenous treatment plan, minimizing the need for manual adjustments after inverse treatment planning. MATERIALS AND METHODS The study included 25 previously treated prostate cancer patients. The treatment plans were evaluated on dose-volume histogram parameters established clinical and quantitative measures of the high dose volumes. The volumes of the four largest hot spots were compared and complemented with a human observer study with visual grading by eight oncologists. Statistical analysis was done using ordinal logistic regression. Weighted kappa and Fleiss' kappa were used to evaluate intra- and interobserver reliability. RESULTS The quantitative analysis showed that there was no change in planning target volume (PTV) coverage and dose to the rectum. There were significant improvements for the adjusted treatment plan in: V150% and V200% for PTV, dose to urethra, conformal index, and dose nonhomogeneity ratio. The three largest hot spots for the adjusted treatment plan were significantly smaller compared to the clinical treatment plan. The observers preferred the adjusted treatment plan in 132 cases and the clinical in 83 cases. The observers preferred the adjusted treatment plan on homogeneity and organs at risk but preferred the clinical plan on PTV coverage. CONCLUSIONS Quantitative analysis showed that the postadjustment optimization tool could improve the spatial properties of the treatment plans while maintaining the target coverage.
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Affiliation(s)
- Frida Dohlmar
- Medical Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden.
| | - Björn Morén
- Department of Mathematics, Linköping University, Linköping, Sweden
| | - Michael Sandborg
- Medical Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Örjan Smedby
- Department of Biomedical Engineering and Health Systems, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Alexander Valdman
- Department of Oncology Pathology, Karolinska Institute, Stockholm, Sweden
| | - Torbjörn Larsson
- Department of Mathematics, Linköping University, Linköping, Sweden
| | - Åsa Carlsson Tedgren
- Medical Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden; Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Oncology Pathology, Karolinska Institute, Stockholm, Sweden
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Morén B, Bokrantz R, Dohlmar F, Andersson B, Setterquist E, Larsson T, Tedgren ÅC. Technical note: Evaluation of a spatial optimization model for prostate high dose-rate brachytherapy in a clinical treatment planning system. Med Phys 2023; 50:688-693. [PMID: 36542400 DOI: 10.1002/mp.16166] [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: 10/09/2022] [Revised: 11/24/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Spatial properties of a dose distribution, such as volumes of contiguous hot spots, are of clinical importance in treatment planning for high dose-rate brachytherapy (HDR BT). We have in an earlier study developed an optimization model that reduces the prevalence of contiguous hot spots by modifying a tentative treatment plan. PURPOSE The aim of this study is to incorporate the correction of hot spots in a standard inverse planning workflow and to validate the integrated model in a clinical treatment planning system. The spatial function is included in the objective function for the inverse planning, as opposed to in the previous study where it was applied as a separate post-processing step. Our aim is to demonstrate that fine-adjustments of dose distributions, which are often performed manually in today's clinical practice, can be automated. METHODS A spatial optimization function was introduced in the treatment planning system RayStation (RaySearch Laboratories AB, Stockholm, Sweden) via a research interface. A series of 10 consecutive prostate patients treated with HDR BT was retrospectively replanned with and without the spatial function. RESULTS Optimization with the spatial function decreased the volume of the largest contiguous hot spot by on average 31%, compared to if the function was not included. The volume receiving at least 200% of the prescription dose decreased by on average 11%. Target coverage, measured as the fractions of the clinical target volume (CTV) and the planning target volume (PTV) receiving at least the prescription dose, was virtually unchanged (less than a percent change for both metrics). Organs-at-risk received comparable or slightly decreased doses if the spatial function was included in the optimization model. CONCLUSIONS Optimization of spatial properties such as the volume of contiguous hot spots can be integrated in a standard inverse planning workflow for brachytherapy, and need not be conducted as a separate post-processing step.
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Affiliation(s)
- Björn Morén
- Department of Mathematics, Linköping University, Linköping, Sweden
| | | | - Frida Dohlmar
- Medical Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | | | | | - Torbjörn Larsson
- Department of Mathematics, Linköping University, Linköping, Sweden
| | - Åsa Carlsson Tedgren
- Medical Radiation Physics, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden.,Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Oncology Pathology, Karolinska Institute, Stockholm, Sweden
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Mourya A, Aggarwal LM, Choudhary S, Shahi UP, Sharma N, Prakash R, Mishra R. Feasibility of using polytetrafluoroethylene flexible implant tube for interstitial brachytherapy patients. Brachytherapy 2022; 21:754-763. [PMID: 36088225 DOI: 10.1016/j.brachy.2022.07.007] [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: 05/24/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE To design the different Polytetrafluoroethylene (PTFE) based flexible implant tubes using an in-house developed device and to evaluate them for High dose rate (HDR) interstitial brachytherapy using computer tomography images. METHODS AND MATERIALS PTFE hollow tube having a 2 mm (6 French) outer diameter (OD) and 1.4 mm inner diameter (ID) was used to design in-house single and/or double leader flexible catheters for interstitial brachytherapy implant. An in-house Plastic Wire Drawing Plate (PWDP) machine was developed. Customization of PTFE hollow flexible implant tube (FIT) was done through PWDP. Different percentages of BaSO4 (5%, 10%, & 15%) were added to Nylon 6 to make radiopaque button. Various quality assurance tests were performed with the PTFE tubes implanted in the brinjal (phantom) before using them on the patients. That is, coupling of brachytherapy machine transfer tube with flexible PTFE Tubes, CT scan artifacts, tube kinks, breast template, and free-hand compatibility. RESULTS With the help of the PWDP machine, plastic wires of different lengths were made for single leader and double leader tubes. The different plastic leader ends of 1 cm to 50 cm lengths having 1 mm diameter were created. The radiopaque button of Nylon 6 in circular shape having 1 cm diameter and 0.5 cm thick was created. Developed radiopaque buttons were visible on CT scan images as well as on radiograph images. CONCLUSIONS PTFE tubes of the desired length can be made depending upon the size of the brachytherapy implant and are inexpensive than commercially available flexible implant tubes.
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Affiliation(s)
- Ankur Mourya
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Lalit Mohan Aggarwal
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India.
| | - Sunil Choudhary
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Uday Pratap Shahi
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Neeraj Sharma
- School of Biomedical Engineering, Indian Institute of Technology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Rajiv Prakash
- School of Materials Science and Technology, Indian Institute of Technology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Ritusha Mishra
- Department of Radiotherapy and Radiation Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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Automating implant reconstruction in interstitial brachytherapy of the breast: A hybrid approach combining electromagnetic tracking and image segmentation. Radiother Oncol 2022; 176:172-178. [PMID: 36181920 DOI: 10.1016/j.radonc.2022.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/24/2022] [Accepted: 09/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE To develop a method for automatic reconstruction of catheter implants in interstitial brachytherapy (iBT) of the breast by means of electromagnetic tracking (EMT) with the goal of making treatment planning as time-effective and accurate as possible. MATERIALS AND METHODS The implant geometry of 64 patients was recorded using an afterloader prototype with EMT functionality immediately after the planning CT. EMT data were transferred to the CT image space by rigidly registering the catheter fixation buttons as landmarks. To further improve reconstruction accuracy, the EMT reconstruction points were used as starting points to define small regions of interest (ROI) in the CT image. Within these ROIs, the catheter track was segmented in the CT using image processing operations such as thresholding and blob detection, thus refining the reconstruction. The perpendicular distance between the refined EMT implant reconstruction points and the manually reconstructed catheters by an experienced treatment planner was calculated as a measure of their geometric agreement. RESULTS Geometrically, the refined EMT based implant reconstruction shows excellent agreement with the manual reconstruction. The median distance across all patients is 0.25 mm and the 95th percentile is 1 mm. Refinement takes approximately 0.5 s per reconstruction point and typically does not exceed 3 min per implant at no user interaction. CONCLUSION The refined EMT based implant reconstruction proved to be extremely accurate and fast compared to manual reconstruction. The presented procedure can in principle be easily transferred to clinical routine and therefore has enormous potential to provide significant time savings in iBT treatment planning whilst improving reconstruction accuracy.
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Cozzi S, Augugliaro M, Ciammella P, Botti A, Trojani V, Najafi M, Blandino G, Ruggieri MP, Giaccherini L, Alì E, Iori F, Sardaro A, Finocchi Ghersi S, Deantonio L, Gutierrez Miguelez C, Iotti C, Bardoscia L. The Role of Interstitial Brachytherapy for Breast Cancer Treatment: An Overview of Indications, Applications, and Technical Notes. Cancers (Basel) 2022; 14:cancers14102564. [PMID: 35626168 PMCID: PMC9139312 DOI: 10.3390/cancers14102564] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Breast cancer is the most common cancer in the female population. Adjuvant radiotherapy has become increasingly important as conservative treatment. Muticatheter interstitial brachytherapy is a type of radiation technique wherein the radioactive sources are directly implanted into or close to the target tissue and may be considered an extremely precise, versatile, and variable radiation technique. Literature data support muticatheter interstitial brachytherapy as the only method with strong scientific evidence to perform partial breast irradiation and reirradiation after previous conservative surgery and external beam radiotherapy. The aim of our work is to provide a comprehensive view of the use of interstitial brachytherapy, with particular focus on the implant description, limits, and advantages of the technique. Abstract Breast cancer represents the second leading cause of cancer-related death in the female population, despite continuing advances in treatment options that have significantly accelerated in recent years. Conservative treatments have radically changed the concept of healing, also focusing on the psychological aspect of oncological treatments. In this scenario, radiotherapy plays a key role. Brachytherapy is an extremely versatile radiation technique that can be used in various settings for breast cancer treatment. Although it is invasive, technically complex, and requires a long learning curve, the dosimetric advantages and sparing of organs at risk are unequivocal. Literature data support muticatheter interstitial brachytherapy as the only method with strong scientific evidence to perform partial breast irradiation and reirradiation after previous conservative surgery and external beam radiotherapy, with longer follow-up than new, emerging radiation techniques, whose effectiveness is proven by over 20 years of experience. The aim of our work is to provide a comprehensive view of the use of interstitial brachytherapy to perform breast lumpectomy boost, breast-conserving accelerated partial breast irradiation, and salvage reirradiation for ipsilateral breast recurrence, with particular focus on the implant description, limits, and advantages of the technique.
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Affiliation(s)
- Salvatore Cozzi
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
- Correspondence: ; Tel.: +39-329-731-7608
| | - Matteo Augugliaro
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Patrizia Ciammella
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Andrea Botti
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.B.); (V.T.)
| | - Valeria Trojani
- Medical Physics Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (A.B.); (V.T.)
| | - Masoumeh Najafi
- Department of Radiation Oncology, Shohadaye Haft-e-Tir Hospital, Iran University of Medical Science, Teheran 1997667665, Iran;
| | - Gladys Blandino
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Maria Paola Ruggieri
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Lucia Giaccherini
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Emanuele Alì
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Federico Iori
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Angela Sardaro
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari “Aldo Moro”, 70124 Bari, Italy;
| | - Sebastiano Finocchi Ghersi
- Radiation Oncolgy Unit, AOU Sant’Andrea, Facoltà di Medicina e Psicologia, Università La Sapienza, 00185 Rome, Italy;
| | - Letizia Deantonio
- Radiation Oncology Clinic, Oncology Institute of Southern Switzerland (IOSI), Bellinzona, 6500 Lugano, Switzerland;
| | - Cristina Gutierrez Miguelez
- Brachytherapy Unit, Department of Radiation Oncology, Catalan Institute of Oncology, University of Barcelona, L’Hospitalet de Llobregat, 08908 Barcelona, Spain;
| | - Cinzia Iotti
- Radiation Oncology Unit, Azienda USL-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (M.A.); (P.C.); (G.B.); (M.P.R.); (L.G.); (E.A.); (F.I.); (C.I.)
| | - Lilia Bardoscia
- Radiation Oncology Unit, S. Luca Hospital, Healthcare Company Tuscany Nord Ovest, 55100 Lucca, Italy;
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Herein A, Stelczer G, Pesznyák C, Fröhlich G, Smanykó V, Mészáros N, Polgár C, Takácsi-Nagy Z, Major T. CyberKnife versus multicatheter interstitial brachytherapy for accelerated partial breast irradiation: a dosimetrical assessment with focus on organs at risk. Rep Pract Oncol Radiother 2022; 27:152-160. [PMID: 35402040 PMCID: PMC8989445 DOI: 10.5603/rpor.a2022.0011] [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: 12/08/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background The purpose of the study was to dosimetrically compare multicatheter interstitial brachytherapy (MIBT) and stereotactic radiotherapy with CyberKnife (CK) for accelerated partial breast irradiation with special focus on dose to organs at risk (OARs). Materials and methods Treatment plans of thirty-one patients treated with MIBT were selected and additional CK plans were created on the same CT images. The OARs included ipsilateral non-target and contralateral breast, ipsilateral and contralateral lung, skin, ribs, and heart for left sided cases. The fractionation was identical (4 × 6.25 Gy). Dose-volume parameters were calculated for both techniques and compared. Results The D90 of the PTV for MIBT and CK were similar (102.4% vs. 103.6%, p = 0.0654), but in COIN the MIBT achieved lower value (0.75 vs. 0.91, p < 0.001). Regarding the V100 parameter of non-target breast CK performed slightly better than MIBT (V100: 1.1% vs. 1.6%), but for V90, V50 and V25 MIBT resulted in less dose. Every examined parameter of ipsilateral lung, skin, ribs and contralateral lung was significantly smaller for MIBT than for CK. Protection of the heart was slightly better with MIBT, but only the difference of D2cm3 was statistically significant (17.3% vs. 20.4%, p = 0.0311). There were no significant differences among the dose-volume parameters of the contralateral breast. Conclusion The target volume can be properly irradiated by both techniques with high conformity and similar dose to the OARs. MIBT provides more advantageous plans than CK, except for dose conformity and the dosimetry of the heart and contralateral breast. More studies are needed to analyze whether these dosimetrical findings have clinical significance.
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Affiliation(s)
- András Herein
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Budapest University of Technology and Economic, Institute of Nuclear Techniques, Budapest, Hungary
| | - Gábor Stelczer
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Budapest University of Technology and Economic, Institute of Nuclear Techniques, Budapest, Hungary
| | - Csilla Pesznyák
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Budapest University of Technology and Economic, Institute of Nuclear Techniques, Budapest, Hungary
| | - Georgina Fröhlich
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Eötvös Loránd University, Faculty of Science, Budapest, Hungary
| | - Viktor Smanykó
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary
| | - Norbert Mészáros
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Semmelweis University, Department of Oncology, Budapest, Hungary
| | - Csaba Polgár
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Semmelweis University, Department of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Semmelweis University, Department of Oncology, Budapest, Hungary
| | - Tibor Major
- National Institute of Oncology, Centre of Radiotherapy, Budapest, Hungary.,Semmelweis University, Department of Oncology, Budapest, Hungary
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Four-fraction ultra-accelerated minimal breast irradiation in early breast cancer: The initial feasibility results of an institutional experience. Brachytherapy 2022; 21:475-486. [PMID: 35396137 DOI: 10.1016/j.brachy.2022.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the feasibility, early toxicity, and clinical outcomes of early-breast cancer patients in a single-arm, phase I/II study of an ultra-accelerated, four-fraction schedule of minimal breast irradiation (4f-AMBI) using a multicatheter, minimally-invasive, intraoperative tumor bed implant (MITBI) during breast-conserving surgery (BCS). METHODS AND MATERIALS Eligible women aged >40 years with clinically and radiologically confirmed, unifocal invasive or in situ ≤3 cm tumors were considered as potential candidates for MITBI during BCS. After the pathology report, patients who met APBI criteria received ultra-accelerated four-fractions irradiation (6.2 Gy BID x 4fx over 2 days) with perioperative HDR-brachytherapy (PHDRBT). Early complications, toxicity, clinical outcomes, and cosmetic results were analyzed. RESULTS Of 89 patients initially implanted, 60(67.4%) were definitively included in the 4f-AMBI-protocol. The median age was 64.4 years; the median CTV was 32.1 cc (6.9-75.4 cc), and the external-V100 was 43.1 cc (12.87-107 cc), representing 5% of the breast tissue irradiated with a median CTV D90 of 6.2 Gy (5.6-6.28 Gy). The entire local treatment (BCS&MITBI-4f-AMBI) was completed at a median of 8 days (4-10 days). The rate of early complications was 11%. There were no major complications. Acute skin-subcutaneous G1 toxicity was reported in 11.7%, and late G1 toxicity on 36.7%. After a median follow-up of 27 months (11-51 months), the local, elsewhere, locoregional and distant-control rates were 100%, 98.3%, 100%, and 100% respectively. The early-cosmetic evaluation was excellent-good in 94.5% of patients evaluated. CONCLUSIONS Ultra-accelerated, four-fraction, minimal breast irradiation (4f-AMBI) using a minimally-invasive tumor bed implant procedure is safe, dosimetrically feasible, and shows small irradiated volumes. This program provides low toxicity rates and excellent short-term clinical and cosmesis outcomes.
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Thermal Boost to Breast Tumor Bed—New Technique Description, Treatment Application and Example Clinical Results. Life (Basel) 2022; 12:life12040512. [PMID: 35455003 PMCID: PMC9032001 DOI: 10.3390/life12040512] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/28/2022] [Indexed: 11/25/2022] Open
Abstract
(1) Current breast-conserving therapy for breast cancer consists of a combination of many consecutive treatment modalities. The most crucial goal of postoperative treatment is to eradicate potentially relapse-forming residual cancerous cells within the tumor bed. To achieve this, the HDR brachytherapy boost standardly added to external beam radiotherapy was enhanced with an initial thermal boost. This study presents an original thermal boost technique developed in the clinic. (2) A detailed point-by-point description of thermal boost application is presented. Data on proper patient selection, microwave thermal boost planning, and interstitial hyperthermia treatment delivery are supported by relevant figures and schemes. (3) Out of 1134 breast cancer patients who were administered HDR brachytherapy boost in the tumor bed, 262 were also pre-heated interstitially without unexpected complications. The results are supported by two example cases of hyperthermia planning and delivery. (4) Additional breast cancer interstitial thermal boost preceding HDR brachytherapy boost as a part of combined treatment in a unique postoperative setting was feasible, well-tolerated, completed in a reasonable amount of time, and reproducible. A commercially available interstitial hyperthermia system fit and worked well with standard interstitial brachytherapy equipment.
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Sarria GR, Ramos ML, Palacios A, Del Castillo R, Castro F, Calvo A, Cotrina JM, Heredia A, Galarreta JA, Fuentes-Rivera P, Avalos A, Martinez DA, Colqui K, Ziegler G, Schmeel LC, Pinillos LV, Wenz F, Giordano FA, Sarria GJ, Sperk E. Long-Term Outcomes of an International Cooperative Study of Intraoperative Radiotherapy Upfront Boost With Low Energy X-Rays in Breast Cancer. Front Oncol 2022; 12:850351. [PMID: 35371998 PMCID: PMC8968081 DOI: 10.3389/fonc.2022.850351] [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: 01/07/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose The purpose of this study was to assess the effectivity of upfront kilovoltage intraoperative radiotherapy (IORT) as a boost in high-risk early-stage breast cancer patients from an international pooled cohort. Materials/Methods Patients from four centers in three different countries were retrospectively screened. Those with a minimum 1-year follow-up were included. Cumulative local (LR), regional (RR), and distant metastasis rates (DM) were analyzed. Additionally, the estimated overall survival (OS) was assessed. The Cox regression analysis was performed to identify failure predicting factors. Results A total of 653 patients from centers in Peru, Spain, and Germany were included. The median follow-up was 55 (12-180) months, and age was 58 (27-86) years. Clinical tumor (T) staging was T1 65.85%, T2 30.17%, and T3 3.98%. Positive margins were found in 7.9% and in-situ component in 20.06%. The median IORT dose was 20 (6-20). The median time from IORT to EBRT was 74.5 (13-364) days. An overall 3.4% (n = 22) of patients developed local recurrence at some point during follow-up. The 12-, 60-, and 120-month cumulative LR were 0.3%, 2.3%, and 7.9%, respectively. After multivariate analysis, only age <50 remained to be a significant prognostic factor for local recurrence (HR 0.19, 95% CI 0.08-0.47; p < 0.05). The 10-year estimated OS was 81.2%. Conclusion Upfront boost with IORT yields similar local control outcomes to those EBRT-based reports. Results from prospective trials, regarding toxicity, cosmesis, and effectivity are awaited to confirm these findings.
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Affiliation(s)
- Gustavo R. Sarria
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Maria L. Ramos
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Amalia Palacios
- Department of Radiation Oncology, University Hospital Reina Sofia, Cordoba, Spain
| | | | - Felipe Castro
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angel Calvo
- Department of Radiation Oncology, University Hospital Reina Sofia, Cordoba, Spain
| | - Jose M. Cotrina
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Adela Heredia
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Jose A. Galarreta
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Paola Fuentes-Rivera
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Alicia Avalos
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | - Kevin Colqui
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
| | - Gonzalo Ziegler
- Department of Mastology, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | | | | | - Frederik Wenz
- University Hospital Freiburg, University of Freiburg, Freiburg, Germany
| | - Frank A. Giordano
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Gustavo J. Sarria
- Department of Radiation Oncology, Oncosalud-Auna, Lima, Peru
- Department of Radiotherapy, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Elena Sperk
- Department of Radiation Oncology, Mannheim Cancer Center, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Hypofractionated Whole Breast Irradiation and Boost-IOERT in Early Stage Breast Cancer (HIOB): First Clinical Results of a Prospective Multicenter Trial (NCT01343459). Cancers (Basel) 2022; 14:cancers14061396. [PMID: 35326548 PMCID: PMC8946807 DOI: 10.3390/cancers14061396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/03/2022] [Accepted: 03/06/2022] [Indexed: 02/05/2023] Open
Abstract
Background and purpose: To investigate intraoperative electron radiation therapy (IOERT) as a tumor bed boost during breast conserving surgery (BCS) followed by hypofractionated whole breast irradiation (HWBI) on age-correlated in-breast recurrence (IBR) rates in patients with low- to high-risk invasive breast cancer. Material and methods: BCS and IOERT (11.1 Gy) preceded a HWBI (40.5 Gy) in 15 fractions. Five-year IBR-rates were compared by a sequential ratio test (SQRT) with best evidences in three age groups (35−40 y and 41−50 y: 3.6%, >50 y: 2%) in a prospective single arm design. Null hypothesis (H0) was defined to undershoot these benchmarks for proof of superiority. Results: Of 1445 enrolled patients, 326 met exclusion criteria, leaving 1119 as eligible for analysis. After a median follow-up of 50 months (range 0.7−104), we detected two local recurrences, both in the age group >50 y. With no observed IBR, superiority was demonstrated for the patient groups 41−50 and >50 y, respectively. For the youngest group (35−40 y), no appropriate statistical evaluation was yet possible due to insufficient recruitment. Conclusions: In terms of five-year IBR-rates, Boost-IOERT followed by HWBI has been demonstrated to be superior in patients older than 50 and in the age group 41−50 when compared to best published evidence until 2010.
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Dürrbeck C, Gulde S, Abu-Hossin N, Fietkau R, Strnad V, Bert C. Influence and compensation of patient motion in electromagnetic tracking based quality assurance in interstitial brachytherapy of the breast. Med Phys 2022; 49:2652-2662. [PMID: 35143053 DOI: 10.1002/mp.15517] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/21/2021] [Accepted: 01/21/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Electromagnetic tracking (EMT) is a versatile and viable technique for various quality assurance (QA) tasks in interstitial brachytherapy (iBT). As the duration of EMT measurements in iBT is on the order of minutes, they can be strongly affected by patient motion, especially breathing, which gives rise to motion artefacts. Since the centrepiece of EMT related QA in iBT is to assess the geometry of the iBT implant or applicator, the absence of adequate motion compensation techniques could impede the use of EMT for QA purposes. A common way to compensate for this is to reference the data to either external or internal reference sensors (ERS, IRS) which are fixated on the patient's body or inside the applicator and therefore move with the patient. The purpose of the presented study is to provide a quantitative and in-depth analysis on the use of reference sensors for motion compensation. METHODS First, the need for adequate motion compensation is identified both qualitatively and quantitatively using a phantom subjected to simulated breathing motion. An evaluation routine is developed to assess the influence of motion compensation using reference sensors on the acquired EMT data. The evaluation metric is based on the observed displacement of the EMT sensor from its mean position while dwelling at a dwell position (DP) for a dwell time of 1 s. After that the routine is applied to a cohort of 54 breast cancer patients treated with iBT and the quality of an ERS based compensation approach is assessed. In a subgroup of four patients, an IRS is inserted into the iBT implant and IRS based compensation is compared to the ERS based approach. Moreover, a correlation analysis of the ERS and IRS approach is performed, also including respiratory signals derived from the trajectories of the different reference sensors. RESULTS It was found that motion compensation with ERS effectively reduced the mean sensor displacement per DP to median values as low as 0.11 mm in both phantom and patient measurements, which is below the precision of the EMT system (0.48 mm). Compensation using the IRS yielded comparable results and was as good as compensation with ERS. The results obtained from both approaches showed a strong correlation. Also the respiratory signals calculated from the different reference sensors were well correlated in most cases. CONCLUSION These results indicate that motion compensation with ERS can effectively remove motion artefacts in EMT data. While compensation with an IRS leads to comparable results, the IRS occupies one catheter whose geometry hence cannot be assessed. The use of ERS has proven to be both effective and practical in clinical routine. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Christopher Dürrbeck
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Sarah Gulde
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Nadin Abu-Hossin
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Meattini I, Becherini C, Boersma L, Kaidar-Person O, Marta GN, Montero A, Offersen BV, Aznar MC, Belka C, Brunt AM, Dicuonzo S, Franco P, Krause M, MacKenzie M, Marinko T, Marrazzo L, Ratosa I, Scholten A, Senkus E, Stobart H, Poortmans P, Coles CE. European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice consensus recommendations on patient selection and dose and fractionation for external beam radiotherapy in early breast cancer. Lancet Oncol 2022; 23:e21-e31. [PMID: 34973228 DOI: 10.1016/s1470-2045(21)00539-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 12/17/2022]
Abstract
High-quality randomised clinical trials testing moderately fractionated breast radiotherapy have clearly shown that local control and survival is at least as effective as with 2 Gy daily fractions with similar or reduced normal tissue toxicity. Fewer treatment visits are welcomed by patients and their families, and reduced fractions produce substantial savings for health-care systems. Implementation of hypofractionation, however, has moved at a slow pace. The oncology community have now reached an inflection point created by new evidence from the FAST-Forward five-fraction randomised trial and catalysed by the need for the global radiation oncology community to unite during the COVID-19 pandemic and rapidly rethink hypofractionation implementation. The aim of this paper is to support equity of access for all patients to receive evidence-based breast external beam radiotherapy and to facilitate the translation of new evidence into routine daily practice. The results from this European Society for Radiotherapy and Oncology Advisory Committee in Radiation Oncology Practice consensus state that moderately hypofractionated radiotherapy can be offered to any patient for whole breast, chest wall (with or without reconstruction), and nodal volumes. Ultrafractionation (five fractions) can also be offered for non-nodal breast or chest wall (without reconstruction) radiotherapy either as standard of care or within a randomised trial or prospective cohort. The consensus is timely; not only is it a pragmatic framework for radiation oncologists, but it provides a measured proposal for the path forward to influence policy makers and empower patients to ensure equity of access to evidence-based radiotherapy.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences M Serio, University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Carlotta Becherini
- Department of Experimental and Clinical Biomedical Sciences M Serio, University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Orit Kaidar-Person
- Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, Netherlands; Sheba Medical Center, Ramat Gan and Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gustavo Nader Marta
- Department of Radiation Oncology-Hospital Sírio-Libanês, São Paulo, Brazil; Latin American Cooperative Oncology Group, Porto Alegre, Brazil
| | - Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Marianne C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; The Christie NHS Foundation Trust, Manchester, UK
| | - Claus Belka
- Department of Radiation Oncology, LMU Klinikum, Ludwig-Maximilians University Munich, Munich, Germany
| | - Adrian Murray Brunt
- School of Medicine, University of Keele, Keele, UK; Clinical Trials and Statistics Unit, The Institute of Cancer Research, London, UK
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Pierfrancesco Franco
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy; Department of Radiation Oncology, Maggiore della Carità University Hospital, Novara, Italy
| | - Mechthild Krause
- Department of Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; OncoRay-National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden and Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany; National Center for Tumor Diseases, Partner Site Dresden, German Cancer Research Center, Heidelberg, Germany; German Cancer Research Center, Heidelberg and German Cancer Consortium, Dresden, Germany; Helmholtz-Zentrum Dresden-Rossendorf, Institute of Radiooncology, Dresden, Germany
| | | | - Tanja Marinko
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Livia Marrazzo
- Medical Physics Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Ivica Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Astrid Scholten
- Department of Radiotherapy, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, Netherlands
| | - Elżbieta Senkus
- Department of Oncology and Radiotherapy, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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Ivanov O, Licina J, Petrovic B, Trivkovic J, Marjanovic M. Implementation of accelerated partial breast irradiation at the Oncology Institute of Vojvodina. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh200422010i] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction. Early breast cancer is usually treated with breast conserving
surgery followed by radiation treatment. Whole breast irradiation is
standard of care so far, but currently there is an increasement in
accelerated partial breast irradiation for selected patients which showed
many advantages. The aim of this paper is to present the implementation of
the accelerated partial breast irradiation in Oncology Institute of
Vojvodina. Case outline. A 54-year-old woman was referred to radiotherapy
after breast conserving surgery. After she met all of the inclusion
criteria, she underwent accelerated partial breast irradiation with 38.5 Gy
in 10 fractions. Active breathing control device was used during the
treatment and cone beam computed tomography was performed before each
fraction for purpose of target position control. She terminated therapy in
good health condition with only adverse effect of mild radiation dermatitis
of irradiated area. On the first follow up, she was without any symptom or
sign of disease or complication. Conclusion. Accelerated partial breast
irradiation is safe and effective. Radiation oncologist should be encouraged
to implement this technique.
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Affiliation(s)
- Olivera Ivanov
- Oncology Institute of Vojvodina, Sremska Kamenica, Serbia + University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
| | - Jelena Licina
- Oncology Institute of Vojvodina, Sremska Kamenica, Serbia + University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia
| | - Borislava Petrovic
- Oncology Institute of Vojvodina, Sremska Kamenica, Serbia + University of Novi Sad, Faculty of Sciences, Department of Physics, Novi Sad, Serbia
| | | | - Milana Marjanovic
- Oncology Institute of Vojvodina, Sremska Kamenica, Serbia + University of Novi Sad, Faculty of Sciences, Department of Physics, Novi Sad, Serbia
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Hennequin C, Belkacémi Y, Bourgier C, Cowen D, Cutuli B, Fourquet A, Hannoun-Lévi JM, Pasquier D, Racadot S, Rivera S. Radiotherapy of breast cancer. Cancer Radiother 2021; 26:221-230. [PMID: 34955414 DOI: 10.1016/j.canrad.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Adjuvant radiotherapy is an essential component of the treatment of breast cancer. After conservative surgery for an infiltrating carcinoma, radiotherapy must be systematically performed, regardless of the characteristics of the disease, because it decreases the rate of local recurrence and by this way, specific mortality. A boost dose over the tumour bed is required if the patient is younger than 50 years-old. Partial breast irradiation could be routinely proposed as an alternative to whole breast irradiation, but only in selected and informed patients. For ductal carcinoma in situ, adjuvant radiotherapy must be also systematically performed after lumpectomy. After mastectomy, chest wall irradiation is required for pT3-T4 tumours and if there is an axillary nodal involvement, whatever the number of involved lymph nodes. After neoadjuvant chemotherapy and mastectomy, in case of pN0 disease, chest wall irradiation is recommended if there is a clinically or radiologically T3-T4 or node positive disease before chemotherapy. Axillary irradiation is recommended only if there is no axillary surgical dissection and a positive sentinel lymph node. Supra- and infraclavicular irradiation is advised in case of positive axillary nodes. Internal mammary irradiation must be discussed case by case, according to the benefit/risk ratio (cardiac toxicity). Hypofractionation regimens (42.5Gy in 16 fractions, or 41,6Gy en 13 or 40Gy en 15) are equivalent to conventional irradiation and must prescribe after tumorectomy in selected patients. Delineation of the breast, the chest wall and the nodal areas are based on clinical and radiological evaluations. 3D-conformal irradiation is the recommended technique, intensity-modulated radiotherapy must be proposed only in specific clinical situations. Respiratory gating could be useful to decrease the cardiac dose. Concomitant administration of chemotherapy in unadvised, but hormonal treatment could be start with or after radiotherapy.
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Affiliation(s)
- C Hennequin
- Service de cancérologie-radiothérapie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Y Belkacémi
- Hôpital Henri-Mondor, AP-HP, 94000 Créteil, France
| | - C Bourgier
- Institut du cancer Montpellier (ICM), 34000 Montpellier, France
| | - D Cowen
- Hôpital La Timone, AP-HM, 13000 Marseille, France
| | - B Cutuli
- Polyclinique Courlancy, 51000 Reims, France
| | - A Fourquet
- Institut Curie, 26, rue d'Ulm, 75005 Paris, France
| | - J-M Hannoun-Lévi
- Centre Antoine-Lacassagne, 33, avenue Valombrose, 06000 Nice, France
| | - D Pasquier
- Centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - S Racadot
- Centre Léon-Bérard, 69000 Lyon, France
| | - S Rivera
- Institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif, France
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Jiang P, Zou L, Wei L, Cheng G, Sun B, Zhang F, Wang R, Wang T, Qu A, Yuan X, Qiu B, Wei S, Liu Z, Zhang Y, Wang J. Chinese Expert Consensus on Iodine 125 Seed Implantation for Recurrent Cervical Cancer in 2021. Front Oncol 2021; 11:700710. [PMID: 34858802 PMCID: PMC8630633 DOI: 10.3389/fonc.2021.700710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/14/2021] [Indexed: 01/07/2023] Open
Abstract
The treatment modality for recurrent cervical cancer (rCC) is limited, and the prognosis of these patients is poor. Seed implantation could be an important component of rCC management in the context of dose boost or salvage therapy after surgery or radiotherapy, which is characterized by a minimally invasive, high local dose, and rapidly does fall, sparing normal tissue. For patients with good performance status and lateral pelvic wall recurrence with an available puncture path, seed implantation was recommended, as well as for selected central pelvic recurrence and extra-pelvic recurrence. The combination of brachytherapy treatment planning system and CT guidance was needed, and three-dimensional printing templates could greatly improve the accuracy, efficiency, and quality of seed implantation to achieve a potential ablative effect and provide an efficient treatment for rCC. However, the recommendations of seed implantation were mainly based on retrospective articles and lack high-quality evidence, and multicenter prospective randomized studies are needed. In this consensus on iodine125 seed implantation for rCC, indication selection, technical process and requirements, dosimetry criteria, radiation protection, combined systemic therapy, and outcomes of seed implantation for rCC are discussed.
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Affiliation(s)
- Ping Jiang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Lijuan Zou
- Department Radiation Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lichun Wei
- Department of Radiation Oncology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Guanghui Cheng
- Department of Radiation Oncology, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Baosheng Sun
- Department of Radiation Oncology, Jilin Cancer Hospital, Changchun, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Beijing, China
| | - Ruoyu Wang
- Department of Radiation Oncology, Affiliated Zhongshan Hospital of Dalian University, Dalian, China
| | - Tiejun Wang
- Department of Radiation Oncology, The Second Hospital of Jilin University, Changchun, China
| | - Ang Qu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Xiangkun Yuan
- Department of Radiation Oncology, Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine, Cangzhou, China
| | - Bin Qiu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Shuhua Wei
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
| | - Zi Liu
- Department of Radiation Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xian, China
| | - Yunyan Zhang
- Department of Radiation Oncology, Harbin Medical University Cancer Hospital, Harbin, China
| | - Junjie Wang
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, China
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Franceschini D, Fogliata A, Spoto R, Dominici L, Lo Faro L, Franzese C, Comito T, Lobefalo F, Reggiori G, Cozzi L, Sagona A, Gentile D, Scorsetti M. Long term results of a phase II trial of hypofractionated adjuvant radiotherapy for early-stage breast cancer with volumetric modulated arc therapy and simultaneous integrated boost. Radiother Oncol 2021; 164:50-56. [PMID: 34537289 DOI: 10.1016/j.radonc.2021.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE to report toxicity and cosmetic outcome with a median follow-up of 6 years of a phase II trial of hypofractionated radiotherapy with volumetric modulated arc therapy (VMAT) and simultaneous integrated boost (SIB) for early-stage breast cancer after conservative surgery. MATERIALS AND METHODS From August 2010 to September 2014, patients requiring adjuvant radiotherapy for early-stage breast cancer were treated according to a phase I-II protocol with SIB to 40.5 and 48 Gy to the breast and the boost region, respectively, with VMAT technique. The primary endpoint evaluated the treatment feasibility regarding adherence to required dose constraints for target, heart and lungs. Acute and late toxicity, local and distant control were secondary endpoints. RESULTS 450 patients were included in the trial and analysed after a median follow-up of 6 years. Acute toxicity was already presented in a previous paper. Regarding late toxicity, 93% of patients had no skin alteration at five years, while 5.3% and 1.3% did record G1 and G2 residual toxicity, respectively. Cosmetic outcome was scored good or excellent in almost all cases (97.2%), fair only in 2.3% of patients. Residual tenderness in the irradiated breast was reported by 10% of patients. Cosmesis and breast pain improved during follow-up. Two cases of G2 pneumonitis and two cases of ischemic cardiopathy were registered during follow-up. Five cases presented local recurrence in the homolateral breast, four patients had a new primary cancer in the contralateral breast, while distant metastasis developed in 7 patients. CONCLUSION After more than six years, hypofractionated VMAT with SIB for adjuvant radiotherapy in early-stage breast cancer patients remains a safe and effective approach. Mature data on skin toxicity and cosmetic outcome are encouraging. However, longer follow-up is required to evaluate local control, cardiac toxicity and secondary carcinogenesis.
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Affiliation(s)
- D Franceschini
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - A Fogliata
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy.
| | - R Spoto
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - L Dominici
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - L Lo Faro
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - C Franzese
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| | - T Comito
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - F Lobefalo
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - G Reggiori
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - L Cozzi
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| | - A Sagona
- IRCCS Humanitas Research Hospital, Breast Unit, Milan-Rozzano, Italy
| | - D Gentile
- Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Breast Unit, Milan-Rozzano, Italy
| | - M Scorsetti
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
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Patient-reported quality of life with interstitial partial breast brachytherapy and external beam whole breast radiotherapy: a comparison using propensity-score matching. J Contemp Brachytherapy 2021; 13:387-394. [PMID: 34484352 PMCID: PMC8407260 DOI: 10.5114/jcb.2021.107690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/01/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose The aim of this study was to compare patient-reported quality of life (QOL) scores after accelerated partial breast irradiation (APBI) using interstitial brachytherapy vs. external beam whole breast radiotherapy (WBRT) for breast cancer. Material and methods Women with breast cancer treated with WBRT or APBI after breast conservation surgery were enrolled in this prospective study. Single cross-sectional QOL assessment was performed using EORTC QLQ-C30 and BR-23 questionnaires. Patients treated with APBI were propensity-score matched to similar cohort of patients treated with WBRT. QOL scores were analyzed for the entire unmatched cohort and compared between the two matched cohorts using Student’s two-tailed t-test. P-value of < 0.05 was considered statistically significant, and a 10-point difference between mean scores was considered clinically meaningful. Results A total of 64 APBI patients were matched with 99 WBRT patients out of the entire study cohort of 320 cases. QOL scores for functional scales of QLQ-C30 were similar between the two groups for both matched and unmatched cohorts, while symptom scores of QLQ-C30 did not show any clinically significant difference. Functional scales of BR-23 did not show any clinical or statistically significant difference. Among symptom scales of BR-23, scores were similar for APBI and WBRT groups except for a worse score of “upset by hair loss” sub-scale in the brachytherapy group of the matched cohort (51.9 vs. 22.7, p = 0.006). Conclusions Patients undergoing APBI reported similar QOL compared to WBRT when matched for various factors.
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Pignol JP, Hoekstra N, Wilke D, Dahn H, Nolan M, Vicini F. Estimation of Annual Secondary Lung Cancer Deaths Using Various Adjuvant Breast Radiotherapy Techniques for Early-Stage Cancers. Front Oncol 2021; 11:713328. [PMID: 34434899 PMCID: PMC8381359 DOI: 10.3389/fonc.2021.713328] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose Secondary lung cancer (SLC) can offset the benefit of adjuvant breast radiotherapy (RT), and risks compound sharply after 25 to 30 years. We hypothesized that SLC risk is mainly an issue for early-stage breast cancer, and that lives could be saved using different RT techniques. Patients and Methods The SEER database was used to extract breast patient age, stage survival, and radiotherapy utilization over time and per stage and to assess the factors associated with increased SLC risk with a multivariable competing risk Cox model. The number of SLC was calculated using the BEIR model modified with patient survival, age, and use of RT from the SEER database. Stage distribution and number of new breast cancer cases were obtained from the NAACCR. Mean lung dose for various irradiation techniques was obtained from measurement or literature. Results Out of the 765,697 non-metastatic breast cancers in the SEER database from 1988 to 2012, 49.8% received RT. RT significantly increased the SLC risk for longer follow-up (HR=1.58), early stage including DCIS, stage I and IIA (HR = 1.11), and younger age (HR=1.061) (all p<0.001). More advanced stages did not have significantly increased risk. In 2019, 104,743 early-stage breast patients received radiotherapy, and an estimated 3,413 will develop SLC (3.25%) leading to an excess of 2,900 deaths (2.77%). VMAT would reduce this mortality by 9.9%, hypofractionation 26 Gy in five fractions by 38.8%, a prone technique by 70.3%, 3D-CRT APBI by 43.3%, HDR brachytherapy by 71.1%, LDR by 80.7%, and robotic 4π APBI by 85.2%. Conclusions SLC after breast RT remains a clinically significant issue for early-stage breast cancers. This mortality could be significantly reduced using a prone technique or APBI.
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Affiliation(s)
- Jean-Philippe Pignol
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada.,Radiation Oncology Department, Erasmus MC, Rotterdam, Netherlands
| | - Nienke Hoekstra
- Radiation Oncology Department, Erasmus MC, Rotterdam, Netherlands
| | - Derek Wilke
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada
| | - Hannah Dahn
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada
| | - Maureen Nolan
- Radiation Oncology Department, Dalhousie University, Halifax, NS, Canada
| | - Frank Vicini
- Radiation Oncology, 21st Century Oncology, Farmington Hills, MI, United States
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Comparison between Accelerated Partial Breast Irradiation with multicatheter interstitial brachytherapy and Whole Breast Irradiation, in clinical practice. Clin Transl Oncol 2021; 24:24-33. [PMID: 34213744 PMCID: PMC8251685 DOI: 10.1007/s12094-021-02664-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/07/2021] [Indexed: 11/05/2022]
Abstract
Purpose The aim of this study was to compare accelerated partial breast irradiation (APBI) with multicatheter interstitial brachytherapy (BT) and whole breast irradiation (WBI), in terms of toxicity, aesthetic result, quality of life and survival, in clinical practice.
Materials and methods A comparative study of two prospectively recorded cohorts of 76 breast cancer patients who complied with the recommendations of GEC-ESTRO for APBI was conducted. The main objective was toxicity, quality of life measured through validated questionnaires and the aesthetic results. Secondary objectives were overall survival and disease-free survival.
Results Seventy-six stage I/II breast cancer patients, with a mean age of 66 years entered the study. APBI group showed less acute G1-2 dermatitis (51.4 vs 94.9%, p < 0.001) and late hyperpigmentation (0 vs 17.9%, p = 0.04). There were no differences in aesthetic results, both assessed by the patient herself and by the doctor. Statistically significant differences in measures of quality of life were observed in favour of the APBI, both in EORTC QLQ-BR23 and body image scale questionnaires. With a median follow-up of 72 months (6 years), the estimated overall survival at 5 and 10 years was 96.8 and 77.7%, respectively, and disease-free survival at 5 and 10 years was 91.1 and 69.4%, respectively, without statistically significant differences between groups.
Discussion APBI is an attractive alternative in candidate patients with initial breast cancer, with benefits in acute toxicity and quality of life and fewer visits to the hospital, without compromising tumor control or survival.
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Jones BM, Green S. Modern radiation techniques in early stage breast cancer for the breast radiologist. Clin Imaging 2021; 80:19-25. [PMID: 34224950 DOI: 10.1016/j.clinimag.2021.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 01/22/2023]
Abstract
Partial breast irradiation (PBI) and ultra-hypofractionated whole breast irradiation (uWBI) are contemporary alternatives to conventional and standard hypofractionated whole breast irradiation (WBI), which shorten treatment from 3 to 6 weeks to 1-2 weeks for select patients. PBI and accelerated PBI (APBI) can be delivered with external beam radiation (3D conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT)), intraoperative radiation (IORT), or brachytherapy. These new radiation techniques offer the advantage of convenience and lower cost, which ultimately improves access to care. Globally, the COVID 19 pandemic has accelerated APBI/PBI and ultra-hypofractionated regimens into routine practice for carefully selected patients. Recent long-term data from randomized controlled trials (RCTs) have demonstrated these techniques are safe and effective in suitable patients demonstrating equivalent or improved local recurrence, acute/late toxicity, and cosmesis. PBI and APBI should be limited to low risk unifocal invasive ductal carcinoma and ductal carcinoma in situ with tumor size < 2 cm, clear margins (≥2 mm), ER+, and negative nodes. Based on the results from UK Fast-Forward and UK FAST ultra-hypofractionated breast radiation can be safely employed for early stage node negative patients, but is not yet considered an international standard of care. In this review, authors will appraise recent data for these shorter course radiation treatment regimens, as well as, considerations for breast radiologists including surveillance imaging and radiographic findings.
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Affiliation(s)
- Brianna M Jones
- Icahn School of Medicine at Mount Sinai, United States of America.
| | - Sheryl Green
- Icahn School of Medicine at Mount Sinai, United States of America.
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Bruand M, Renard S, Salleron J, Meknaci E, Charra-Brunaud C, Peiffert D. Interstitial multi-catheter breast brachytherapy: Technical aspects and experience feedback in a comprehensive cancer center. Cancer Radiother 2021; 26:450-457. [PMID: 34147341 DOI: 10.1016/j.canrad.2021.06.001] [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: 03/28/2021] [Revised: 05/08/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To focus on technical aspects of the implementation of interstitial high dose rate brachytherapy, with a step-by-step approach. MATERIALS AND METHODS Patients were selected during multidisciplinary tumor boards, according to inclusion criteria adapted from GEC-ESTRO guidelines. A CT scan was performed a few days before implantation. On pre-implant CT, using surgical scar and clips, surgical and pathological reports, and preoperative images, we delineated the tumor bed to be included in the Clinical Target Volume (CTV), according to GEC ESTRO Recommendations. A 3D virtual implant simulation of the best catheter positions was performed in order to cover the target volume. Implantation was then carried out under local anaesthetic using 3D projections of the catheter inlets and outlets. Dosimetry was performed on post-implantation CT scan. A dose of 34Gy was delivered in 10 fractions. Acute and late side effects, and local control were evaluated 2 and 8 months after treatment. RESULTS Between July 2017 and January 2020, 20 patients were treated with accelerated partial breast irradiation. Dose constraints regarding target volume coverage, overdose, dose homogeneity, conformation index and organs at risk were met in 94.7%, 100%, 63.2%, 0% and 89.5% of the treatment plans, respectively. Grade 1-2 acute adverse events were observed in 21% of patients, with no grade 3-4 events. CONCLUSION The first dosimetric results and early clinical tolerance and efficacy achieved by the implementation of breast interstitial multicatheter brachytherapy in routine clinical practice are very encouraging, and confirm the interest of extending this practice.
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Affiliation(s)
- M Bruand
- Department of radiotherapy, institut de cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France; Faculté de médecine de Nancy, université de Lorraine, 9, avenue de la Forêt de Haye, 54505 Vandœuvre-lès-Nancy, France.
| | - S Renard
- Department of radiotherapy, institut de cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - J Salleron
- Biostatistic unit, institut de cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - E Meknaci
- Department of radiotherapy, institut de cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - C Charra-Brunaud
- Department of radiotherapy, institut de cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France
| | - D Peiffert
- Department of radiotherapy, institut de cancérologie de Lorraine, 54519 Vandœuvre-lès-Nancy, France
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47
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Haussmann J, Budach W, Strnad V, Corradini S, Krug D, Schmidt L, Tamaskovics B, Bölke E, Simiantonakis I, Kammers K, Matuschek C. Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:2967. [PMID: 34199281 PMCID: PMC8231985 DOI: 10.3390/cancers13122967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE/OBJECTIVE The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials. MATERIAL AND METHODS We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes. RESULTS For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively). CONCLUSION Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Vratislav Strnad
- Department of Radiation Oncology, University Erlangen, 91054 Erlangen, Germany;
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU (Ludwig Maximillian), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Ioannis Simiantonakis
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
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Dickhoff LR, Vrancken Peeters MJ, Bosman PA, Alderliesten T. Therapeutic applications of radioactive sources: from image-guided brachytherapy to radio-guided surgical resection. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2021; 65:190-201. [PMID: 34105339 DOI: 10.23736/s1824-4785.21.03370-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is well known nowadays that radioactivity can destroy the living cells it interacts with. It is therefore unsurprising that radioactive sources, such as iodine-125, were historically developed for treatment purposes within radiation oncology with the goal of damaging malignant cells. However, since then, new techniques have been invented that make creative use of the same radioactivity properties of these sources for medical applications. Here, we review two distinct kinds of therapeutic uses of radioactive sources with applications to prostate, cervical, and breast cancer: brachytherapy and radioactive seed localization. In brachytherapy (BT), the radioactive sources are used for internal radiation treatment. Current approaches make use of real-time image guidance, for instance by means of magnetic resonance imaging, ultrasound, computed tomography, and sometimes positron emission tomography, depending on clinical availability and cancer type. Such image-guided BT for prostate and cervical cancer presents a promising alternative and/or addition to external beam radiation treatments or surgical resections. Radioactive sources can also be used for radio-guided tumor localization during surgery, for which the example of iodine-125 seed use in breast cancer is given. Radioactive seed localization (RSL) is increasingly popular as an alternative tumor localization technique during breast cancer surgery. Advantages of applying RSL include added flexibility in the clinical scheduling logistics, an increase in tumor localization accuracy, and higher patient satisfaction; safety measures do however have to be employed. We exemplify the implementation of RSL in a clinic through experiences at the Netherlands Cancer Institute.
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Affiliation(s)
- Leah R Dickhoff
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands -
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Peter A Bosman
- Life Sciences and Health group, Centrum Wiskunde & Informatica, Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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Ciérvide R, Montero Á, Potdevin G, García J, Aranda MG, Álvarez B, Rossi K, López M, Hernando O, Valero J, Sánchez E, Chen X, Alonso R, Letón PF, Rubio C. 5-year results of accelerated partial breast irradiation (APBI) with SBRT (stereotactic body radiation therapy) and exactrac adaptive gating (Novalis ®) for very early breast cancer patients: was it all worth it? Clin Transl Oncol 2021; 23:2358-2367. [PMID: 34043153 DOI: 10.1007/s12094-021-02636-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/05/2021] [Indexed: 12/25/2022]
Abstract
PURPOSE To explore the feasibility of image-guided and respiratory-gated Stereotactic Body Radiation Therapy (SBRT) for Accelerated Partial Breast Irradiation (APBI) in patients with very early breast cancer. MATERIAL AND METHODS Selected patients with early breast carcinoma after breast-conserving surgery were enrolled in this phase II trial. A fiducial marker was percutaneously placed close to surgical bed and five external fiducials were set on the skin. A CT scan for planning was acquired at free breathing. The treatment was planned and DVH were assessed according to international recommendations. Prescription dose was 30 Gy in five consecutive fractions of 6 Gy. A 6MV monoenergetic LINAC (linear accelerator) that combines stereoscopic X-ray imaging system and ExacTrac Adaptive Gating technique was used. PTV (planning target volume) intrafraction motion was controlled and PTV was irradiated in a selected gated area of the respiratory cycle. Shifts for a correct, gated set-up were calculated and automatically applied. RESULTS Between April 2013 and October 2015, a total of 23 patients were included. The median tumor size was 12 mm. The mean PTV volume was 114 cc. The mean ipsilateral lung V9 Gy was 2.2% and for left-sided breast cancers, the volume of the heart receiving 1.5 Gy was 11.5%. Maximum skin dose was 30.8 Gy. Acute toxicity was grade1 in all the patients and 100% experienced excellent/good breast cosmesis outcomes. With a median follow-up of 66 months (range 8-99 months) local-relapse-free-survival reaches 100%. One patient developed a second breast cancer outside the treated quadrant after 25.1 months. CONCLUSION APBI with SBRT and ExacTrac Adaptive Gating System was feasible. The acute and late toxicities were almost null and cosmesis was excellent. We also found that the margins of 5 mm applied from CTV to PTV were sufficient to compensate for geometric uncertainties.
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MESH Headings
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Disease-Free Survival
- Dose Fractionation, Radiation
- Feasibility Studies
- Female
- Fiducial Markers
- Heart/radiation effects
- Humans
- Lung/radiation effects
- Mastectomy, Segmental
- Middle Aged
- Organ Motion
- Organs at Risk/radiation effects
- Postoperative Care/methods
- Prospective Studies
- Radiosurgery/instrumentation
- Radiosurgery/methods
- Respiration
- Skin/radiation effects
- Time Factors
- Tomography, X-Ray Computed
- Tumor Burden
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Affiliation(s)
- R Ciérvide
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain.
| | - Á Montero
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - G Potdevin
- Department of Radiation Oncology, Fundación Valle del Lili, Cali, Colombia
| | - J García
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - M G Aranda
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - B Álvarez
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - K Rossi
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - M López
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - O Hernando
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - J Valero
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - E Sánchez
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
| | - X Chen
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - R Alonso
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - P F Letón
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
| | - C Rubio
- Department of Radiation Oncology, U.H. Sanchinarro. HM Hospitales, Calle Oña, 10, 28050, Madrid, Spain
- Department of Radiation Oncology, U.H. Puerta del Sur. HM Hospitales, Madrid, Spain
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50
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Dosimetric comparison between interstitial brachytherapy and volumetric-modulated arc therapy for tumor bed boost in breast cancer. J Contemp Brachytherapy 2021; 13:302-309. [PMID: 34122570 PMCID: PMC8170527 DOI: 10.5114/jcb.2021.106141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/08/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To dosimetrically compare high-dose-rate interstitial brachytherapy (HDR-BT) with volumetric-modulated arc therapy (VMAT) for tumor bed boost, following breast conservative treatment. Material and methods 50 patients with early-stage breast cancer who underwent breast conservation surgery, followed by either HDR-BT (n = 25) of 15 Gy in 6 fractions over a period of 3 days, or VMAT dose of 16 Gy in 8 fractions (n = 25) for tumor bed boost, were retrospectively reviewed. All patients received whole breast irradiation of 46 Gy in 23 fractions. Dosimetric parameters for organs at risk (OARs), including ipsilateral and contralateral lungs, heart, contralateral breast, skin, and ribs, were evaluated with the help of dose-volume histograms (DVH). Results Heart sparing was similar in both modalities (left-sided breast irradiation, HDR-BT D2cc 20.5% vs. VMAT 30.2%, p-value = 0.243; right-sided breast irradiation, D2cc 6.5% vs. 4.4%, p-value = 0.165). Left-sided cases received higher dose to heart compared to right-sided patients. Interstitial brachytherapy resulted in significantly less dose to contralateral breast (D2cc 4.3% vs. 9.6%, p-value < 0.0001), ipsilateral lung (D2cc 27.6% vs. 73.2%, p-value < 0.0001), contralateral lung (D2cc 4.2% vs. 14.5%, p-value < 0.0001), ribs (D2cc 24.1% vs. 41.2%, p-value < 0.0001), and skin (D2cc 77.3% vs. 95%, p-value < 0.0001). Conclusions HDR-BT-based tumor bed boost irradiation results in significantly lower doses to most organs at risk with similar heart sparing compared to VMAT.
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