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Arbab M, Frame R, Alluri P, Parsons D, Lin MH, Cleaton J, Rahimi A. Master Breast Radiation Planning: Simple Guide for Radiation Oncology Residents. Adv Radiat Oncol 2024; 9:101476. [PMID: 38690296 PMCID: PMC11059315 DOI: 10.1016/j.adro.2024.101476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 02/04/2024] [Indexed: 05/02/2024] Open
Abstract
This article focuses on various aspects of breast radiation treatment planning, from simulation to field design. It covers the most common techniques including tangents, mono isocentric, dual isocentric, electron-photon match, and VMAT. This can serve as a guide for radiation oncology residents and medical students to advance their understanding of key aspects of breast radiation treatment and planning processes.
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Affiliation(s)
- Mona Arbab
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Romona Frame
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Prasanna Alluri
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - David Parsons
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Mu-Han Lin
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Jennifer Cleaton
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Asal Rahimi
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, Texas
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2
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Jacobs DHM, Mast ME, Horeweg N, Speijer G, Petoukhova AL, Straver M, Coerkamp EG, Hazelbag HM, Merkus J, Roeloffzen EMA, Zwanenburg LG, van der Sijp J, Fiocco M, Marijnen CAM, Koper PCM. Accelerated Partial Breast Irradiation using External-Beam or Intraoperative Electron Radiotherapy: 5 year oncological outcomes of a prospective cohort study. Int J Radiat Oncol Biol Phys 2022; 113:570-581. [PMID: 35301990 DOI: 10.1016/j.ijrobp.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 11/12/2022]
Abstract
PURPOSE To evaluate the ipsilateral breast tumor recurrence (IBTR) after two accelerated partial breast irradiation (APBI) techniques (intraoperative electron radiotherapy, IOERT and external-beam APBI, EB-APBI) in patients with early stage breast cancer. PATIENTS AND METHODS Between 2011 and 2016, women ≥60 years with breast carcinoma or DCIS of ≤30mm and cN0 undergoing breast conserving therapy were included in a two-armed prospective multi-center cohort study. IOERT (1 × 23.3Gy prescribed at the 100% isodose line) was applied in one hospital and EB-APBI (10 × 3.85Gy daily) in 2 other hospitals. Primary endpoint was IBTR (all recurrences in the ipsilateral breast irrespective of localization) at 5 years after lumpectomy. A competing risk model was used to estimate the cumulative incidences of IBTR, which were compared using Fine and Gray's test. Secondary endpoints were locoregional recurrence rate (LRR), distant recurrence, disease specific survival and overall survival. Univariate Cox-regression models were estimated to identify risk factors for IBTR. Analyses were performed of the intention to treat (ITT) population (IOERT n=305; EB-APBI n=295), and sensitivity analyses were done of the per-protocol population (PP) (IOERT n=270; EB-APBI n=207). RESULTS Median follow up was 5.2 years (IOERT) and 5 years (EB-APBI). Cumulative incidence of IBTR in the ITT population at 5 years after lumpectomy was 10.6% (95% confidence interval 7.0-14.2%) after IOERT and 3.7% (95%CI 1.2-5.9%) after EB-APBI (p=0.002). LRR was significantly higher after IOERT than EB-APBI (12.1% vs 4.5%, p=0.001). There were no differences between groups in other endpoints. Sensitivity analysis showed similar results. For both groups, no significant risk factors for IBTR were identified in the ITT population. In the PP population surgical margin status was the only significant risk factor for developing IBTR in both treatment groups. CONCLUSION Ipsilateral breast tumor recurrences and locoregional recurrence rates were unexpectedly high in patients treated with IOERT, and acceptable in patients treated with EB-APBI.
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Affiliation(s)
- Daphne H M Jacobs
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, The Netherlands; Haaglanden Medical Center, Department of Radiation Oncology, Leidschendam, The Netherlands.
| | - Mirjam E Mast
- Haaglanden Medical Center, Department of Radiation Oncology, Leidschendam, The Netherlands.
| | - Nanda Horeweg
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, The Netherlands
| | - Gabrielle Speijer
- Haga Hospital, Department of Radiation Oncology, The Hague, The Netherlands
| | - Anna L Petoukhova
- Haaglanden Medical Center, Department of Radiation Oncology, Leidschendam, The Netherlands
| | - Marieke Straver
- Haaglanden Medical Center, Department of Surgery, Leidschendam, The Netherlands
| | - Emile G Coerkamp
- Haaglanden Medical Center, Department of Radiology, Leidschendam, The Netherlands
| | - Hans-Marten Hazelbag
- Haaglanden Medical Center, Department of Pathology, Leidschendam, The Netherlands
| | - Jos Merkus
- Haga Hospital, Department of Surgery, The Hague, The Netherlands
| | | | | | - Joost van der Sijp
- Haaglanden Medical Center, Department of Surgery, Leidschendam, The Netherlands
| | - Marta Fiocco
- Leiden University Medical Center, Department of Statistics, Leiden, The Netherlands
| | - Corrie A M Marijnen
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, The Netherlands; The Netherlands Cancer Institute, Department of Radiation Oncology, Amsterdam, The Netherlands
| | - Peter C M Koper
- Leiden University Medical Center, Department of Radiation Oncology, Leiden, The Netherlands
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Choi JI, Fox J, Bakst R, Hasan S, Press RH, Chhabra AM, Yeh B, Simone CB, Cahlon O. Proton Therapy for Partial Breast Irradiation: Rationale and Considerations. J Pers Med 2021; 11:289. [PMID: 33918662 PMCID: PMC8069416 DOI: 10.3390/jpm11040289] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 04/06/2021] [Accepted: 04/06/2021] [Indexed: 11/17/2022] Open
Abstract
In an era of continued advancements in personalized medicine for the treatment of breast cancer, select patients with early stage breast cancer may be uniquely poised to benefit from partial breast irradiation (PBI) delivered with proton therapy. PBI presents an opportunity to improve quality of life during treatment with a significantly shorter treatment duration. By targeting less non-target breast tissue, excess radiation exposure and resulting toxicities are also reduced. Proton therapy represents a precision radiotherapy technology that builds on these advantages by further limiting the normal tissue exposure to unnecessary radiation dose not only to uninvolved breast tissue but also the underlying thoracic organs including the heart and lungs. Herein, we present a concise review of the rationale for the use of proton therapy for PBI, evidence available to date, and practical considerations in the implementation and use of proton therapy for this indication.
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Affiliation(s)
- J. Isabelle Choi
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Jana Fox
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Montefiore Medical Center, Department of Radiation Oncology, New York, NY 10467, USA
| | - Richard Bakst
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shaakir Hasan
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Montefiore Medical Center, Department of Radiation Oncology, New York, NY 10467, USA
| | - Robert H. Press
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Arpit M. Chhabra
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Brian Yeh
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Charles B. Simone
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
| | - Oren Cahlon
- Memorial Sloan Kettering Cancer Center, Department of Radiation Oncology, New York, NY 10065, USA; (C.B.S.II); (O.C.)
- New York Proton Center, New York, NY 10035, USA; (J.F.); (R.B.); (S.H.); (R.H.P.); (A.M.C.); (B.Y.)
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Measurement of the photon and thermal neutron doses of contralateral breast surface in breast cancer radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396919000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractIntroduction and purpose:During the radiation therapy of tumoral breast, the contralateral breast (CB) will receive scattered doses. In the present study, the photon and thermal neutron dose values received by CB surface during breast cancer radiation therapy were measured.Materials and methods:The right breast region of RANDO phantom was considered as CB, and the measurements of photon and thermal neutron dose values were carried out on this region surface. The phantom was irradiated with 18 MV photon beams, and the dose values were measured with thermoluminescent dosimeter (TLD-600 and TLD-700) chips for 11 × 13, 11 × 17 and 11 × 21 cm2 field sizes in the presence of physical and dynamic wedges.Results:The total dose values (photon + thermal neutron) received by the CB surface in the presence of physical wedge were 12·06%, 15·75% and 33·40% of the prescribed dose, respectively, for 11 × 13, 11 × 17 and 11 × 21 cm2 field sizes. The corresponding dose values for dynamic wedge were 9·18%, 12·92% and 29·26% of the prescribed dose, respectively. Moreover, the results showed that treatment field size and wedge type affect the received photon and thermal neutron doses at CB surface.Conclusion:According to our results, the total dose values received at CB surface during breast cancer radiotherapy with high-energy photon beams are remarkable. In addition, the dose values received at CB surface when using a physical wedge were greater than when using a dynamic wedge, especially for medial tangential fields.
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Predicting adherence of dose-volume constraints for personalized partial-breast irradiation technique. Brachytherapy 2020; 20:163-170. [PMID: 32741559 DOI: 10.1016/j.brachy.2020.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 11/24/2022]
Abstract
PURPOSE Multicatheter interstitial brachytherapy (MIB) and external-beam (EB) radiotherapy are established partial-breast irradiation (PBI) techniques. Although EB-PBI is widely available, it requires extra irradiated margins for target uncertainties. We examined the impact of EB-PBI on dose-volume constraints as compared to MIB-PBI. METHODS AND MATERIALS Among 653 patients receiving MIB-PBI between October 2008 and April 2020, consequent 159 patients after September 2018 were examined. Clinical target volume (CTV) included the lumpectomy cavity plus 1.0 cm. Planning target volume (PTV) for EB-PBI was defined as CTV with 1.0-cm expansion. Because the ratio of PTV to breast volume (RPB) was related to cosmesis, <25% of RPB was defined as suitable for the ipsilateral breast constraints. Preoperative breast size was classified as very small (<350 cm3), small (350-699 cm3), and medium or large (≥700 cm3). According to each category, the dose-volume constraints of the organs at risk were compared between the two PBI techniques. RESULTS Patients including 84 very small, 59 small, and 16 moderate to large breasts were examined. Although RPB was suitable in all patients receiving MIB-PBI, it was achieved in 74 patients (46.5%) receiving EB-PBI (p < 0.0001). The suitable RPB in patients with very small, small, and moderate to large breast was 32.1%, 55.9%, and 100%, respectively (p < 0.0001). Normal-tissue constraints for the other organs could be satisfied in patients with moderate to large breasts. CONCLUSION Although EB-PBI may be an appropriate option for patients with moderate to large breasts, MIB-PBI could still be a crucial technique, especially for patients with small breasts.
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Stelczer G, Tatai-Szabó D, Major T, Mészáros N, Polgár C, Pálvölgyi J, Pesznyák C. Measurement of dose exposure of image guidance in external beam accelerated partial breast irradiation: Evaluation of different techniques and linear accelerators. Phys Med 2019; 63:70-78. [PMID: 31221412 DOI: 10.1016/j.ejmp.2019.05.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 05/10/2019] [Accepted: 05/25/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Verifying the patient position is always an essential part of the treatment process, especially in hypofractionated treatments such as accelerated partial breast irradiation (APBI). The purpose of the study was to compare five image guidance techniques with respect to imaging dose and image quality. METHODS AND MATERIALS We chose five types of imaging methods applicable for APBI and measured their dose exposure on four different accelerators (Synergy, TrueBeam, Artiste and CyberKnife). Absorbed dose was measured with ionization chamber in thorax phantom. Besides dose exposure image quality was also compared. RESULTS The lowest dose exposure was measured with kV-kV planar imaging followed by kV-CBCT, MV-MV pair and MV-CBCT in ascending order. Average phantom dose with kV-kV image pair on CyberKnife was 0.01 cGy as the lowest and with MV-CBCT on Artiste was 7.11 cGy as the highest. Average dose exposures of MV-MV images with TrueBeam, Synergy and Artiste were 1.18 cGy, 2.13 cGy and 1.61 cGy, respectively, with similar image quality. For the same machines the doses of kV-CT imaging were comparable: 0.65 cGy, 0.65 cGy and 0.52 cGy, with some differences in image quality. MV-CBCT technique resulted in the highest dose and poorest image quality. CONCLUSIONS In APBI the position of the patient and tumour bed can be verified with many tools. When fiducials are available, often 2D imaging is enough to achieve appropriate positioning and the kV-kV method is recommended. Imaging with 2.5MV can also be a good solution instead of 6MV. Without fiducials 3D images should be acquired and the recommended method is the kV-CBCT.
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Affiliation(s)
- Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Institute of Nuclear Techniques, Budapest University of Technology and Economics, Budapest, Hungary.
| | - Dóra Tatai-Szabó
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Institute of Nuclear Techniques, Budapest University of Technology and Economics, Budapest, Hungary
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Jenő Pálvölgyi
- Department for Oncoradiology, Aladár Petz County Teaching Hospital, Győr, Hungary
| | - Csilla Pesznyák
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Institute of Nuclear Techniques, Budapest University of Technology and Economics, Budapest, Hungary
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Corrao G, Rojas DP, Ciardo D, Fanetti G, Dicuonzo S, Mantovani M, Gerardi MA, Dell'Acqua V, Morra A, Fodor C, Galimberti VE, Veronesi P, Cattani F, Orecchia R, Jereczek-Fossa BA, Leonardi MC. Intra- and inter-observer variability in breast tumour bed contouring and the controversial role of surgical clips. Med Oncol 2019; 36:51. [PMID: 31037520 DOI: 10.1007/s12032-019-1273-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
The purpose of this study was to evaluate whether the visualization of surgical clips (SCs) on the same set of planning computed tomography (CT) of breast cancer (BC) patients influences agreement on tumour bed (TB) delineation. Planning CT (CTorig) of 47 BC patients with SCs to visualize the TB was processed in order to blur SCs and create a virtual CT (CTmod). Four radiation oncologists (ROs, 2 juniors and 2 seniors) contoured TB on both the CT sets. Centre of mass distance (CMD), percentage overlap as Dice similarity coefficient (DSC), surface distance as average Hausdorff distance (AHD) and TB volume size were analysed. The intra-observer variability when contouring TB with and without SCs was statistically significant (p-values = 0.016, 0.0002 and ≪ 0.001 for CMD, AHD and DSC, respectively). Junior ROs showed worse reproducibility compared to seniors. The median DSC was < 0.7. The inter-observer variability with and without SCs was statistically significant (p < 0.001) for all metrics, with an increase of 48.7% in DSC and decrease of 50.7% and 57.1% in CMD and AHD, respectively, as relative median values, when SCs were visible. Regarding TB volumes, when SCs were visible, the intra-observer analysis revealed that 3/4 ROs delineated larger volumes, especially juniors. The inter-observer analysis showed that, in presence of visible SCs, the difference in TB volume among all the ROs fell from statistically significant to borderline significance (p = 0.052). TB contouring is confirmed to be an observer-dependent task. SCs decreased the intra and inter-observer variability but the overall agreement between ROs remained low.
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Affiliation(s)
- Giulia Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Delia Ciardo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Giuseppe Fanetti
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy.
| | - Marinella Mantovani
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Marianna Alessandra Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Veronica Dell'Acqua
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
| | | | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Maria Cristina Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141, Milan, Italy
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Analysis of Outcomes in Patients With BRCA1/2 Breast Cancer Mutations Treated With Accelerated Partial Breast Irradiation (APBI). Am J Clin Oncol 2019; 42:446-453. [PMID: 30973374 DOI: 10.1097/coc.0000000000000542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze outcomes and survival for BRCA1/2+ patients treated with accelerated partial breast irradiation (APBI). MATERIALS AND METHODS Retrospective review was performed on 341 women treated with intracavitary APBI (Mammosite or Contura) postlumpectomy from 2002 to 2013. Patients were treated to 34.0 Gy in 10 BID fractions. Of 341 treated patients, 11 (3.2%) had BRCA1/2 mutations, 5 of whom had an oophorectomy. Ipsilateral breast tumor recurrence (IBTR), contralateral breast tumor recurrence (CBTR), and breast tumor recurrence progression-free survival were analyzed using SPSS-17. BRCA1/2+ patient outcomes were compared with a general population treated cohort. RESULTS Median age at diagnosis was 66 years, for BRCA1/2+ women it was 61 years. Median follow-up was 8.4 years and for BRCA1/2+ patients it was 8.8 years. IBTR for the entire cohort was 3.5%, while CBTR was 1.2%. Both IBTR and CBTR for the BRCA1/2+ group were 0%. The 5-year IBTR-free survival was 97.3% (95% confidence interval [CI]=94.9%, 98.6%), and the CBTR-free survival was 99.4% (95% CI=97.6%, 99.9%). The 5-year breast tumor recurrence-free survival was 96.7% (95% CI=94.1%, 98.2%). As no patients with BRCA1/2+ mutation died of metastatic breast cancer or recurrence during follow-up and review, overall survival could not be evaluated. CONCLUSIONS To date, BRCA1/2+ patients treated with APBI sustained no recurrences, or second cancers. Most patients had an ER+ status and underwent oophorectomy, which may be a protective mechanism for recurrence. This is the first outcomes report in the literature of BRCA1/2 mutations treated with APBI technique.
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Bennion NR, Baine M, Granatowicz A, Wahl AO. Accelerated partial breast radiotherapy: a review of the literature and future directions. Gland Surg 2018; 7:596-610. [PMID: 30687631 DOI: 10.21037/gs.2018.11.05] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Breast conservation therapy exemplifies the tailoring of medicine in the care of patients with cancer. Akin to improvements in surgical approaches, accelerated partial breast irradiation (APBI) tailors the treatment volume and duration to the needs of well selected patients. Here, we examine the evidence supporting APBI as well as the lessons in patient selection, dose and delivery techniques. Examination of historical techniques and their associated outcomes will support more correct patient selection and treatment delivery in an era where we await the reports of several large prospective trials.
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Affiliation(s)
- Nathan R Bennion
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Michael Baine
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Andrew O Wahl
- Department of Radiation Oncology, Fred & Pamela Buffet Cancer Center at the University of Nebraska Medical Center, Omaha, Nebraska, USA
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Chan TY, Tang JI, Tan PW, Roberts N. Dosimetric evaluation and systematic review of radiation therapy techniques for early stage node-negative breast cancer treatment. Cancer Manag Res 2018; 10:4853-4870. [PMID: 30425577 PMCID: PMC6205528 DOI: 10.2147/cmar.s172818] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Radiation therapy (RT) is essential in treating women with early stage breast cancer. Early stage node-negative breast cancer (ESNNBC) offers a good prognosis; hence, late effects of breast RT becomes increasingly important. Recent literature suggests a potential for an increase in cardiac and pulmonary events after RT. However, these studies have not taken into account the impact of newer and current RT techniques that are now available. Hence, this review aimed to evaluate the clinical evidence for each technique and determine the optimal radiation technique for ESNNBC treatment. Currently, six RT techniques are consistently used and studied: 1) prone positioning, 2) proton beam RT, 3) intensity-modulated RT, 4) breath-hold, 5) partial breast irradiation, and 6) intraoperative RT. These techniques show dosimetric promise. However, limited data on late cardiac and pulmonary events exist due to challenges in long-term follow-up. Moving forward, future studies are needed to validate the efficacy and clinical outcomes of these current techniques.
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Affiliation(s)
- Tabitha Y Chan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Johann I Tang
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Poh Wee Tan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Neill Roberts
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
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12
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Julian TB, Mamounas EP. Partial Breast Irradiation: Continuing the Retreat from Halstedian Breast Cancer Management. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/10463356.2006.11884348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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13
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Bagheri H, Rabie Mahdavi S, Shekarchi B, Manouchehri F, Farhood B. MEASUREMENT OF THE CONTRALATERAL BREAST PHOTON AND THERMAL NEUTRON DOSES IN BREAST CANCER RADIOTHERAPY: A COMPARISON BETWEEN PHYSICAL AND DYNAMIC WEDGES. RADIATION PROTECTION DOSIMETRY 2018; 178:73-81. [PMID: 28591863 DOI: 10.1093/rpd/ncx076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 05/27/2017] [Indexed: 06/07/2023]
Abstract
This research aimed to measure the received photon and thermal neutron doses to contralateral breast (CB) in breast cancer radiotherapy for various field sizes in presence of physical and dynamic wedges. The measurement of photon and thermal neutron doses was carried out on right breast region of RANDO phantom (as CB) for 18 MV photon beams. The dose measurements were performed by thermoluminescent dosimeter chips. These measurements obtained for various field sizes in presence of physical and dynamic wedges. The findings of this study showed that the received doses (both of the photon and thermal neutron) to CB in presence of physical wedge for 11 × 13, 11 × 17 and 11 × 21 cm2 field sizes were 5.92, 6.36 and 6.77% of the prescribed dose, respectively as well as for dynamic wedge were 2.92, 4.63 and 5.60% of the prescribed dose, respectively. The results showed that the received photon and thermal neutron doses to CB increase with increment of field sizes. The received photon and thermal neutron doses to CB in presence of physical wedge were more than dynamic wedge. According to obtained findings, it is suggested that using a dynamic wedge is preferable than physical wedge, especially for medial tangential field.
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Affiliation(s)
- Hamed Bagheri
- Radiation and Wave Research Center, Aja University of Medical Science, Tehran, Iran
| | - Seyed Rabie Mahdavi
- Department of Medical Physics, Iran University of Medical Sciences, Tehran, Iran
| | - Babak Shekarchi
- Radiation and Wave Research Center, Aja University of Medical Science, Tehran, Iran
| | | | - Bagher Farhood
- Medical Physics and Medical Engineering Department, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
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Di Lillo F, Mettivier G, Sarno A, Castriconi R, Russo P. Towards breast cancer rotational radiotherapy with synchrotron radiation. Phys Med 2017; 41:20-25. [PMID: 28666767 DOI: 10.1016/j.ejmp.2017.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 05/23/2017] [Accepted: 06/10/2017] [Indexed: 11/24/2022] Open
Abstract
PURPOSE We performed the first investigations, via measurements and Monte Carlo simulations on phantoms, of the feasibility of a new technique for synchrotron radiation rotational radiotherapy for breast cancer (SR3T). METHODS A Monte Carlo (MC) code based on Geant4 toolkit was developed in order to simulate the irradiation with the SR3T technique and to evaluate the skin sparing effect in terms of centre-to-periphery dose ratio at different energies in the range 60-175keV. Preliminary measurements were performed at the Australian Synchrotron facility. Radial dose profiles in a 14-cm diameter polyethylene phantom were measured with a 100-mm pencil ionization chamber for different beam sizes and compared with the results of MC simulations. Finally, the dose painting feasibility was demonstrated with measurements with EBT3 radiochromic films in a phantom and collimating the SR beam at 1.5cm in the horizontal direction. RESULTS MC simulations showed that the SR3T technique assures a tumour-to-skin absorbed dose ratio from about 7:1 (at 60keV photon energy) to about 10:1 (at 175keV), sufficient for skin sparing during radiotherapy. The comparison between the results of MC simulations and measurements showed an agreement within 5%. Two off-centre foci were irradiated shifting the rotation centre in the horizontal direction. CONCLUSIONS The SR3T technique permits to obtain different dose distributions in the target with multiple rotations and can be guided via synchrotron radiation breast computed tomography imaging, in propagation based phase-contrast conditions. Use of contrast agents like iodinated solutions or gold nanoparticles for dose enhancement (DE-SR3T) is foreseen and will be investigated in future work.
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Affiliation(s)
- Francesca Di Lillo
- Dipartimento di Fisica "Ettore Pancini", Università di Napoli Federico II, Napoli, Italy; INFN, Sezione di Napoli, Napoli, Italy
| | - Giovanni Mettivier
- Dipartimento di Fisica "Ettore Pancini", Università di Napoli Federico II, Napoli, Italy; INFN, Sezione di Napoli, Napoli, Italy.
| | - Antonio Sarno
- Dipartimento di Fisica "Ettore Pancini", Università di Napoli Federico II, Napoli, Italy; INFN, Sezione di Napoli, Napoli, Italy
| | - Roberta Castriconi
- Dipartimento di Fisica "Ettore Pancini", Università di Napoli Federico II, Napoli, Italy; INFN, Sezione di Napoli, Napoli, Italy
| | - Paolo Russo
- Dipartimento di Fisica "Ettore Pancini", Università di Napoli Federico II, Napoli, Italy; INFN, Sezione di Napoli, Napoli, Italy
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15
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Cuaron JJ, MacDonald SM, Cahlon O. Novel applications of proton therapy in breast carcinoma. Chin Clin Oncol 2017; 5:52. [PMID: 27558253 DOI: 10.21037/cco.2016.06.04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/28/2016] [Indexed: 12/18/2022]
Abstract
This review will focus on the indications, clinical experience, and technical considerations of proton beam radiation therapy in the treatment of patients with breast cancer. For patients with early stage disease, proton therapy delivers less dose to non-target breast tissue for patients receiving partial breast irradiation (PBI) therapy, which may result in improved cosmesis but requires further investigation. For patients with locally advanced breast cancer requiring treatment to the regional lymph nodes, proton therapy allows for an improved dosimetric profile compared with conventional photon and electron techniques. Early clinical results demonstrate acceptable toxicity. The possible reduction in cardiopulmonary events as a result of reduced dose to organs at risk will be tested in a randomized control trial of protons vs. photons.
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Affiliation(s)
- John J Cuaron
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
| | - Shannon M MacDonald
- Massachusetts General Hospital, Francis H. Burr Proton Therapy Center, Boston, MA 02114-7250, USA
| | - Oren Cahlon
- Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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Guo B, Li JB, Wang W, Xu M, Li YK, Liu TH. A comparison of dosimetric variance for external-beam partial breast irradiation using three-dimensional and four-dimensional computed tomography. Onco Targets Ther 2016; 9:1857-63. [PMID: 27099517 PMCID: PMC4821394 DOI: 10.2147/ott.s100629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the potential dosimetric benefits from four-dimensional computed tomography (4DCT) compared with three-dimensional computed tomography (3DCT) in radiotherapy treatment planning for external-beam partial breast irradiation (EB-PBI). Patients and methods 3DCT and 4DCT scan sets were acquired for 20 patients who underwent EB-PBI. The volume of the tumor bed (TB) was determined based on seroma or surgical clips on 3DCT images (defined as TB3D) and the end inhalation (EI) and end exhalation (EE) phases of 4DCT images (defined as TBEI and TBEE, respectively). The clinical target volume (CTV) consisted of the TB plus a 1.0 cm margin. The planning target volume (PTV) was the CTV plus 0.5 cm (defined as PTV3D, PTVEI, and PTVEE). For each patient, a conventional 3D conformal plan (3D-CRT) was generated (defined as EB-PBI3D, EB-PBIEI, and EB-PBIEE). Results The PTV3D, PTVEI, and PTVEE were similar (P=0.549), but the PTV coverage of EB-PBI3D was significantly less than that of EB-PBIEI or EB-PBIEE (P=0.001 and P=0.025, respectively). There were no significant differences in the homogeneity or conformity indexes between the three treatment plans (P=0.125 and P=0.536, respectively). The EB-PBI3D plan resulted in the largest organs at risk dose. Conclusion There was a significant benefit for patients when using 3D-CRT based on 4DCT for EB-PBI with regard to reducing nontarget organ exposure. Respiratory motion did not affect the dosimetric distribution during free breathing, but might result in poor dose coverage when the PTV is determined using 3DCT.
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Affiliation(s)
- Bing Guo
- School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, Shandong Province, People's Republic of China; Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan, Shandong Province, People's Republic of China
| | - Jian-Bin Li
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan, Shandong Province, People's Republic of China
| | - Wei Wang
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan, Shandong Province, People's Republic of China
| | - Min Xu
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan, Shandong Province, People's Republic of China
| | - Yan-Kang Li
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan, Shandong Province, People's Republic of China; School of Medicine, Shandong University, Jinan, Shandong Province, People's Republic of China
| | - Tong-Hai Liu
- Department of Radiation Oncology, Shandong Cancer Hospital & Institute, Jinan, Shandong Province, People's Republic of China
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17
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Quirk S, Conroy L, Smith WL. Accounting for respiratory motion in partial breast intensity modulated radiotherapy during treatment planning: a new patient selection metric. Eur J Cancer 2014; 50:1872-9. [PMID: 24835033 DOI: 10.1016/j.ejca.2014.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/28/2014] [Accepted: 04/12/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE External beam partial breast irradiation intensity modulated radiotherapy (PBI IMRT) plans experience degradation in coverage and dose homogeneity when delivered during respiration. We examine which characteristics of the breast and seroma result in unacceptable plan degradation due to respiration. METHODS Thirty-six patient datasets were planned with inverse-optimised PBI IMRT. Population respiratory data were used to create a probability density function. This probability density function (PDF) was convolved with the static plan fluences to calculate the delivered dose with respiration. To quantify the difference between static and respiratory plan quality, we analysed the mean dose shift of the target dose volume histogram (DVH), the dose shift at 95% of the volume and the dose shift at the hotspot to 2 cm(3)of the volume. We explore which patient characteristics indicate a clinically significant degradation in delivered plan quality due to respiration. RESULTS Dose homogeneity constraints, rather than dosimetric coverage, were the limiting factors for all patient plans. We propose the dose evaluation volume-to-planning target volume (DEV-to-PTV) ratio as a delineating metric for identifying patient plans that will be more degraded by respiratory motion. The DEV-to-PTV ratio may be a more robust metric than ipsilateral breast volume because the seroma volume is contoured more consistently between physicians and clinics. CONCLUSIONS For patients with a DEV-to-PTV ratio less than 55% we recommend either not using PBI IMRT or employing motion management. Small DEV-to-PTV ratios occur when the seroma is close to inhomogeneities (i.e. air/lung), which exacerbates the dosimetric effect of respiratory motion. For small breast sizes it is unlikely that the DEV-to-PTV ratio will meet these criteria.
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Affiliation(s)
- Sarah Quirk
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.
| | - Leigh Conroy
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Wendy L Smith
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Department of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
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18
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Jagsi R. Progress and controversies: radiation therapy for invasive breast cancer. CA Cancer J Clin 2014; 64:135-52. [PMID: 24357525 DOI: 10.3322/caac.21209] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 01/29/2023] Open
Abstract
Radiation therapy is a critical component of the multidisciplinary management of invasive breast cancer. In appropriately selected patients, radiation not only improves local control, sparing patients the morbidity and distress of local recurrence, but it also improves survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. In recent years, considerable progress has been made toward improving our ability to select patients most likely to benefit from radiotherapy and to administer treatment in ways that maximize clinical benefit while minimizing toxicity and burden. This article reviews the role of radiation therapy in invasive breast cancer management, both after breast-conserving surgery and after mastectomy. It focuses particularly on emerging evidence that helps to define the clinical situations in which radiotherapy is indicated, the appropriate targets of treatment, and optimal approaches for minimizing both the toxicity and the burden of treatment, all in the context of the evolving surgical and systemic management of this common disease. It includes a discussion of new approaches in breast cancer radiotherapy, including hypofractionation and intensity modulation, as well as a discussion of promising avenues for future research.
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Affiliation(s)
- Reshma Jagsi
- Associate Professor, Department of Radiation Oncology, Research Investigator, Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor, MI
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19
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Qiu JJ, Chang Z, Horton JK, Wu QRJ, Yoo S, Yin FF. Dosimetric comparison of 3D conformal, IMRT, and V-MAT techniques for accelerated partial-breast irradiation (APBI). Med Dosim 2014; 39:152-8. [PMID: 24480375 DOI: 10.1016/j.meddos.2013.12.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Revised: 11/29/2013] [Accepted: 12/03/2013] [Indexed: 11/18/2022]
Abstract
The purpose is to dosimetrically compare the following 3 delivery techniques: 3-dimensional conformal radiation therapy (3D-CRT), intensity-modulated arc therapy (IMRT), and volumetric-modulated arc therapy (V-MAT) in the treatment of accelerated partial-breast irradiation (APBI). Overall, 16 patients with T1/2N0 breast cancer were treated with 3D-CRT (multiple, noncoplanar photon fields) on the RTOG 0413 partial-breast trial. These cases were subsequently replanned using static gantry IMRT and V-MAT technology to understand dosimetric differences among these 3 techniques. Several dosimetric parameters were used in plan quality evaluation, including dose conformity index (CI) and dose-volume histogram analysis of normal tissue coverage. Quality assurance studies including gamma analysis were performed to compare the measured and calculated dose distributions. The IMRT and V-MAT plans gave more conformal target dose distributions than the 3D-CRT plans (p < 0.05 in CI). The volume of ipsilateral breast receiving 5 and 10Gy was significantly less using the V-MAT technique than with either 3D-CRT or IMRT (p < 0.05). The maximum lung dose and the ipsilateral lung volume receiving 10 (V10) or 20Gy (V20) were significantly less with both V-MAT and IMRT (p < 0.05). The IMRT technique was superior to 3D-CRT and V-MAT of low dose distributions in ipsilateral lung (p < 0.05 in V5 and D5). The total mean monitor units (MUs) for V-MAT (621.0 ± 111.9) were 12.2% less than those for 3D-CRT (707.3 ± 130.9) and 46.5% less than those for IMRT (1161.4 ± 315.6) (p < 0.05). The average machine delivery time was 1.5 ± 0.2 minutes for the V-MAT plans, 7.0 ± 1.6 minutes for the 3D-CRT plans, and 11.5 ± 1.9 minutes for the IMRT plans, demonstrating much less delivery time for V-MAT. Based on this preliminary study, V-MAT and IMRT techniques offer improved dose conformity as compared with 3D-CRT techniques without increasing dose to the ipsilateral lung. In terms of MU and delivery time, V-MAT is significantly more efficient for APBI than for conventional 3D-CRT and static-beam IMRT.
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Affiliation(s)
- Jian-Jian Qiu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC; Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zheng Chang
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Janet K Horton
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Qing-Rong Jackie Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Sua Yoo
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Fang-Fang Yin
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC.
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Abstract
MammoSite is a novel brachytherapy applicator for breast irradiation as a component of breast conservation therapy in the management of early stage breast carcinoma. Early stage breast cancer accounts for over two-thirds of newly diagnosed cases. Breast conservation therapy is an option for most women for local therapy. The standard treatment of partial mastectomy and whole-breast irradiation is being challenged. Physicians and patients are searching for alternatives to a 6- to 7-week course of external beam radiation therapy. The direct application of radioactive materials (brachytherapy) in this setting has been employed for over 10 years. MammoSite has been developed as an easier, more quality assured applicator to allow broader acceptance and wider availability of partial breast irradiation techniques. The background leading to the device will be examined, current clinical results will be reviewed and alternative technologies will be discussed.
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Affiliation(s)
- Martin Keisch
- Mount Sinai Medical Center, Department of Radiation Oncology, Miami Beach, FL 33140, USA.
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Kron T, Willis D, Link E, Lehman M, Campbell G, O'Brien P, Chua B. Can We Predict Plan Quality for External Beam Partial Breast Irradiation: Results of a Multicenter Feasibility Study (Trans Tasman Radiation Oncology Group Study 06.02). Int J Radiat Oncol Biol Phys 2013; 87:817-24. [DOI: 10.1016/j.ijrobp.2013.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 07/19/2013] [Accepted: 07/22/2013] [Indexed: 11/29/2022]
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Trovo M, Polesel J, Biasutti C, Sartor G, Roncadin M, Trovo GM. Fiducial markers for image-guided partial breast irradiation. Radiol Med 2013; 118:1212-9. [PMID: 23892956 DOI: 10.1007/s11547-013-0967-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 09/12/2012] [Indexed: 10/26/2022]
Abstract
PURPOSE This study was undertaken to study the role of fiducial markers for image-guided partial breast irradiation (IG-PBI), and to compare the shifts based on bony anatomy and fiducial markers. MATERIALS AND METHODS Fifteen patients underwent IGPBI. Three fiducial markers were placed in the tumour bed at the time of surgery. Daily orthogonal anterior/ posterior and lateral kV-images were taken before each fraction and compared with the digitally-reconstructed radiographs, both using bony landmarks and fiducial markers as reference. The Student's t test was used to detect a meaningful difference of 3 mm in between the two methods. RESULTS A total of 105 image-guided radiation therapy (IGRT) sessions were obtained. The mean superior/inferior, right/left, and anterior/posterior shifts obtained using the bony landmarks vs. the fiducial markers were 2 mm [standard deviation (SD) 10 mm] vs. 0 mm (SD 7 mm), 0 mm (SD 7 mm) vs. 1 mm (SD 4 mm), and 1 mm (SD 7 mm) vs. 0 mm (SD 5 mm), respectively. The mean shift differences in absolute value between the two methods, along the superior/inferior, right/left and anterior/posterior directions were 5 mm (p=0.001), 3 mm [p=not significant (ns)], and 3 mm (p=ns), respectively. CONCLUSIONS Fiducial markers for IG-PBI increase set-up accuracy compared to the bony landmarks, in particular along the superior/inferior direction.
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Affiliation(s)
- Marco Trovo
- Department of Radiation Oncology, Centro di Riferimento Oncologico, CRO, Via F. Gallini 2, 33081, Aviano (PN), Italy,
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Olivotto IA, Whelan TJ, Parpia S, Kim DH, Berrang T, Truong PT, Kong I, Cochrane B, Nichol A, Roy I, Germain I, Akra M, Reed M, Fyles A, Trotter T, Perera F, Beckham W, Levine MN, Julian JA. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol 2013; 31:4038-45. [PMID: 23835717 DOI: 10.1200/jco.2013.50.5511] [Citation(s) in RCA: 275] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To report interim cosmetic and toxicity results of a multicenter randomized trial comparing accelerated partial-breast irradiation (APBI) using three-dimensional conformal external beam radiation therapy (3D-CRT) with whole-breast irradiation (WBI). PATIENTS AND METHODS Women age > 40 years with invasive or in situ breast cancer ≤ 3 cm were randomly assigned after breast-conserving surgery to 3D-CRT APBI (38.5 Gy in 10 fractions twice daily) or WBI (42.5 Gy in 16 or 50 Gy in 25 daily fractions ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence (IBTR). Secondary outcomes were cosmesis and toxicity. Adverse cosmesis was defined as a fair or poor global cosmetic score. After a planned interim cosmetic analysis, the data, safety, and monitoring committee recommended release of results. There have been too few IBTR events to trigger an efficacy analysis. RESULTS Between 2006 and 2011, 2,135 women were randomly assigned to 3D-CRT APBI or WBI. Median follow-up was 36 months. Adverse cosmesis at 3 years was increased among those treated with APBI compared with WBI as assessed by trained nurses (29% v 17%; P < .001), by patients (26% v 18%; P = .0022), and by physicians reviewing digital photographs (35% v 17%; P < .001). Grade 3 toxicities were rare in both treatment arms (1.4% v 0%), but grade 1 and 2 toxicities were increased among those who received APBI compared with WBI (P < .001). CONCLUSION 3D-CRT APBI increased rates of adverse cosmesis and late radiation toxicity compared with standard WBI. Clinicians and patients are cautioned against the use of 3D-CRT APBI outside the context of a controlled trial.
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Affiliation(s)
- Ivo A Olivotto
- Ivo A. Olivotto, Tanya Berrang, Pauline T. Truong, Alan Nichol, Melanie Reed, and Wayne Beckham, British Columbia Cancer Agency; Ivo A. Olivotto, Tanya Berrang, and Pauline T. Truong, University of British Columbia; Wayne Beckham, University of Victoria, Victoria; Alan Nichol, University of British Columbia, Vancouver; Melanie Reed, University of British Columbia, Kelowna, British Columbia; Timothy J. Whelan, Do-Hoon Kim, Iwa Kong, and Mark N. Levine, Juravinski Cancer Centre; Timothy J. Whelan, Sameer Parpia, Do-Hoon Kim, Iwa Kong, Brandy Cochrane, Mark N. Levine, and Jim A. Julian, McMaster University; Timothy J. Whelan, Sameer Parpia, Brandy Cochrane, Mark N. Levine, and Jim A. Julian, Ontario Clinical Oncology Group, Hamilton; Anthony Fyles, Princess Margaret Hospital, University of Toronto, Toronto; Francisco Perera, London Regional Cancer Centre, University of Western Ontario, London, Ontario; Isabelle Roy, Hôpital Notre-Dame, University of Montreal, Montreal; Isabelle Germain, Hôtel-Dieu de Quebec, Laval University, Quebec City, Quebec; Mohamed Akra, Cancer Care Manitoba, University of Manitoba, Winnipeg, Manitoba; and Theresa Trotter, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Truong MT, Hirsch AE, Kovalchuk N, Qureshi MM, Damato A, Schuller B, Vassilakis N, Stone M, Gierga D, Willins J, Kachnic LA. Cone-beam computed tomography image guided therapy to evaluate lumpectomy cavity variation before and during breast radiotherapy. J Appl Clin Med Phys 2013; 14:4243. [PMID: 23470944 PMCID: PMC5714375 DOI: 10.1120/jacmp.v14i2.4243] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/21/2012] [Accepted: 11/30/2012] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to evaluate the rate of change (RoC) in the size of the lumpectomy cavity (LC) before and during breast radiotherapy (RT) using cone‐beam computed tomography (CBCT), relative to the initial LC volume at CT simulation (CTVLC) and timing from surgery. A prospective institutional review board‐approved study included 26 patients undergoing breast RT: 20 whole breast irradiation (WBI) patients and six partial breast irradiation (PBI) patients, with surgical clips outlining the LC. The patients underwent CT simulation (CTsim) followed by five CBCTs during RT, once daily for PBI and once weekly for WBI. The distance between surgical clips and their centroid (D) acted as a surrogate for LC size. The RoC of the LC size, defined as the percentage change of D between two scans divided by the time interval in days between the scans, was calculated before (CTsim to CBCT1) and during RT (CBCT1 to CBCT5). The mean RoC of D for all patients before starting RT was −0.25%/day (range, −1.3 to 1.4) and for WBI patients during RT was −0.15%/day (range, −0.45 to 0.40). Stratified by median CTVLC, the RoC before RT for large CTVLC group (≥25.7cc) was 15 times higher (−0.47%/day) than for small CTVLC group (<25.7 cc) (−0.03%/day), p=0.06. For patients undergoing CTsim< 42 days from surgery, the RoC before RT was −0.43%/day compared to −0.07%/day for patients undergoing CTsim≥42 days from surgery, p=0.12. For breast cancer RT, the rate of change of the LC is affected by the initial cavity size and the timing from surgery. Resimulation closer to the time of boost treatment should be considered in patients who are initially simulated within six weeks of surgery and/or with large CTVLC. PACS number: 87.55.de
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Affiliation(s)
- Minh Tam Truong
- Department of Radiation Oncology, Boston University School of Medicine, Boston, MA, USA.
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Wang W. Radiotherapy in the management of early breast cancer. J Med Radiat Sci 2013; 60:40-6. [PMID: 26229606 PMCID: PMC4175791 DOI: 10.1002/jmrs.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 09/03/2012] [Accepted: 09/22/2012] [Indexed: 11/27/2022] Open
Abstract
Radiotherapy is an indispensible part of the management of all stages of breast cancer. In this article, the common indications for radiotherapy in the management of early breast cancer (stages 0, I, and II) are reviewed, including whole-breast radiotherapy as part of breast-conserving treatment for early invasive breast cancer and pre-invasive disease of ductal carcinoma in situ, post-mastectomy radiotherapy, locoregional radiotherapy, and partial breast irradiation. Key clinical studies that underpin our current practice are discussed briefly.
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Affiliation(s)
- Wei Wang
- Westmead Breast Cancer Institute, Westmead Hospital Westmead, New South Wales, Australia ; Department of Radiation Oncology, Westmead Hospital New South Wales, Australia
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Xu Q, Chen Y, Grimm J, Fan J, An L, Xue J, Pahlajani N, LaCouture T. Dosimetric investigation of accelerated partial breast irradiation (APBI) using CyberKnife. Med Phys 2012; 39:6621-8. [DOI: 10.1118/1.4757616] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Bourgier C, Dumas I, Marsiglia H, Rossier C, Taright N, Biron B, Auzac G. Irradiation partielle accélérée du cancer du sein : aspect théorique. Cancer Radiother 2012; 16:470-2. [DOI: 10.1016/j.canrad.2012.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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Greenup RA, Camp MS, Taghian AG, Buckley J, Coopey SB, Gadd M, Hughes K, Specht M, Smith BL. Cost comparison of radiation treatment options after lumpectomy for breast cancer. Ann Surg Oncol 2012; 19:3275-81. [PMID: 22851048 DOI: 10.1245/s10434-012-2546-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Radiation therapy (RT) after lumpectomy for breast cancer can be delivered with several different regimens. We evaluated a cost-minimization strategy to select among RT options. METHODS An institutional review board (IRB)-approved retrospective review identified a sample of 100 women who underwent lumpectomy for invasive or in situ breast cancer during 2009. Post lumpectomy RT options included: no radiation in women ≥70 years [T1N0, estrogen receptor (ER)+] per Cancer and Leukemia Group B (CALGB) 9343 (no-RT), accelerated external-beam partial-breast irradiation (APBI), and Canadian fractionation (C-RT), as alternatives to standard whole-breast radiation therapy (WBRT). Eligibility for RT regimens was based on published criteria. RT costs were estimated using the 2011 US Medicare Physician Fee Schedule and average Current Procedural Terminology (CPT) codes billed per regimen at our institution. Costs were modeled in a 1,000-patient theoretical cohort. RESULTS Median patient age was 56.5 years (range 32-93 years). Tumor histology included invasive ductal cancer (78 %), ductal carcinoma in situ (DCIS) (15 %), invasive lobular cancer (6 %), and mixed histology (1 %). Median tumor size was 1 cm (range 0.2-5 cm). Estimated per-patient cost of radiation was US$5,341.81 for APBI, US$9,121.98 for C-RT, and US$13,358.37 for WBRT. When patients received the least expensive radiation regimen for which they were eligible, 14 % received no-RT, 44 % received APBI, 7 % received C-RT, and 35 % defaulted to WBRT. Using a cost-minimization strategy, estimated RT costs were US$7.67 million, versus US$13.36 million had all patients received WBRT, representing cost savings of US$5.69 million per 1,000 patients treated. CONCLUSIONS A cost-minimization strategy results in a 43 % reduction in estimated radiation costs among women undergoing breast conservation.
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Affiliation(s)
- Rachel A Greenup
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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Shikama N, Nakamura N, Kunishima N, Hatanaka S, Sekiguchi K. Identifying Patients Who Are Unsuitable for Accelerated Partial Breast Irradiation Using Three-dimensional External Beam Conformal Techniques. Int J Radiat Oncol Biol Phys 2012; 83:e313-8. [DOI: 10.1016/j.ijrobp.2011.12.091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 12/27/2011] [Accepted: 12/29/2011] [Indexed: 11/26/2022]
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Acevedo-Henao CM, Heymann S, Rossier C, Garbay JR, Arnedos M, Balleyguier C, Ferchiou M, Marsiglia H, Bourgier C. [Conformal accelerated partial breast irradiation: state of the art]. Cancer Radiother 2012; 16:641-9. [PMID: 22727723 DOI: 10.1016/j.canrad.2012.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 03/09/2012] [Accepted: 03/27/2012] [Indexed: 11/26/2022]
Abstract
Breast conserving treatment (breast conserving surgery followed by whole breast irradiation) has commonly been used in early breast cancer since many years. New radiation modalities have been recently developed in early breast cancers, particularly accelerated partial breast irradiation. Three-dimensional conformal accelerated partial breast irradiation is the most commonly used modality of radiotherapy. Other techniques are currently being developed, such as intensity-modulated radiotherapy, arctherapy, and tomotherapy. The present article reviews the indications, treatment modalities and side effects of accelerated partial breast irradiation.
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Affiliation(s)
- C-M Acevedo-Henao
- Département de radiothérapie, institut de cancérologie Gustave-Roussy, Villejuif cedex, France
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Kumar R, Sharma SC, Kapoor R, Singh R, Bhardawaj A. Dosimetric evaluation of 3Dconformal acceleratedpartial-breast irradiation vs. whole-breast irradiation: A comparative study. Int J Appl Basic Med Res 2012; 2:52-7. [PMID: 23776810 PMCID: PMC3657992 DOI: 10.4103/2229-516x.96810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Conventional early breast cancer treatment consists of lumpectomy followed by whole-breast irradiation (WBI) therapy. Accelerated partial-breast irradiation (APBI) is also an approach to post-lumpectomy radiation for early breast cancer. Aim: The purpose of this study is to compare two different external-beam APBI techniques using three-dimensional (3D) conformal radiation therapy (3DCRT), with conventional whole-breast irradiation based on the radiation conformity index, dose homogeneity index, and dose to organs at risk. Materials and Methods: WBI treatment plans were compared with two different 3DCRT APBI plans for each of 15 patients (8 with right sided lesions, 7 with left sided lesions). The first APBI plan (APBI 1) used two small coplanar fields conformed to the planning target volume (PTV) using multileaf collimators (MLCs) and wedges, while the other APBI plan (APBI 2) used three non-coplanar fields conformed to the PTV using MLCs and wedges. Results: Both the APBI techniques improved the conformity index significantly over whole-breast tangents while maintaining dose homogeneity and not causing significant increase in dose to organs at risk. Conclusion: Both the 3DCRT APBI techniques are technically feasible and dosimetrically appealing,with better target coverage and relative sparing of normal critical organs
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Affiliation(s)
- Ritesh Kumar
- Department of Radiotherapy and Oncology, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India
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Njeh CF, Saunders MW, Langton CM. Accelerated partial breast irradiation using external beam conformal radiation therapy: A review. Crit Rev Oncol Hematol 2012; 81:1-20. [PMID: 21376625 DOI: 10.1016/j.critrevonc.2011.01.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Revised: 01/03/2011] [Accepted: 01/25/2011] [Indexed: 01/03/2023] Open
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Aziz MH, Schneider F, Clausen S, Blank E, Herskind C, Afzal M, Wenz F. Can the risk of secondary cancer induction after breast conserving therapy be reduced using intraoperative radiotherapy (IORT) with low-energy x-rays? Radiat Oncol 2011; 6:174. [PMID: 22176703 PMCID: PMC3260102 DOI: 10.1186/1748-717x-6-174] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 12/16/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radiation induced secondary cancers are a rare but severe late effect after breast conserving therapy. Intraoperative radiotherapy (IORT) is increasingly used during breast conserving surgery. The purpose of this analysis was to estimate secondary cancer risks after IORT compared to other modalities of breast radiotherapy (APBI - accelerated partial breast irradiation, EBRT - external beam radiotherapy). METHODS Computer-tomography scans of an anthropomorphic phantom were acquired with an INTRABEAM IORT applicator (diameter 4 cm) in the outer quadrant of the breast and transferred via DICOM to the treatment planning system. Ipsilateral breast, contralateral breast, ipsilateral lung, contralateral lung, spine and heart were contoured. An INTRABEAM source (50 kV) was defined with the tip of the drift tube at the center of the spherical applicator. A dose of 20 Gy at 0 mm depth from the applicator surface was prescribed for IORT and 34 Gy (5 days × 2 × 3.4 Gy) at 10 mm depth for APBI. For EBRT a total dose of 50 Gy in 2 Gy fractions was planned using two tangential fields with wedges. The mean and maximal doses, DVHs and volumes receiving more than 0.1 Gy and 4 Gy of organs at risk (OAR) were calculated and compared. The life time risk for secondary cancers was estimated according to NCRP report 116. RESULTS IORT delivered the lowest maximal doses to contralateral breast (< 0.3 Gy), ipsilateral (1.8 Gy) and contralateral lung (< 0.3 Gy), heart (1 Gy) and spine (< 0.3 Gy). In comparison, maximal doses for APBI were 2-5 times higher. EBRT delivered a maximal dose of 10.4 Gy to the contralateral breast and 53 Gy to the ipsilateral lung. OAR volumes receiving more than 4 Gy were 0% for IORT, < 2% for APBI and up to 10% for EBRT (ipsilateral lung). The estimated risk for secondary cancer in the respective OAR is considerably lower after IORT and/or APBI as compared to EBRT. CONCLUSIONS The calculations for maximal doses and volumes of OAR suggest that the risk of secondary cancer induction after IORT is lower than compared to APBI and EBRT.
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Affiliation(s)
- Muhammad Hammad Aziz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Frank Schneider
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Sven Clausen
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Elena Blank
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Carsten Herskind
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Muhammad Afzal
- Department of Physics, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Frederik Wenz
- Department of Radiation Oncology, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
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Pinnarò P, Arcangeli S, Giordano C, Arcangeli G, Impiombato FA, Pinzi V, Iaccarino G, Soriani A, Landoni V, Strigari L. Toxicity and cosmesis outcomes after single fraction partial breast irradiation in early stage breast cancer. Radiat Oncol 2011; 6:155. [PMID: 22079051 PMCID: PMC3229442 DOI: 10.1186/1748-717x-6-155] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Accepted: 11/11/2011] [Indexed: 01/30/2023] Open
Abstract
Background To report the clinical outcome after a Single Shot 3D-CRT PBI (SSPBI) in breast cancer patients after conservative surgery (ClinicalTrials.gov Identifier: NCT01316328). Methods A dose of 18Gy (in the first 4 patients) and 21Gy (in the remaining 60 patients) was prescribed in a single session and delivered to the index area (i.e. the area of breast including the primary tumor bed and the surrounding tissue) using 3D-CRT with patients in prone position. Acute and late toxicity was assessed using the National Cancer Institute's CTC for Adverse Events. Cosmesis was defined based on modified Harvard criteria. Differences between dosimetric or clinical parameters of patients with/without G2 or more late toxicity or unsatisfactory (poor or fair) cosmetic outcome were evaluated with the Mann-Whitney test. Odds ratios and 95% confidence interval were calculated for cosmesis and fibrosis. Univariate and multivariate analyses(UVA/MVA) were used to determine covariates associated with an increase in fibrosis or fat necrosis rate. Results Sixty four patients were enrolled. With a median follow-up of 3 years, G2 and G3 subcutaneous fibrosis was detected in 20(31%) and in 8(13%) patients, and ≥G2 fat necrosis was observed in 2(3%) patients. Good to excellent, fair and poor cosmesis was observed in 38(59%), 23(36%) and 3(5%) patients, respectively. Based on UVA, the breast volume receiving more than 21Gy (V21Gy) was found to be a predictor of the ≥G1 or ≥G2 fibrosis/fat necrosis. Based on MVA, V21Gy was confirmed as a predictor for ≥G1 fibrosis/fat necrosis, the results correlated as a trend for ≥G2. Cosmesis was correlated with whole breast (WB) mean dose (p = 0.030). Conclusion Our choice of a single dose of 21Gy significantly increased the treatment related toxicity. However, this should not discourage novel SSPBI approaches with lower equivalent doses.
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Affiliation(s)
- Paola Pinnarò
- Department of Radiation Oncology, Laboratory of Medical Physics and Expert Systems, Regina Elena National Cancer Institute, Rome, Italy
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Shaitelman SF, Kim LH, Grills IS, Chen PY, Ye H, Kestin LL, Yan D, Vicini FA. Predictors of Long-Term Toxicity Using Three-Dimensional Conformal External Beam Radiotherapy to Deliver Accelerated Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2011; 81:788-94. [DOI: 10.1016/j.ijrobp.2010.06.062] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 06/20/2010] [Indexed: 11/15/2022]
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Kacprowska A, Jassem J. Partial breast irradiation techniques in early breast cancer. Rep Pract Oncol Radiother 2011; 16:213-20. [PMID: 24376983 DOI: 10.1016/j.rpor.2011.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 07/27/2011] [Accepted: 08/24/2011] [Indexed: 01/08/2023] Open
Abstract
Whole breast irradiation represents an integral part of combined breast-conserving treatment of early breast cancer. A new concept includes replacing traditionally fractionated whole breast postoperative radiotherapy by accelerated partial breast irradiation. The latter involves a variety of techniques and may be applied intraoperatively or shortly after the surgery. The intraoperative techniques include photon or electron external beam irradiation and interstitial high dose rate (HDR) brachytherapy, whereas the postoperative techniques comprise interstitial brachytherapy, be it HDR, pulse dose rate (PDR) or low dose rate (LDR), intracavitary brachytherapy and external beam radiotherapy using electrons, photons or protons. This article presents accelerated partial breast irradiation techniques, ongoing phase III trials evaluating their value and recommendations for clinical practice.
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Affiliation(s)
- Agata Kacprowska
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Debinki 7, 80-952 Gdansk, Poland
| | - Jacek Jassem
- Department of Oncology and Radiotherapy, Medical University of Gdansk, Debinki 7, 80-952 Gdansk, Poland
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Débats autour du cancer du sein : « contre » la radiothérapie peropératoire. Cancer Radiother 2011; 15:453-4. [DOI: 10.1016/j.canrad.2011.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 05/23/2011] [Indexed: 11/23/2022]
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Lin R, Tripuraneni P. Radiation therapy in early-stage invasive breast cancer. Indian J Surg Oncol 2011; 2:101-11. [PMID: 22693401 DOI: 10.1007/s13193-011-0048-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Accepted: 01/06/2010] [Indexed: 10/18/2022] Open
Abstract
The treatment of breast cancer involves a multi-disciplinary approach with radiation therapy playing a key role. Breast-conserving surgery has been an option for women with early-stage breast cancer for over two decades now. Multiple randomized trials now have demonstrated the efficacy of breast-conserving surgery followed by radiation therapy. With the advancements in breast imaging and the successful campaign for early detection of breast cancer, more women today are found to have early-stage small breast cancers. Patient factors (breast size, tumor location, history of prior radiation therapy, preexisting conditions such as collagen vascular disease, age, having prosthetically augmented breasts), pathological factors (margin status, tumor size, presence of extensive intraductal component requiring multiple surgical excisions), as well as patient preference are all taken into consideration prior to surgical management of breast cancer. Whole-breast fractionated radiation therapy between 5 and 7 weeks is considered as the standard of care treatment following breast-conserving surgery. However, new radiation treatment strategies have been developed in recent years to provide alternatives to the conventional 5-7 week whole-breast radiation therapy for some patients. Accelerated partial breast radiation therapy (APBI) was introduced because the frequency of breast recurrences outside of the surgical cavity has been shown to be low. This technique allows treatments to be delivered quicker (usually 1 week, twice daily) to a limited volume. Often times, this treatment involves the use of a brachytherapy applicator to be placed into the surgical cavity following breast-conserving surgery. Accelerated hypofractionated whole-breast irradiation may be another faster way to deliver radiation therapy following breast-conserving surgery. This journal article reviews the role of radiation therapy in women with early-stage breast cancer addressing patient selection in breast-conserving therapy, a review of pertinent trials in breast-conserving therapy, as well as the different treatment techniques available to women following breast-conserving surgery.
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Affiliation(s)
- Ray Lin
- Department of Radiation Oncology, Scripps Clinic and Scripps Green Hospital, La Jolla, CA USA
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Donovan EM, Ciurlionis L, Fairfoul J, James H, Mayles H, Manktelow S, Raj S, Tsang Y, Tywman N, Yarnold J, Coles C. Planning With Intensity-Modulated Radiotherapy and Tomotherapy to Modulate Dose Across Breast to Reflect Recurrence Risk (IMPORT High Trial). Int J Radiat Oncol Biol Phys 2011; 79:1064-72. [DOI: 10.1016/j.ijrobp.2009.12.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Revised: 11/25/2009] [Accepted: 12/14/2009] [Indexed: 10/19/2022]
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Pignol JP, Keller BM, Ravi A. Doses to internal organs for various breast radiation techniques--implications on the risk of secondary cancers and cardiomyopathy. Radiat Oncol 2011; 6:5. [PMID: 21235766 PMCID: PMC3027128 DOI: 10.1186/1748-717x-6-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 01/14/2011] [Indexed: 01/20/2023] Open
Abstract
Background Breast cancers are more frequently diagnosed at an early stage and currently have improved long term outcomes. Late normal tissue complications induced by adjuvant radiotherapy like secondary cancers or cardiomyopathy must now be avoided at all cost. Several new breast radiotherapy techniques have been developed and this work aims at comparing the scatter doses of internal organs for those techniques. Methods A CT-scan of a typical early stage left breast cancer patient was used to describe a realistic anthropomorphic phantom in the MCNP Monte Carlo code. Dose tally detectors were placed in breasts, the heart, the ipsilateral lung, and the spleen. Five irradiation techniques were simulated: whole breast radiotherapy 50 Gy in 25 fractions using physical wedge or breast IMRT, 3D-CRT partial breast radiotherapy 38.5 Gy in 10 fractions, HDR brachytherapy delivering 34 Gy in 10 treatments, or Permanent Breast 103Pd Seed Implant delivering 90 Gy. Results For external beam radiotherapy the wedge compensation technique yielded the largest doses to internal organs like the spleen or the heart, respectively 2,300 mSv and 2.7 Gy. Smaller scatter dose are induced using breast IMRT, respectively 810 mSv and 1.1 Gy, or 3D-CRT partial breast irradiation, respectively 130 mSv and 0.7 Gy. Dose to the lung is also smaller for IMRT and 3D-CRT compared to the wedge technique. For multicatheter HDR brachytherapy a large dose is delivered to the heart, 3.6 Gy, the spleen receives 1,171 mSv and the lung receives 2,471 mSv. These values are 44% higher in case of a balloon catheter. In contrast, breast seeds implant is associated with low dose to most internal organs. Conclusions The present data support the use of breast IMRT or virtual wedge technique instead of physical wedges for whole breast radiotherapy. Regarding partial breast irradiation techniques, low energy source brachytherapy and external beam 3D-CRT appear safer than 192Ir HDR techniques.
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Affiliation(s)
- Jean-Philippe Pignol
- Radiation Oncology Department, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Richardson SL, Pino R. Dosimetric effects of an air cavity for the SAVI partial breast irradiation applicator. Med Phys 2010; 37:3919-26. [PMID: 20879554 DOI: 10.1118/1.3457328] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To investigate the dosimetric effect of the air inside the SAVI partial breast irradiation device. METHODS The authors have investigated how the air inside the SAVI partial breast irradiation device changes the delivered dose from the homogeneously calculated dose. Measurements were made with the device filled with air and water to allow comparison to a homogenous dose calculation done by the treatment planning system. Measurements were made with an ion chamber, TLDs, and film. Monte Carlo (MC) simulations of the experiment were done using the EGSnrc suite. The MC model was validated by comparing the water-filled calculations to those from a commercial treatment planning system. RESULTS The magnitude of the dosimetric effect depends on the size of the cavity, the arrangement of sources, and the relative dwell times. For a simple case using only the central catheter of the largest device, MC results indicate that the dose at the prescription point 1 cm away from the air-water boundary is about 9% higher than the homogeneous calculation. Independent measurements in a water phantom with a similar air cavity gave comparable results. MC simulation of a realistic multidwell position plan showed discrepancies of about 5% on average at the prescription point for the largest device. CONCLUSIONS The dosimetric effect of the air cavity is in the range of 3%-9%. Unless a heterogeneous dose calculation algorithm is used, users should be aware of the possibility of small treatment planning dose errors for this device and make modifications to the treatment delivery, if necessary.
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Affiliation(s)
- Susan L Richardson
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110, USA.
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Impact of residual and intrafractional errors on strategy of correction for image-guided accelerated partial breast irradiation. Radiat Oncol 2010; 5:96. [PMID: 20977723 PMCID: PMC2987941 DOI: 10.1186/1748-717x-5-96] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Accepted: 10/26/2010] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The cone beam CT (CBCT) guided radiation can reduce the systematic and random setup errors as compared to the skin-mark setup. However, the residual and intrafractional (RAIF) errors are still unknown. The purpose of this paper is to investigate the magnitude of RAIF errors and correction action levels needed in cone beam computed tomography (CBCT) guided accelerated partial breast irradiation (APBI). METHODS Ten patients were enrolled in the prospective study of CBCT guided APBI. The postoperative tumor bed was irradiated with 38.5 Gy in 10 fractions over 5 days. Two cone-beam CT data sets were obtained with one before and one after the treatment delivery. The CBCT images were registered online to the planning CT images using the automatic algorithm followed by a fine manual adjustment. An action level of 3 mm, meaning that corrections were performed for translations exceeding 3 mm, was implemented in clinical treatments. Based on the acquired data, different correction action levels were simulated, and random RAIF errors, systematic RAIF errors and related margins before and after the treatments were determined for varying correction action levels. RESULTS A total of 75 pairs of CBCT data sets were analyzed. The systematic and random setup errors based on skin-mark setup prior to treatment delivery were 2.1 mm and 1.8 mm in the lateral (LR), 3.1 mm and 2.3 mm in the superior-inferior (SI), and 2.3 mm and 2.0 mm in the anterior-posterior (AP) directions. With the 3 mm correction action level, the systematic and random RAIF errors were 2.5 mm and 2.3 mm in the LR direction, 2.3 mm and 2.3 mm in the SI direction, and 2.3 mm and 2.2 mm in the AP direction after treatments delivery. Accordingly, the margins for correction action levels of 3 mm, 4 mm, 5 mm, 6 mm and no correction were 7.9 mm, 8.0 mm, 8.0 mm, 7.9 mm and 8.0 mm in the LR direction; 6.4 mm, 7.1 mm, 7.9 mm, 9.2 mm and 10.5 mm in the SI direction; 7.6 mm, 7.9 mm, 9.4 mm, 10.1 mm and 12.7 mm in the AP direction, respectively. CONCLUSIONS Residual and intrafractional errors can significantly affect the accuracy of image-guided APBI with nonplanar 3DCRT techniques. If a 10-mm CTV-PTV margin is applied, a correction action level of 5 mm or less is necessary so as to maintain the RAIF errors within 10 mm for more than 95% of fractions. Pre-treatment CBCT guidance is not a guarantee for safe delivery of the treatment despite its known benefits of reducing the initial setup errors. A patient position verification and correction during the treatment may be a method for the safe delivery.
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Qiu JJ, Chang Z, Wu QJ, Yoo S, Horton J, Yin FF. Impact of Volumetric Modulated Arc Therapy Technique on Treatment With Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2010; 78:288-96. [PMID: 20444558 DOI: 10.1016/j.ijrobp.2009.10.036] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 10/30/2009] [Accepted: 10/30/2009] [Indexed: 10/19/2022]
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Does a Three-Field Electron/Minitangent Photon Technique Offer Dosimetric Advantages to a Multifield, Photon-Only Technique for Accelerated Partial Breast Irradiation? Am J Clin Oncol 2010; 33:336-40. [DOI: 10.1097/coc.0b013e3181b0c370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Vicini F, Winter K, Wong J, Pass H, Rabinovitch R, Chafe S, Arthur D, Petersen I, White J, McCormick B. Initial efficacy results of RTOG 0319: three-dimensional conformal radiation therapy (3D-CRT) confined to the region of the lumpectomy cavity for stage I/ II breast carcinoma. Int J Radiat Oncol Biol Phys 2010; 77:1120-7. [PMID: 19910132 PMCID: PMC3365530 DOI: 10.1016/j.ijrobp.2009.06.067] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 12/24/2022]
Abstract
PURPOSE This prospective study (Radiation Therapy Oncology Group 0319) examines the use of three-dimensional conformal external beam radiotherapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI). Initial data on efficacy and toxicity are presented. METHODS AND MATERIALS Patients with Stage I or II breast cancer with lesions < or =3 cm, negative margins and with < or =3 positive nodes were eligible. The 3D-CRT was 38.5 Gy in 3.85 Gy/fraction delivered 2x/day. Ipsilateral breast, ipsilateral nodal, contralateral breast, and distant failure (IBF, INF, CBF, DF) were estimated using the cumulative incidence method. Mastectomy-free, disease-free, and overall survival (MFS, DFS, OS) were recorded. The National Cancer Institute Common Terminology Criteria for Adverse Events, version 3, was used to grade acute and late toxicity. RESULTS Fifty-eight patients were entered and 52 patients are eligible and evaluable for efficacy. The median age of patients was 61 years with the following characteristics: 46% tumor size <1 cm; 87% invasive ductal histology; 94% American Joint Committee on Cancer Stage I; 65% postmenopausal; 83% no chemotherapy; and 71% with no hormone therapy. Median follow-up is 4.5 years (1.7-4.8). Four-year estimates (95% CI) of efficacy are: IBF 6% (0-12%) [4% within field (0-9%)]; INF 2% (0-6%); CBF 0%; DF 8% (0-15%); MFS 90% (78-96%); DFS 84% (71-92%); and OS 96% (85-99%). Only two (4%) Grade 3 toxicities were observed. CONCLUSIONS Initial efficacy and toxicity using 3D-CRT to deliver APBI appears comparable to other experiences with similar follow-up. However, additional patients, further follow-up, and mature Phase III data are needed to evaluate the extent of application, limitations, and value of this particular form of APBI.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Follow-Up Studies
- Humans
- Mastectomy, Segmental
- Middle Aged
- Prospective Studies
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/methods
- Reproducibility of Results
- Survival Analysis
- Treatment Outcome
- Tumor Burden
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Affiliation(s)
- Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Strauss JB, Gielda BT, Chen SS, Shah AP, Abrams RA, Griem KL. Variation in Post-Surgical Lumpectomy Cavity Volume With Delay in Initiation of Breast Irradiation Because of Chemotherapy. Int J Radiat Oncol Biol Phys 2010; 77:831-5. [DOI: 10.1016/j.ijrobp.2009.05.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/28/2009] [Accepted: 05/29/2009] [Indexed: 11/16/2022]
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Willis DJ, Kron T, Chua B. An optimized online verification imaging procedure for external beam partial breast irradiation. Med Dosim 2010; 36:171-7. [PMID: 20510600 DOI: 10.1016/j.meddos.2010.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 02/08/2010] [Accepted: 02/26/2010] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to evaluate the capabilities of a kilovoltage (kV) on-board imager (OBI)-equipped linear accelerator in the setting of on-line verification imaging for external-beam partial breast irradiation. Available imaging techniques were optimized and assessed for image quality using a modified anthropomorphic phantom. Imaging dose was also assessed. Imaging techniques were assessed for physical clearance between patient and treatment machine using a volunteer. Nonorthogonal kV image pairs were identified as optimal in terms of image quality, clearance, and dose. After institutional review board approval, this approach was used for 17 patients receiving accelerated partial breast irradiation. Imaging was performed before every fraction verification with online correction of setup deviations >5 mm (total image sessions = 170). Treatment staff rated risk of collision and visibility of tumor bed surgical clips where present. Image session duration and detected setup deviations were recorded. For all cases, both image projections (n = 34) had low collision risk. Surgical clips were rated as well as visualized in all cases where they were present (n = 5). The average imaging session time was 6 min, 16 sec, and a reduction in duration was observed as staff became familiar with the technique. Setup deviations of up to 1.3 cm were detected before treatment and subsequently confirmed offline. Nonorthogonal kV image pairs allowed effective and efficient online verification for partial breast irradiation. It has yet to be tested in a multicenter study to determine whether it is dependent on skilled treatment staff.
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Affiliation(s)
- David J Willis
- Division of Radiation Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.
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Nichols EM, Dhople AA, Mohiuddin MM, Flannery TW, Yu CX, Regine WF. Comparative Analysis of the Post-Lumpectomy Target Volume Versus the Use of Pre-Lumpectomy Tumor Volume for Early-Stage Breast Cancer: Implications for the Future. Int J Radiat Oncol Biol Phys 2010; 77:197-202. [DOI: 10.1016/j.ijrobp.2009.04.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Revised: 03/02/2009] [Accepted: 04/21/2009] [Indexed: 10/19/2022]
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Abstract
The addition of whole-breast external beam radiotherapy (EBRT) to breast-conserving surgery results in a significant reduction in the risk of death due to breast cancer, but this may be offset by an increase in deaths from other causes and toxicity to surrounding organs. Because of this, and with a view to patterns of local recurrence, irradiation of the tumour bed has been explored in selected patients with early breast cancer using a variety of radiotherapeutic modalities. This review article explores the treatment options for partial breast irradiation and examines their role within the field of breast cancer treatment.
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