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Everett AS, De Los Santos JF, Boggs DH. The Evolving Role of Postmastectomy Radiation Therapy. Surg Clin North Am 2018; 98:801-817. [DOI: 10.1016/j.suc.2018.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Leite ETT, Ugino RT, Santana MA, Ferreira DV, Lopes MR, Pelosi EL, da Silva JLF, Carvalho HDA. Incidental irradiation of internal mammary lymph nodes in breast cancer: conventional two-dimensional radiotherapy versus conformal three-dimensional radiotherapy. Radiol Bras 2016; 49:170-5. [PMID: 27403017 PMCID: PMC4938447 DOI: 10.1590/0100-3984.2015.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate incidental irradiation of the internal mammary lymph nodes (IMLNs) through opposed tangential fields with conventional two-dimensional (2D) or three-dimensional (3D) radiotherapy techniques and to compare the results between the two techniques. MATERIALS AND METHODS This was a retrospective study of 80 breast cancer patients in whom radiotherapy of the IMLNs was not indicated: 40 underwent 2D radiotherapy with computed tomography for dosimetric control, and 40 underwent 3D radiotherapy. The total prescribed dose was 50.0 Gy or 50.4 Gy (2.0 or 1.8 Gy/day, respectively). We reviewed all plans and defined the IMLNs following the Radiation Therapy Oncology Group recommendations. For the IMLNs, we analyzed the proportion of the volume that received 45 Gy, the proportion of the volume that received 25 Gy, the dose to 95% of the volume, the dose to 50% of the volume, the mean dose, the minimum dose (Dmin), and the maximum dose (Dmax). RESULTS Left-sided treatments predominated in the 3D cohort. There were no differences between the 2D and 3D cohorts regarding tumor stage, type of surgery (mastectomy, breast-conserving surgery, or mastectomy with immediate reconstruction), or mean delineated IMLN volume (6.8 vs. 5.9 mL; p = 0.411). Except for the Dmin, all dosimetric parameters presented higher mean values in the 3D cohort (p < 0.05). The median Dmax in the 3D cohort was 50.34 Gy. However, the mean dose to the IMLNs was 7.93 Gy in the 2D cohort, compared with 20.64 Gy in the 3D cohort. CONCLUSION Neither technique delivered enough doses to the IMLNs to achieve subclinical disease control. However, all of the dosimetric parameters were significantly higher for the 3D technique.
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Affiliation(s)
- Elton Trigo Teixeira Leite
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês; Radiation Oncology Department - Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira (Icesp), São Paulo, SP, Brazil
| | - Rafael Tsuneki Ugino
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Marco Antônio Santana
- MD, Radiation Oncologist, Department of Radiology and Oncology - Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Denis Vasconcelos Ferreira
- MD, Radiation Oncologist, Department of Radiology and Oncology - Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
| | - Maurício Russo Lopes
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | - Edilson Lopes Pelosi
- MD, Radiation Oncologist, Radiation Oncology Department - Hospital Sírio-Libanês, São Paulo, SP, Brazil
| | | | - Heloisa de Andrade Carvalho
- MD, PhD, Department of Radiology and Oncology - Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP, Brazil
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Mayadev J, Einck J, Elson S, Rugo H, Hwang S, Bold R, Daroui P, McCloskey S, Yashar C, Kim D, Fowble B. Practice Patterns in the Delivery of Radiation Therapy After Mastectomy Among the University of California Athena Breast Health Network. Clin Breast Cancer 2015; 15:43-7. [DOI: 10.1016/j.clbc.2014.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 07/09/2014] [Accepted: 07/11/2014] [Indexed: 11/24/2022]
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Gültekin M, Karabuğa M, Yıldız F, Özyiğit G, Cengiz M, Zorlu F, Akyol F, Gürkaynak M. Comparison of Chest Wall and Lymphatic Radiotherapy Techniques in Patients with Left Breast Carcinoma. THE JOURNAL OF BREAST HEALTH 2014; 10:106-110. [PMID: 28331653 PMCID: PMC5351467 DOI: 10.5152/tjbh.2014.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Accepted: 03/16/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to find the most appropriate technique for postmastectomy chest wall (CW) and lymphatic irradiation. MATERIALS AND METHODS Partially wide tangent, 30/70 photon/electron mix, 20/80 photon/electron mix and CW and internal mammary en face electron field, were studied on computerized tomography (CT) scans of 10 left breast carcinoma patients and dosimetric calculations have been studied. Dose volume histograms (DVH) obtained from treatment planning system (TPS) were used for minimal, maximal and mean doses received by the clinical target volumes and critical structures. RESULTS Partially wide tangent field resulted in the most homogeneous dose distribution for the CW and a significantly lower lung and heart doses compared with all other techniques. However, right breast dose was significantly higher for partially wide tangent technique than that each of the other techniques. Approximately 0.6-7.9% differences were found between thermoluminescent dosimeter (TLD) and treatment planning system (TPS). The daily surface doses calculating using Gafchromic® external beam therapy (EBT) dosimetry films were 161.8±2.7 cGy for the naked, 241.0±1.5 cGy when 0.5 cm bolus was used and 255.3±2.7 cGy when 1 cm bolus was used. CONCLUSION As a result of this study, partially wide tangent field was found to be the most appropriate technique in terms of the dose distribution, treatment planning and set-up procedure. The main disadvantage of this technique was the higher dose to the contralateral breast comparing the other techniques.
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Affiliation(s)
- Melis Gültekin
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Karabuğa
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ferah Yıldız
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gökhan Özyiğit
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mustafa Cengiz
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Faruk Zorlu
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Fadıl Akyol
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Murat Gürkaynak
- Department of Radiation Oncology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Jagsi R. Postmastectomy radiation therapy: an overview for the practicing surgeon. ISRN SURGERY 2013; 2013:212979. [PMID: 24109522 PMCID: PMC3786459 DOI: 10.1155/2013/212979] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 06/24/2013] [Indexed: 12/21/2022]
Abstract
Locoregional control of breast cancer is the shared domain and responsibility of surgeons and radiation oncologists. Because surgeons are often the first providers to discuss locoregional control and recurrence risks with patients and because they serve in a key gatekeeping role as referring providers for radiation therapy, a sophisticated understanding of the evidence regarding radiotherapy in breast cancer management is essential for the practicing surgeon. This paper synthesizes the complex and evolving evidence regarding the role of radiation therapy after mastectomy. Although substantial evidence indicates that radiation therapy can reduce the risk of locoregional failure after mastectomy (with a relative reduction of risk of approximately two-thirds), debate persists regarding the specific subgroups who have sufficient risks of residual microscopic locoregional disease after mastectomy to warrant treatment with radiation. This paper reviews the evidence available to guide appropriate referral and patient decision making, with special attention to areas of controversy, including patients with limited nodal disease, those with large tumors but negative nodes, node-negative patients with high risk features, patients who have received systemic chemotherapy in the neoadjuvant setting, and patients who may wish to integrate radiation therapy with breast reconstruction surgery.
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Affiliation(s)
- Reshma Jagsi
- Department of Radiation Oncology, University of Michigan, UHB2C490, SPC 5010, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5010, USA
- Center for Bioethics and Social Science in Medicine, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800, USA
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Healy E, Anderson S, Cui J, Beckett L, Chen AM, Perks J, Stern R, Mayadev J. Skin dose effects of postmastectomy chest wall radiation therapy using brass mesh as an alternative to tissue equivalent bolus. Pract Radiat Oncol 2012; 3:e45-53. [PMID: 24674320 DOI: 10.1016/j.prro.2012.05.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 05/25/2012] [Accepted: 05/29/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The use of brass mesh as a bolus is relatively uncommon in postmastectomy chest wall radiation therapy (PMRT). This study aimed to characterize the skin dose effects of using 2-mm fine brass mesh as an alternative to the traditional tissue-equivalent bolus during chest wall PMRT. METHODS AND MATERIALS Data were collected from patients who received PMRT using brass mesh at the University of California Davis Department of Radiation Oncology between January 2008 and June 2011. Several patient characteristics including age, body habitus, and ethnicity were analyzed along with several disease and treatment characteristics to determine whether or not they had an impact on the skin reaction observed during radiation treatment. Additionally, in vivo surface dose measurements were obtained for 16 of the 48 patients (33%). RESULTS Forty-eight female patients aged 28-83 received PMRT using brass mesh. As expected, the severity of skin toxicity increased with subsequent doses of radiation with all patients beginning treatment with no skin reaction (National Cancer Institute scores [NCIS] = 0) and the majority of patients completing treatment with either faint to moderate erythema (n = 19, 40%, NCIS = 1) or moderate to brisk erythema (n = 23, 48%, NCIS = 2). In vivo dosimetry analysis revealed surface doses between 81% and 122% of the prescribed dose, with an average of 99% of the prescribed radiation dose and standard deviation of 10% being delivered. CONCLUSIONS For postmastectomy chest wall radiation therapy, brass mesh is an effective alternative to tissue-equivalent bolus. The brass mesh achieved moderate erythema in the majority of patients at the end of treatment and the surface dose was validated using in vivo dosimetry.
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Affiliation(s)
- Erin Healy
- University of California, Davis, Sacramento, California
| | - Shawnee Anderson
- Department of Mathematics, California State University, Sacramento, California
| | - Jing Cui
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
| | - Laurel Beckett
- Department of Biostatistics, University of California, Davis, Sacramento, California
| | - Allen M Chen
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
| | - Julian Perks
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
| | - Robin Stern
- Department of Radiation Oncology, University of California, Davis, Sacramento, California
| | - Jyoti Mayadev
- Department of Radiation Oncology, University of California, Davis, Sacramento, California.
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Wang SL, Li YX, Song YW, Wang WH, Jin J, Liu YP, Liu XF, Yu ZH. Postmastectomy chest wall radiotherapy with single low-energy electron beam: An assessment of outcome and prognostic factors. Pract Radiat Oncol 2012; 2:106-13. [DOI: 10.1016/j.prro.2011.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 06/17/2011] [Accepted: 07/04/2011] [Indexed: 11/29/2022]
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Valli MC. Controversies in loco-regional treatment: post-mastectomy radiation for pT2-pT3N0 breast cancer arguments in favour. Crit Rev Oncol Hematol 2010; 84 Suppl 1:e70-4. [PMID: 21134765 DOI: 10.1016/j.critrevonc.2010.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Revised: 10/21/2010] [Accepted: 11/03/2010] [Indexed: 11/16/2022] Open
Abstract
Post-mastectomy RT decreases the rate of locoregional recurrences of about 70% in all patients irrespective of age, tumor characteristics or systemic therapy. Post-mastectomy RT has to be proposed, moreover when locoregional lymph nodes are part of the PTV, if an optimal coverage of the PTV and a satisfactory sparing of the OAR could be obtained. Due to the results of meta-analysis, consensus conferences and randomized trials the long-term efficacy of RT in decreasing the risk of LRF is well established and the vast majority of women, treated with mastectomy, will benefit from it.
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Affiliation(s)
- Maria Carla Valli
- Radiation Oncology Department, Oncology Institute of Southern Switzerland, Switzerland.
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Abstract
BACKGROUND The optimal timing and technique of breast reconstruction in patients who may require postmastectomy radiation therapy are controversial. To help surgeons make the best decisions, the authors reviewed the recent literature on this topic. METHODS The authors searched the MEDLINE database for studies of radiation therapy and breast reconstruction with most patients treated after 1985 and mean follow-up of more than 1 year. Forty-nine articles were reviewed. RESULTS Even with the latest prosthetic materials and modern radiation delivery techniques, the complication rate for implant-based breast reconstruction in patients undergoing postmastectomy radiation therapy is greater than 40 percent, and the extrusion rate is 15 percent. Modified sequencing of two-stage implant reconstruction, such that the expander is exchanged for the permanent implant before postmastectomy radiation therapy, results in higher rates of capsular contracture and is not generally feasible after neoadjuvant chemotherapy. Current evidence suggests that postmastectomy radiation therapy also adversely affects autologous tissue reconstruction. Even with modern radiation delivery techniques, immediate implant-based or autologous tissue breast reconstruction can distort the chest wall and limit the ability to treat the targeted tissues without excessive exposure of the heart and lungs. In patients for whom postmastectomy radiation therapy appears likely but may not be required, "delayed-immediate reconstruction," in which tissue expanders are placed at mastectomy, avoids the difficulties associated with radiation delivery after immediate reconstruction and preserves the opportunity for the aesthetic benefits of skin-sparing mastectomy. CONCLUSIONS In patients who will receive or have already received postmastectomy radiation therapy, the optimal approach is delayed autologous tissue reconstruction after postmastectomy radiation therapy. If postmastectomy radiation therapy appears likely but may not be required, delayed-immediate reconstruction may be considered.
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Kirova YM, Campana F, Fournier-Bidoz N, Stilhart A, Dendale R, Bollet MA, Fourquet A. Postmastectomy Electron Beam Chest Wall Irradiation in Women With Breast Cancer: A Clinical Step Toward Conformal Electron Therapy. Int J Radiat Oncol Biol Phys 2007; 69:1139-44. [PMID: 17689024 DOI: 10.1016/j.ijrobp.2007.05.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Revised: 04/26/2007] [Accepted: 04/30/2007] [Indexed: 11/18/2022]
Abstract
PURPOSE Electron beam radiotherapy of the chest wall with or without lymph node irradiation has been used at the Institut Curie for >20 years. The purpose of this report was to show the latest improvements of our technique developed to avoid hot spots and improve the homogeneity. METHODS AND MATERIALS The study was split into two parts. A new electron irradiation technique was designed and compared with the standard one (dosimetric study). The dose distributions were calculated using our treatment planning software ISIS (Technologie Diffusion). The dose calculation was performed using the same calculation parameters for the new and standard techniques. Next, the early skin toxicity of our new technique was evaluated prospectively in the first 25 patients using Radiation Therapy Oncology Group criteria (clinical study). RESULTS The maximal dose found on the five slices was 53.4 +/- 1.1 Gy for the new technique and 59.1 +/- 2.3 Gy for the standard technique. The hot spots of the standard technique plans were situated at the overlap between the internal mammary chain and chest wall fields. The use of one unique field that included both chest wall and internal mammary chain volumes solved the problem of junction. To date, 25 patients have been treated with the new technique. Of these patients, 12% developed Grade 0, 48% Grade 1, 32% Grade 2, and 8% Grade 3 toxicity. CONCLUSIONS This report describes an improvement in the standard postmastectomy electron beam technique of the chest wall. This new technique provides improved target homogeneity and conformality compared with the standard technique. This treatment was well tolerated, with a low rate of early toxicity events.
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Affiliation(s)
- Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France.
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Schechter NR, Strom EA, Perkins GH, Arzu I, McNeese MD, Langstein HN, Kronowitz SJ, Meric-Bernstam F, Babiera G, Hunt KK, Hortobagyi GN, Buchholz TA. Immediate Breast Reconstruction can Impact Postmastectomy Irradiation. Am J Clin Oncol 2005; 28:485-94. [PMID: 16199989 DOI: 10.1097/01.coc.0000170582.38634.b6] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Immediate breast reconstruction is an attractive option for patients who undergo mastectomy. The purpose of this study was to qualitatively assess the effect of immediate reconstruction on the design of postmastectomy radiotherapy fields at our institution. METHODS We retrospectively reviewed the records of 152 patients treated at our institution with postmastectomy radiotherapy over a 1-year period. We identified 18 postmastectomy radiotherapy plans in the setting of prior reconstruction. By consensus, 2 board-certified radiation oncologists scored the 18 plans in terms of 4 outcomes: coverage of the chest wall breadth, coverage of the ipsilateral internal mammary chain (IMC) region, minimization of lung exposure, and avoidance of the heart. RESULTS Only 4 of the 18 plans resulted in optimal treatment of the chest wall breadth and IMC region while well avoiding the heart and lung. Of the remaining 14 plans, 12 compromised coverage of the chest wall breadth medially and/or laterally, and 9 provided no IMC coverage. CONCLUSION Immediate breast reconstruction may impose limitations on the treatment planning of postmastectomy radiotherapy, particularly in regard to providing broad coverage of the chest wall and IMC region while avoiding excess exposure of the heart and lung.
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Affiliation(s)
- Naomi R Schechter
- Departments of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.
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Kukołowicz PF, Debrowski A, Gut P, Chmielewski L, Wieczorek A, Kedzierawski P. Evaluation of set-up deviations during the irradiation of patients suffering from breast cancer treated with two different techniques. Radiother Oncol 2005; 75:22-7. [PMID: 15878097 DOI: 10.1016/j.radonc.2005.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 12/01/2004] [Accepted: 02/17/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare reproducibility of set-up for two different treatment techniques for external irradiation of the breast. METHODS AND MATERIALS In total, the analysis comprised 56 pairs of portal and simulator films for 14 consecutive patients treated following breast conserving therapy and 98 pairs of portal and simulator films for 20 consecutive patients treated after mastectomy. For the first group the tangential field technique (TF technique) was used, for the second the inverse hockey stick technique (IHS technique). Evaluation of the treatment reproducibility was performed in terms of systematic and random error calculated for the whole groups, comparison of set-up accuracy by means of comparison of cumulative distribution of the length of the displacement vector. RESULTS In the IHS and TF techniques for medial and lateral fields, displacement larger than 5 mm occurred in 28.3, 15.8 and 25.4%, respectively. For the IHS technique, the systematic errors for lateral and cranial-caudal direction were 1.9 and 1.7 mm, respectively (1 SD), the random errors for lateral and cranial-caudal direction were 2.0 and 2.5 mm. For the TF technique, the systematic errors for ventral-dorsal and cranial-caudal direction were 2.6 and 1.3 mm for medial field and 3.7 and 0.7 mm for lateral fields, respectively, the random errors for lateral and cranial-caudal direction were 2.2 and 1.0 mm for medial field and 2.9 and 1.1 for lateral field, respectively. Rotations were negligible in the IHS technique. For the TF technique the systematic and random components amounted to about 2.0 degrees (1 SD). CONCLUSIONS Both the inverse hockey stick and standard tangential techniques showed good reproducibility of patients' set-up with respect to cranial-caudal direction. For the TF technique, the accuracy should be improved for the medial field with respect to the ventral-dorsal direction.
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Affiliation(s)
- Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI, USA.
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Hinrichs CS, Watroba NL, Rezaishiraz H, Giese W, Hurd T, Fassl KA, Edge SB. Lymphedema Secondary to Postmastectomy Radiation: Incidence and Risk Factors. Ann Surg Oncol 2004; 11:573-80. [PMID: 15172932 DOI: 10.1245/aso.2004.04.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postmastectomy radiotherapy (PMRT) has proven benefits for certain patients with breast cancer; however, one of its complications is lymphedema. This study examines the incidence of and risk factors associated with lymphedema secondary to PMRT. METHODS The charts of patients treated with mastectomy at Roswell Park Cancer Institute between January 1, 1995, and April 20, 2001, who received PMRT were reviewed. Univariate analysis of patient, disease, and treatment variables was conducted. Multivariate analysis was performed on variables found to be significant in univariate analysis. RESULTS One hundred five patients received PMRT. The incidence of lymphedema was 27%. Patient age, body mass index, disease stage, positive lymph nodes, nodes resected, postoperative infection, duration of drainage, chemotherapy, and hormonal therapy were not associated with lymphedema. Total dose (P =.032), posterior axillary boost (P =.047), overlap technique (P =.037), radiotherapy before 1999 (P =.028), and radiotherapy at Roswell Park Cancer Institute (P =.028) were significantly associated with lymphedema. Increased lymphedema was noted with supraclavicular, internal mammary, mastectomy scar boost, and chest wall tangential photon beam radiation, but the associations were not statistically significant. CONCLUSIONS The high incidence and debilitating effects of lymphedema must be weighed against the benefits of PMRT. Efforts to prevent lymphedema should be emphasized.
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Affiliation(s)
- Christian S Hinrichs
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm and Carlton Streets, Buffalo, NY 14263, USA
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15
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Abstract
Evaluation of a mastectomy site is more effective with ultrasonography (US) than with either mammography or chest computed tomography because abnormalities are usually small and close to the skin surface. US does not involve the use of ionizing radiation and has a multiplanar scanning capability. The technique is readily available and inexpensive, and it allows real-time monitoring of needle tip placement during biopsy of a lesion. Normal US anatomy of the chest wall after mastectomy usually consists of four layers: skin, subcutaneous fat, pectoral muscles, and rib and intercostal muscle. The axilla is changed in appearance after lymph node dissection, but it remains the same in patients who have undergone simple mastectomy. US can accurately depict benign and malignant conditions in the mastectomy site, including fluid collection, fibrosis, local recurrent tumor, and metastatic lymphadenopathy, and can enable accurate diagnosis based on findings at fine needle aspiration biopsy.
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Affiliation(s)
- Sun Mi Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea
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Fortin A, Dagnault A, Larochelle M, Vu TTT. Impact of locoregional radiotherapy in node-positive patients treated by breast-conservative treatment. Int J Radiat Oncol Biol Phys 2003; 56:1013-22. [PMID: 12829137 DOI: 10.1016/s0360-3016(03)00202-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE The aim of this study is to evaluate the impact of locoregional radiation in node-positive patients treated by tumorectomy and radiation therapy. METHODS A retrospective study including all our 1368 T1-2 node-positive patients was conducted. Conservative surgery was followed by breast irradiation. Axillary and supraclavicular irradiation was left to the discretion of the treating radiation oncologist. RESULTS In the group receiving locoregional radiation (472 patients), the 10-year regional control was 97% vs. 91% for the group receiving radiation to the breast only (896 patients) (p = 0.004). In a Cox model analysis, locoregional radiation is associated with a better regional control rate (hazard ratio: 0.27; 95% confidence interval: 0.13-0.54, p = 0.0001). Locoregional radiotherapy is associated with a better rate of locoregional control (hazard ratio: 0.56; 95% confidence interval: 0.38-0.8, p = 0.002). In particular, for the N>3 group, the substantial 10-year locoregional failure rate (26% with breast irradiation only) is cut by 50%. Locoregional radiotherapy, however, is not associated with a lower rate of distant metastases. CONCLUSION Locoregional radiation decreases the rate of locoregional failure by nearly 50%. Locoregional radiotherapy should be considered for node-positive patients, especially if they have more than 3 positive nodes.
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Affiliation(s)
- André Fortin
- Department of Radiation Oncology, l'Hotel-Dieu de Québec Hospital, Laval University, Quebec City, Quebec, Canada.
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Remouchamps VM, Vicini FA, Sharpe MB, Kestin LL, Martinez AA, Wong JW. Significant reductions in heart and lung doses using deep inspiration breath hold with active breathing control and intensity-modulated radiation therapy for patients treated with locoregional breast irradiation. Int J Radiat Oncol Biol Phys 2003; 55:392-406. [PMID: 12527053 DOI: 10.1016/s0360-3016(02)04143-3] [Citation(s) in RCA: 280] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE To evaluate the heart and lung sparing effects of moderate deep inspiration breath hold (mDIBH) achieved using an active breathing control (ABC) device, compared with free breathing (FB) during treatment with deep tangents fields (DT) for locoregional (LR) irradiation of breast cancer patients, including the internal mammary (IM) nodes (IMNs). To compare the DT-mDIBH technique to other standard techniques and to evaluate the dosimetric effect of intensity-modulated radiation therapy (IMRT). METHODS AND MATERIALS Fifteen patients (9 left-sided and 6 right-sided lesions) with Stages 0-III breast cancer underwent standard FB and ABC computed tomographic (CT) scans in the treatment position. A dosimetric planning study was performed. In FB, the 9 left-sided patients were planned with a 5-field technique where electron fields covering the IM region were matched to shallow tangents using wedges (South West Oncology Group [SWOG] protocol S9927 technique A). This method was compared with a 3-field DT technique covering the breast and the IMNs (SWOG S9927 technique B). Compensation with IMRT was then compared with wedges for each technique. For the 15 total patients, dosimetric planning using DT with IMRT was then reoptimized on the mDIBH CT data set for comparison. Dose-volume histograms for the clinical target volume (CTV) (including the IMNs), planning target volume (PTV), ipsilateral and contralateral breast, and organs at risk (OAR) were analyzed. In addition, normal tissue complication probabilities (NTCP) for lung and heart, mean lung doses, and the number of monitor units (MUs) for a 1.8 Gy fraction were compared. RESULTS For the 9 left-sided patients, the mean percentage of heart receiving more than 30 Gy (heart V30) was lower with the 5-field wedged technique than with the DT wedged technique (6.8% and 19.1%, respectively, p < 0.004). For the DT technique, the replacement of wedges with IMRT slightly diminished the mean heart V30 to 16.3% (p < 0.51). The introduction of mDIBH to the DT-IMRT technique reduced the heart V30 by 81% to a mean of 3.1% (p < 0.0004). Compared with 5-field IMRT, DT-IMRT with mDIBH reduced the heart V30 for 6 of the 9 patients, entirely avoiding heart irradiation in 2 of these 6 patients. For DT-IMRT, mDIBH reduced the mean lung dose and NTCP to levels obtained with the 5-field IMRT technique. For the 15 patients planned with DT-IMRT in FB, the use of mDIBH reduced the mean percentage of both lungs receiving more than 20 Gy from 20.4% to 15.2% (p < 0.00007). With DT-IMRT, more than 5% of the contralateral breast received more than 10 Gy for 6 of the 9 left-sided patients in FB, 3 of those 9 patients in mDIBH, and only 1 of those 9 patients planned with 5 fields. The mean % of the PTV receiving more than 55 Gy (110% of the prescribed dose) was 36.4% for 5-field wedges, 33.4% for 5-field IMRT, 28.7% for DT-wedges, 12.5% for DT-IMRT, and 18.4% for DT-IMRT mDIBH. The CTV remained covered by the 95% isodose in all the DT plans but one (99.1% of the volume covered). DT-wedges required more MUs than DT-IMRT (mean of 645 and 416, respectively, p < 0.00004). CONCLUSION mDIBH significantly reduces heart and lung doses when DT are used for LR breast irradiation including the IMNs. Compared with shallow tangents matched with electrons, DT with mDIBH reduces the heart dose (in most patients) and results in comparable lung toxicity parameters, but may increase the dose to the contralateral breast. IMRT improves dose homogeneity, slightly reduces the dose to the heart, and diminishes the number of MUs required.
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Affiliation(s)
- Vincent M Remouchamps
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA
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Perkins GH, McNeese MD, Antolak JA, Buchholz TA, Strom EA, Hogstrom KR. A custom three-dimensional electron bolus technique for optimization of postmastectomy irradiation. Int J Radiat Oncol Biol Phys 2001; 51:1142-51. [PMID: 11704339 DOI: 10.1016/s0360-3016(01)01744-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Postmastectomy irradiation (PMI) is a technically complex treatment requiring consideration of the primary tumor location, possible risk of internal mammary node involvement, varying chest wall thicknesses secondary to surgical defects or body habitus, and risk of damaging normal underlying structures. In this report, we describe the application of a customized three-dimensional (3D) electron bolus technique for delivering PMI. METHODS AND MATERIALS A customized electron bolus was designed using a 3D planning system. Computed tomography (CT) images of each patient were obtained in treatment position and the volume to be treated was identified. The distal surface of the wax bolus matched the skin surface, and the proximal surface was designed to conform to the 90% isodose surface to the distal surface of the planning target volume (PTV). Dose was calculated with a pencil-beam algorithm correcting for patient heterogeneity. The bolus was then fabricated from modeling wax using a computer-controlled milling device. To aid in quality assurance, CT images with the bolus in place were generated and the dose distribution was computed using these images. RESULTS This technique optimized the dose distribution while minimizing irradiation of normal tissues. The use of a single anterior field eliminated field junction sites. Two patients who benefited from this option are described: one with altered chest wall geometry (congenital pectus excavatum), and one with recurrent disease in the medial chest wall and internal mammary chain (IMC) area. CONCLUSION The use of custom 3D electron bolus for PMI is an effective method for optimizing dose delivery. The radiation dose distribution is highly conformal, dose heterogeneity is reduced compared to standard techniques in certain suboptimal settings, and excellent immediate outcome is obtained.
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MESH Headings
- Adenocarcinoma/diagnostic imaging
- Adenocarcinoma/radiotherapy
- Adenocarcinoma/surgery
- Adult
- Algorithms
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Combined Modality Therapy
- Electrons/therapeutic use
- Female
- Humans
- Mastectomy
- Mastectomy, Modified Radical
- Middle Aged
- Postoperative Period
- Radiotherapy Dosage
- Radiotherapy Planning, Computer-Assisted/methods
- Radiotherapy, Conformal/methods
- Tomography, X-Ray Computed
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Affiliation(s)
- G H Perkins
- Department of Radiation Oncology, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
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Sixel KE, Aznar MC, Ung YC. Deep inspiration breath hold to reduce irradiated heart volume in breast cancer patients. Int J Radiat Oncol Biol Phys 2001; 49:199-204. [PMID: 11163515 DOI: 10.1016/s0360-3016(00)01455-3] [Citation(s) in RCA: 187] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the use of deep inspiration breath hold (DIBH) during tangential breast radiation therapy as a means of reducing irradiated cardiac volume. METHODS AND MATERIALS The Active Breathing Control (ABC) device designed at William Beaumont Hospital, Michigan was used to quantify the potential benefit of radiation delivery during DIBH for five left-sided breast cancer patients. This device initiates a breath hold at a predefined, reproducible lung volume. For each patient, two CT scans were acquired with and without breath hold, and virtual simulation was performed for regular tangent and wide-tangent techniques. The resulting dose-volume histograms were calculated, and the volume of heart irradiated to 25 Gy or more was assessed. RESULTS The influence of ABC on irradiated heart volumes varied considerably among the five patients. Three patients with substantial cardiac volume in the treatment field during normal respiration showed a significant dose-volume histogram reduction when deep inspiration was applied, with decreases in the heart volume receiving 25 Gy of more than 40 cc observed. For one patient, deep inspiration reduced irradiated cardiac volumes only with the wide-tangent technique, while one patient showed no substantial irradiated volume decrease. CONCLUSION A DIBH technique during tangential breast irradiation has the potential to significantly decrease irradiated cardiac volume for suitably selected patients. The magnitude of the impact of the breath hold application depends on patient anatomy, lung capacity, and pulmonary function.
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Affiliation(s)
- K E Sixel
- Toronto-Sunnybrook Regional Cancer Centre, Toronto, Ontario, Canada.
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