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Kim E, Yoo JS, Kim YJ, Joo J, Oh ES, Chung Y, Chung SH, Kim TH. Toxicity Evaluation of Dose-Escalation in Hypofractionated Regional Nodal Irradiation for Breast Cancer: A Retrospective Study. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00513-3. [PMID: 38631540 DOI: 10.1016/j.ijrobp.2024.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE Regional nodal irradiation (RNI) to the axilla and supraclavicular area presents distinct toxicities, such as lymphedema and shoulder stiffness, compared with whole-breast irradiation. There is insufficient evidence on the safety of dose-escalation in hypofractionated RNI. We aimed to evaluate and compare toxicity rates in patients with breast cancer who received hypofractionated RNI with and without dose-escalation. METHODS AND MATERIALS We retrospectively analyzed 381 patients with breast cancer treated with hypofractionated RNI between March 2015 and February 2017. Patients received either the standard-dose to the regional nodal area (43.2 Gy/16 fx; 48.7 Gy3.5 equivalent dose [EQD2], 2 Gy equivalent dose with α/β= 3.5 Gy) or dose-escalation with a median dose of 54.8 Gy3.5 EQD2 (range, 51.7-60.9 Gy3.5 EQD2), depending on clinical and pathologic nodal stage. Toxicity rates of lymphedema and shoulder stiffness were assessed, and statistical analyses were conducted to identify associated factors. RESULTS The median follow-up time was 32.3 months (5.7-47.0 months). After radiation therapy, 71 (18.6%) patients developed lymphedema, and 48 (12.6%) developed shoulder stiffness. Patients who received dose-escalation exhibited significantly higher rates of lymphedema (32.1% vs 14.8%; odds ratio, 2.72, P = .0004) and shoulder stiffness (23.8% vs 9.4%; odds ratio, 2.01, P = .0205) compared with the standard-dose group. Moreover, dose-escalation showed a tendency to increase the severity of lymphedema and shoulder stiffness. CONCLUSIONS Patients who received dose-escalation in hypofractionated RNI face a higher risk of developing lymphedema and shoulder stiffness compared with those who received standard-dose hypofractionated RNI. Therefore, it is crucial to implement close and frequent monitoring for early detection, along with timely rehabilitation interventions for these patients.
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Affiliation(s)
- Euidam Kim
- Department of Nuclear Engineering, Hanyang University, Seoul, Republic of Korea
| | - Ji Sung Yoo
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.
| | - Yeon-Joo Kim
- Department of Radiation Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea.
| | - Jungnam Joo
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Eun Sang Oh
- Department of Radiation Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Yoonsun Chung
- Department of Nuclear Engineering, Hanyang University, Seoul, Republic of Korea
| | - Seung Hyun Chung
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Tae Hyun Kim
- Department of Radiation Oncology, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
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Park YI, Chang JS, Ko H, Im SH, Kim JS, Byun HK, Kim YB, Jung W, Kim K, Hong CS. Development and Validation of a Normal Tissue Complication Probability Model for Lymphedema After Radiation Therapy in Breast Cancer. Int J Radiat Oncol Biol Phys 2023:S0360-3016(23)00106-2. [PMID: 36739918 DOI: 10.1016/j.ijrobp.2023.01.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/09/2023] [Accepted: 01/28/2023] [Indexed: 02/05/2023]
Abstract
PURPOSE To develop and test a multivariable normal tissue complication probability (NTCP) model predicting lymphedema in patients with breast cancer receiving radiation therapy. METHODS AND MATERIALS We retrospectively reviewed 1345 patients with breast cancer who received radiation therapy from 2 independent institutions. The patients were divided into a training cohort (institution A, n = 368, all treated with 3-dimensional conformal external beam radiation therapy [RT] with 2 Gy/fraction) and an external validation cohort (institution B, n = 977, treated either with 3-dimensional conformal external beam RT or with volumetric modulated RT and either with 1.8-2.0 Gy/fraction or with 2.67 Gy/fraction). Axillary-lateral thoracic vessel juncture (ALTJ) was delineated. The multivariable model was generated using dosimetric and clinical parameters. The performance of the model was comprehensively validated internally and externally. RESULTS During a median follow-up of 78.7 months for the entire cohort, 97 patients (7.2%) developed lymphedema. The multivariable model that took into account the number of lymph nodes dissected, as well as the volume of the ALTJ receiving a dose ≥35 Gy equivalent doses in 2-Gy fractions (ALTJ V35), showed good agreement between predicted and observed results for both internal and external validation (Hosmer-Lemeshow P value > .05). The area under the receiver operating characteristic curve (AUC) and negative log-likelihood values for the multivariable NTCP model were 0.89 and 0.19 in internal validation and 0.83 and 0.19 in external validation. In addition, the multivariable model performance was acceptable for hypofractionated regimens (AUC 0.70) and volumetric modulated arc therapy (AUC 0.69). The number of lymph nodes dissected and ALTJ V35 were found to be the most important factors influencing lymphedema after radiation therapy. CONCLUSIONS We first developed and validated the multivariable NTCP model for the lymphedema incidence in patients with breast cancer after radiation therapy. The multivariable NTCP model showed excellent performance and robustness in predicting lymphedema in both internal and completely independent external validations. The multivariable model for lymphedema prediction was robust and reliable for different treatment modalities and fractionation regimens.
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Affiliation(s)
- Ye-In Park
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Heejoo Ko
- College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hee Im
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Sung Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Wonguen Jung
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University College of Medicine, Seoul, Republic of Korea.
| | - Chae-Seon Hong
- Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Long-Term Effects of Breast Cancer Therapy and Care: Calm after the Storm? J Clin Med 2022; 11:jcm11237239. [PMID: 36498813 PMCID: PMC9738151 DOI: 10.3390/jcm11237239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Breast cancer is still a lethal disease and the leading cause of death in women, undermining patients' survival and quality of life. Modern techniques of surgery and radiotherapy allow for the obtaining of good results in terms of survival, however they cause long-term side effects that persist over time, such as lymphedema and neuropathy. Similarly, the advent of new therapies such as endocrine therapy revolutionized breast cancer outcomes, but side effects are still present even in years of follow-up after cure. Besides the side effects of medical and surgical therapy, breast cancer is a real disruption in patients' lives considering quality of life-related aspects such as the distortion of body image, the psychological consequences of the diagnosis, and the impact on family dynamics. Therefore, the doctor-patient relationship is central to providing the best support both during treatment and afterwards. The aim of this review is to summarize the consequences of medical and surgical treatment on breast cancer patients and to emphasize the importance of early prevention of side effects to improve patients' quality of life.
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Stick LB, Jensen MF, Bentzen SM, Kamby C, Lundgaard AY, Maraldo MV, Offersen BV, Yu J, Vogelius IR. Radiation-Induced Toxicity Risks in Photon Versus Proton Therapy for Synchronous Bilateral Breast Cancer. Int J Part Ther 2021; 8:1-13. [PMID: 35530186 PMCID: PMC9009461 DOI: 10.14338/ijpt-21-00023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose This study compares photon and proton therapy plans for patients with synchronous bilateral early breast cancer and estimates risks of early and late radiation-induced toxicities. Materials and Methods Twenty-four patients with synchronous bilateral early breast cancer receiving adjuvant radiation therapy using photons, 3-dimensional conformal radiation therapy or volumetric modulated arc therapy, were included and competing pencil beam scanning proton therapy plans were created. Risks of dermatitis, pneumonitis, acute esophageal toxicity, lung and breast fibrosis, hypothyroidism, secondary lung and esophageal cancer and coronary artery events were estimated using published dose-response relationships and normal tissue complication probability (NTCP) models. Results The primary clinical target volume V95% and/or nodal clinical target volume V90% were less than 95% in 17 photon therapy plans and none of the proton plans. Median NTCP of radiation dermatitis ≥ grade 2 was 18.3% (range, 5.4-41.7) with photon therapy and 58.4% (range, 31.4-69.7) with proton therapy. Median excess absolute risk (EAR) of secondary lung cancer at age 80 for current and former smokers was 4.8% (range, 0.0-17.0) using photons and 2.7% (range, 0.0-13.6) using protons. Median EAR of coronary event at age 80, assuming all patients have preexisting cardiac risk factors, was 1.0% (range, 0.0-5.6) with photons and 0.2% (range, 0.0-1.3) with protons. Conclusion Proton therapy plans improved target coverage and reduced risk of coronary artery event and secondary lung cancer while increasing the risk of radiation dermatitis.
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Affiliation(s)
- Line Bjerregaard Stick
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Niels Bohr Institute, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Søren M. Bentzen
- Greenebaum Comprehensive Cancer Center and Department of Epidemiology and Public, Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Claus Kamby
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anni Young Lundgaard
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Maja Vestmø Maraldo
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Vrou Offersen
- Danish Center for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jen Yu
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ivan Richter Vogelius
- Department of Oncology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Aoishi Y, Oura S, Nishiguchi H, Hirai Y, Miyasaka M, Kawaji M, Shima A, Nishimura Y. Risk factors for breast cancer-related lymphedema: correlation with docetaxel administration. Breast Cancer 2020; 27:929-937. [PMID: 32270417 DOI: 10.1007/s12282-020-01088-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/02/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Upper-limb lymphedema is a well-known complication of breast cancer and its treatment. This retrospective cohort study aims to determine what risk factors affect breast cancer-related lymphedema in patients with breast cancer. METHODS This retrospective study comprised patients diagnosed with breast cancer and who underwent surgery at Wakayama Medical University Hospital between January 1, 2012 and December 31, 2018. Assessed factors using univariate and multivariate analyses were patient-related factors (age, gender, and BMI), breast cancer-related factors (tumor size, nodal status, histology, tumor location, and intrinsic subtype), and treatment-related factors (type of surgery, application, timing and regimen of chemotherapy, and application of radiotherapy). RESULTS This study included 1041 patients. BMI did not affect the onset of breast cancer-related lymphedema. There were only six sentinel lymph node biopsy cases in the breast cancer-related lymphedema group (6.6%). In cases of axillary lymph node dissection, adjuvant chemotherapy was marginally associated with increased risk of breast cancer-related lymphedema compared to no chemotherapy (HR 2.566; 95% CI 0.955-6.892; p = 0.0616). Among anti-cancer agents, docetaxel (HR 3.790; 95% CI 1.413-10.167; p = 0.0081) and anti-HER2 therapy (HR 2.507; 95% CI 1.083-5.803; p = 0.0318) were associated with increased risk of lymphedema according to multivariate analysis. Neo-adjuvant chemotherapy did not affect the onset of breast cancer-related lymphedema. Radiotherapy (HR 2.525; 95% CI 1.364-4.676; p = 0.0032) was an important risk factor for breast cancer-related lymphedema. CONCLUSIONS Axillary lymph node dissection, radiotherapy and adjuvant chemotherapy, especially docetaxel, were risk factors for breast cancer-related lymphedema, but BMI and neo-adjuvant chemotherapy were not.
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Affiliation(s)
- Yuka Aoishi
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Shoji Oura
- Mammary Surgery, Medical Corporation Tokushukai, Kishiwada Tokushukai Hospital, Osaka, Japan
| | | | - Yoshimitsu Hirai
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Miwako Miyasaka
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Mari Kawaji
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Aya Shima
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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Castelo M, Hu SY, Dossa F, Acuna SA, Scheer AS. Comparing Observation, Axillary Radiotherapy, and Completion Axillary Lymph Node Dissection for Management of Axilla in Breast Cancer in Patients with Positive Sentinel Nodes: A Systematic Review. Ann Surg Oncol 2020; 27:2664-2676. [PMID: 32020394 DOI: 10.1245/s10434-020-08225-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Several randomized controlled trials (RCTs) have investigated observation or axillary radiotherapy (ART) in place of completion axillary lymph node dissection (cALND) for management of positive sentinel nodes (SNs) in clinically node-negative women with breast cancer. The optimal treatment strategy for this population is not known. METHODS MEDLINE, Embase, and EBM Reviews-NHS Economic Evaluation Database were searched from inception until July 2019. A systematic review and narrative summary was performed of RCTs comparing observation or ART versus cALND in clinically node-negative female breast cancer patients with positive SNs. The Cochrane risk of bias tool for RCTs was used to assess risk of bias. Outcomes of interest included overall survival (OS), disease-free survival (DFS), axillary recurrence, and axillary surgery-related morbidity. RESULTS Three trials compared observation with cALND, and two trials compared ART with cALND. No studies blinded participants or personnel, and there was heterogeneity in inclusion criteria, study design, and follow-up. Neither observation nor ART resulted in statistically inferior 5- or 8-year OS or DFS compared with cALND. There was also no statistically significant increase in axillary recurrences associated with either approach. Four trials reported morbidity outcomes, and all showed cALND was associated with significantly more lymphedema, paresthesia, and shoulder dysfunction compared with observation or ART. CONCLUSIONS Women with clinically node-negative breast cancer and positive SNs can safely be managed without cALND.
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Affiliation(s)
- Matthew Castelo
- Division of General Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Shu Yang Hu
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fahima Dossa
- Division of General Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Sergio A Acuna
- Division of General Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adena S Scheer
- Division of General Surgery, Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada. .,Department of Surgery, St. Michael's Hospital, Toronto, ON, Canada.
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Cui S, Luo Y, Tseng HH, Ten Haken RK, El Naqa I. Combining handcrafted features with latent variables in machine learning for prediction of radiation-induced lung damage. Med Phys 2019; 46:2497-2511. [PMID: 30891794 DOI: 10.1002/mp.13497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 02/18/2019] [Accepted: 03/08/2019] [Indexed: 12/23/2022] Open
Abstract
PURPOSE There has been burgeoning interest in applying machine learning methods for predicting radiotherapy outcomes. However, the imbalanced ratio of a large number of variables to a limited sample size in radiation oncology constitutes a major challenge. Therefore, dimensionality reduction methods can be a key to success. The study investigates and contrasts the application of traditional machine learning methods and deep learning approaches for outcome modeling in radiotherapy. In particular, new joint architectures based on variational autoencoder (VAE) for dimensionality reduction are presented and their application is demonstrated for the prediction of lung radiation pneumonitis (RP) from a large-scale heterogeneous dataset. METHODS A large-scale heterogeneous dataset containing a pool of 230 variables including clinical factors (e.g., dose, KPS, stage) and biomarkers (e.g., single nucleotide polymorphisms (SNPs), cytokines, and micro-RNAs) in a population of 106 nonsmall cell lung cancer (NSCLC) patients who received radiotherapy was used for modeling RP. Twenty-two patients had grade 2 or higher RP. Four methods were investigated, including feature selection (case A) and feature extraction (case B) with traditional machine learning methods, a VAE-MLP joint architecture (case C) with deep learning and lastly, the combination of feature selection and joint architecture (case D). For feature selection, Random forest (RF), Support Vector Machine (SVM), and multilayer perceptron (MLP) were implemented to select relevant features. Specifically, each method was run for multiple times to rank features within several cross-validated (CV) resampled sets. A collection of ranking lists were then aggregated by top 5% and Kemeny graph methods to identify the final ranking for prediction. A synthetic minority oversampling technique was applied to correct for class imbalance during this process. For deep learning, a VAE-MLP joint architecture where a VAE aimed for dimensionality reduction and an MLP aimed for classification was developed. In this architecture, reconstruction loss and prediction loss were combined into a single loss function to realize simultaneous training and weights were assigned to different classes to mitigate class imbalance. To evaluate the prediction performance and conduct comparisons, the area under receiver operating characteristic curves (AUCs) were performed for nested CVs for both handcrafted feature selections and the deep learning approach. The significance of differences in AUCs was assessed using the DeLong test of U-statistics. RESULTS An MLP-based method using weight pruning (WP) feature selection yielded the best performance among the different hand-crafted feature selection methods (case A), reaching an AUC of 0.804 (95% CI: 0.761-0.823) with 29 top features. A VAE-MLP joint architecture (case C) achieved a comparable but slightly lower AUC of 0.781 (95% CI: 0.737-0.808) with the size of latent dimension being 2. The combination of handcrafted features (case A) and latent representation (case D) achieved a significant AUC improvement of 0.831 (95% CI: 0.805-0.863) with 22 features (P-value = 0.000642 compared with handcrafted features only (Case A) and P-value = 0.000453 compared to VAE alone (Case C)) with an MLP classifier. CONCLUSION The potential for combination of traditional machine learning methods and deep learning VAE techniques has been demonstrated for dealing with limited datasets in modeling radiotherapy toxicities. Specifically, latent variables from a VAE-MLP joint architecture are able to complement handcrafted features for the prediction of RP and improve prediction over either method alone.
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Affiliation(s)
- Sunan Cui
- Applied Physics Program, University of Michigan, Ann Arbor, MI, USA
| | - Yi Luo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Huan-Hsin Tseng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Randall K Ten Haken
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
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Lee H, Uhm KE, Cheong IY, Yoo JS, Chung SH, Park YH, Lee JY, Hwang JH. Patient Satisfaction with Mobile Health (mHealth) Application for Exercise Intervention in Breast Cancer Survivors. J Med Syst 2018; 42:254. [PMID: 30402781 DOI: 10.1007/s10916-018-1096-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 10/09/2018] [Indexed: 01/21/2023]
Abstract
This study aimed to assess user satisfaction with mobile health (mHealth) application in breast cancer survivors after a 12-week exercise program and provide developers with reference points for mHealth applications from the perspective of patients and physicians. This is a retrospective review of prospectively collected multicenter data of 88 breast cancer survivors who carried out a 12-week exercise program via smartphone application with pedometer. Personalized programs including aerobic and resistance exercise were prescribed by physiatrists. Also, telephone counseling was performed at the 3rd and 9th week. All patients completed the user satisfaction questionnaire at the end of the intervention. The mean achievement rates of aerobic and resistance exercise for 12 weeks were 78.8 and 71.3%, respectively. The mean score of overall satisfaction rated on the 5-point Likert scale was 4.22 ± 0.73. When the patients were grouped according to age, the overall satisfaction score increased significantly with age (P = 0.040). Also, the satisfaction scores of patients with radiotherapy were significantly higher than patients without radiotherapy (P = 0.001). In terms of system characteristics, the most satisfying was data transmission accuracy (4.32 ± 0.74). In addition, patients were very satisfied with telephone counseling (4.55 ± 0.62). The results suggest the direction of mHealth should go to meet the detailed requirements of the specific user group as a more targeted approach. In addition, if a mutual feedback platform can be implanted in mHealth applications, it will increase user loyalty and make mHealth a more available motivational technology in our lives.
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Affiliation(s)
- Hannah Lee
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Kyeong Eun Uhm
- Department of Rehabilitation Medicine, Konkuk University School of Medicine, Seoul, South Korea
| | - In Yae Cheong
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Ji Sung Yoo
- Department of Rehabilitation Medicine, National Cancer Center, Goyang-si, Gyeonggi-do, South Korea
| | - Seung Hyun Chung
- Department of Rehabilitation Medicine, National Cancer Center, Goyang-si, Gyeonggi-do, South Korea
| | - Yong Hyun Park
- Department of Urology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Ji Youl Lee
- Department of Urology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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The CivaSheet: The new frontier of intraoperative radiation therapy or a pricier alternative to LDR brachytherapy? Adv Radiat Oncol 2018; 3:87-91. [PMID: 29556586 PMCID: PMC5856973 DOI: 10.1016/j.adro.2017.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 09/23/2017] [Accepted: 10/03/2017] [Indexed: 12/25/2022] Open
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10
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Recommendations for the follow-up care of female breast cancer survivors: a guideline of the Spanish Society of Medical Oncology (SEOM), Spanish Society of General Medicine (SEMERGEN), Spanish Society for Family and Community Medicine (SEMFYC), Spanish Society for General and Family Physicians (SEMG), Spanish Society of Obstetrics and Gynecology (SEGO), Spanish Society of Radiation Oncology (SEOR), Spanish Society of Senology and Breast Pathology (SESPM), and Spanish Society of Cardiology (SEC). Clin Transl Oncol 2017; 20:687-694. [PMID: 29139040 PMCID: PMC5942338 DOI: 10.1007/s12094-017-1801-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 10/17/2017] [Indexed: 01/08/2023]
Abstract
The increased incidence
and decreased mortality of breast cancer have produced an increased number of breast cancer survivors. The type of sequelae and comorbidities that these patients present call for a collaborative follow-up by hospital-based specialized care and primary care. In this document, we present a guideline drafted and agreed among scientific societies whose members care for breast cancer survivors. The purpose of this guideline is to achieve the shared and coordinated follow-up of these patients by specialized care and primary care professionals. In it, we review the health issues derived from the treatments performed, with recommendations about the therapeutic approach to each of them, as well as a proposal for joint follow-up by primary and specialized care.
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Tseng HH, Luo Y, Cui S, Chien JT, Ten Haken RK, Naqa IE. Deep reinforcement learning for automated radiation adaptation in lung cancer. Med Phys 2017; 44:6690-6705. [PMID: 29034482 DOI: 10.1002/mp.12625] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/25/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To investigate deep reinforcement learning (DRL) based on historical treatment plans for developing automated radiation adaptation protocols for nonsmall cell lung cancer (NSCLC) patients that aim to maximize tumor local control at reduced rates of radiation pneumonitis grade 2 (RP2). METHODS In a retrospective population of 114 NSCLC patients who received radiotherapy, a three-component neural networks framework was developed for deep reinforcement learning (DRL) of dose fractionation adaptation. Large-scale patient characteristics included clinical, genetic, and imaging radiomics features in addition to tumor and lung dosimetric variables. First, a generative adversarial network (GAN) was employed to learn patient population characteristics necessary for DRL training from a relatively limited sample size. Second, a radiotherapy artificial environment (RAE) was reconstructed by a deep neural network (DNN) utilizing both original and synthetic data (by GAN) to estimate the transition probabilities for adaptation of personalized radiotherapy patients' treatment courses. Third, a deep Q-network (DQN) was applied to the RAE for choosing the optimal dose in a response-adapted treatment setting. This multicomponent reinforcement learning approach was benchmarked against real clinical decisions that were applied in an adaptive dose escalation clinical protocol. In which, 34 patients were treated based on avid PET signal in the tumor and constrained by a 17.2% normal tissue complication probability (NTCP) limit for RP2. The uncomplicated cure probability (P+) was used as a baseline reward function in the DRL. RESULTS Taking our adaptive dose escalation protocol as a blueprint for the proposed DRL (GAN + RAE + DQN) architecture, we obtained an automated dose adaptation estimate for use at ∼2/3 of the way into the radiotherapy treatment course. By letting the DQN component freely control the estimated adaptive dose per fraction (ranging from 1-5 Gy), the DRL automatically favored dose escalation/de-escalation between 1.5 and 3.8 Gy, a range similar to that used in the clinical protocol. The same DQN yielded two patterns of dose escalation for the 34 test patients, but with different reward variants. First, using the baseline P+ reward function, individual adaptive fraction doses of the DQN had similar tendencies to the clinical data with an RMSE = 0.76 Gy; but adaptations suggested by the DQN were generally lower in magnitude (less aggressive). Second, by adjusting the P+ reward function with higher emphasis on mitigating local failure, better matching of doses between the DQN and the clinical protocol was achieved with an RMSE = 0.5 Gy. Moreover, the decisions selected by the DQN seemed to have better concordance with patients eventual outcomes. In comparison, the traditional temporal difference (TD) algorithm for reinforcement learning yielded an RMSE = 3.3 Gy due to numerical instabilities and lack of sufficient learning. CONCLUSION We demonstrated that automated dose adaptation by DRL is a feasible and a promising approach for achieving similar results to those chosen by clinicians. The process may require customization of the reward function if individual cases were to be considered. However, development of this framework into a fully credible autonomous system for clinical decision support would require further validation on larger multi-institutional datasets.
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Affiliation(s)
- Huan-Hsin Tseng
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Yi Luo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Sunan Cui
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Jen-Tzung Chien
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA.,Department of Electrical and Computer Engineering, National Chiao Tung University, Hsinchu, Taiwan
| | - Randall K Ten Haken
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Issam El Naqa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
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Luo Y, El Naqa I, McShan DL, Ray D, Lohse I, Matuszak MM, Owen D, Jolly S, Lawrence TS, Kong FMS, Ten Haken RK. Unraveling biophysical interactions of radiation pneumonitis in non-small-cell lung cancer via Bayesian network analysis. Radiother Oncol 2017; 123:85-92. [PMID: 28237401 DOI: 10.1016/j.radonc.2017.02.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 01/05/2017] [Accepted: 02/05/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND In non-small-cell lung cancer radiotherapy, radiation pneumonitis≥grade 2 (RP2) depends on patients' dosimetric, clinical, biological and genomic characteristics. METHODS We developed a Bayesian network (BN) approach to explore its potential for interpreting biophysical signaling pathways influencing RP2 from a heterogeneous dataset including single nucleotide polymorphisms, micro RNAs, cytokines, clinical data, and radiation treatment plans before and during the course of radiotherapy. Model building utilized 79 patients (21 with RP2) with complete data, and model testing used 50 additional patients with incomplete data. A developed large-scale Markov blanket approach selected relevant predictors. Resampling by k-fold cross-validation determined the optimal BN structure. Area under the receiver-operating characteristics curve (AUC) measured performance. RESULTS Pre- and during-treatment BNs identified biophysical signaling pathways from the patients' relevant variables to RP2 risk. Internal cross-validation for the pre-BN yielded an AUC=0.82 which improved to 0.87 by incorporating during treatment changes. In the testing dataset, the pre- and during AUCs were 0.78 and 0.82, respectively. CONCLUSIONS Our developed BN approach successfully handled a high number of heterogeneous variables in a small dataset, demonstrating potential for unraveling relevant biophysical features that could enhance prediction of RP2, although the current observations would require further independent validation.
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Affiliation(s)
- Yi Luo
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Issam El Naqa
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Daniel L McShan
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Dipankar Ray
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Ines Lohse
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Martha M Matuszak
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Dawn Owen
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Shruti Jolly
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | - Theodore S Lawrence
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States
| | | | - Randall K Ten Haken
- Department of Radiation Oncology, The University of Michigan, Ann Arbor, United States.
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Monten C, Lievens Y, Olteanu LAM, Paelinck L, Speleers B, Deseyne P, Van Den Broecke R, De Neve W, Veldeman L. Highly Accelerated Irradiation in 5 Fractions (HAI-5): Feasibility in Elderly Women With Early or Locally Advanced Breast Cancer. Int J Radiat Oncol Biol Phys 2017; 98:922-930. [PMID: 28366576 DOI: 10.1016/j.ijrobp.2017.01.229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/09/2017] [Accepted: 01/25/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE To investigate, in a prospective phase 1 to 2 trial, the safety and feasibility of delivering external beam radiation therapy in 5 fractions to the breast or thoracic wall, including boost and/or lymph nodes if needed, to women aged ≥65 years with breast cancer. METHODS AND MATERIALS Ninety-five patients aged ≥65 years, referred for adjuvant radiation therapy, were treated in 5 fractions over 12 days with a total dose of 28.5 Gy/5.7 Gy to the breast or thoracic wall and, if indicated, 27 Gy/5.4 Gy to the lymph node regions and 32.5 Gy/6.5 Gy to 34.5 Gy/6.9 Gy to the tumor bed. The primary endpoint was clinically relevant dermatitis (grade ≥2). RESULTS Mean follow-up time was 5.6 months, and mean age was 73.6 years. Clinically relevant dermatitis was observed in 11.6% of patients and only occurred in breast irradiation with boost (17.5% grade 2-3 vs 0% in the no-boost group). Although doses were high, treatment delivery with intensity modulated radiation therapy was swift, except for complex treatments, including lymph nodes for which single-arc volumetric modulated arc therapy was needed to reduce beam-on time. CONCLUSION Accelerated radiation therapy in 5 fractions was technically feasible and resulted in low acute toxicity. Clinically relevant erythema was only observed in patients receiving a boost, but still at an acceptable rate. Although the follow-up is still short, the results on acute toxicity after accelerated radiation therapy were encouraging. A 5-fraction schedule is well tolerated in the elderly and may lower the threshold for radiation therapy in this population.
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Affiliation(s)
- Chris Monten
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium.
| | - Yolande Lievens
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Speleers
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Pieter Deseyne
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Rudy Van Den Broecke
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Liv Veldeman
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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Lee SY, Sim MK, Do J, Jeong SY, Jeon JY. Pilot study of effective methods for measuring and stretching for pectoral muscle tightness in breast cancer patients. J Phys Ther Sci 2016; 28:3030-3035. [PMID: 27942114 PMCID: PMC5140794 DOI: 10.1589/jpts.28.3030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 07/19/2016] [Indexed: 12/01/2022] Open
Abstract
[Purpose] To evaluate differences in pectoral muscle tightness according to arm abduction
angle and to determine the best arm abduction angle for stretching of pectoral muscle
tightness in breast cancer patients. [Subjects and Methods] Horizontal abduction
differences of shoulders were measured bilaterally by arm abduction to 45°, 90°, and 135°
to determine the best arm abduction angle for measuring pectoral muscle tightness.
Thirty-two patients were divided into three pectoral muscle stretching groups (A: 45°, B:
90°, and C: 135°). We measured the shoulder range of motion, scores of the Disabilities of
the Arm, Shoulder, and Hand, European Organization for Research and Treatment of Cancer
Quality of Life Questionnaire and the Breast Module, and pain levels (using a visual
analog scale) before and after therapy. [Results] The differences in degree of horizontal
abduction between shoulders were significantly larger for arm abduction to 90° and 135°
than that to 45°. Groups B and C showed greater improvements in horizontal abduction
limitations than group A. [Conclusion] Horizontal abduction differences between shoulders
are prominent when arms are abducted to 90° and 135°. The appropriate arm abduction angle
for measuring horizontal abduction and effective stretching of pectoral muscle tightness
may be >90°.
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Affiliation(s)
- So Young Lee
- Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea; Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea
| | - Mi Kyung Sim
- Ilsan Median Rehabilitation Hospital, Republic of Korea; Department of Rehabilitation Medicine, Jeju National University Hospital, Jeju National University School of Medicine, Republic of Korea
| | - Junghwa Do
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Soon Young Jeong
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
| | - Jae Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Republic of Korea
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Peppa V, Pappas EP, Karaiskos P, Major T, Polgár C, Papagiannis P. Dosimetric and radiobiological comparison of TG-43 and Monte Carlo calculations in 192Ir breast brachytherapy applications. Phys Med 2016; 32:1245-1251. [PMID: 27720277 DOI: 10.1016/j.ejmp.2016.09.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 07/28/2016] [Accepted: 09/28/2016] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To investigate the clinical significance of introducing model based dose calculation algorithms (MBDCAs) as an alternative to TG-43 in 192Ir interstitial breast brachytherapy. MATERIALS AND METHODS A 57 patient cohort was used in a retrospective comparison between TG-43 based dosimetry data exported from a treatment planning system and Monte Carlo (MC) dosimetry performed using MCNP v. 6.1 with plan and anatomy information in DICOM-RT format. Comparison was performed for the target, ipsilateral lung, heart, skin, breast and ribs, using dose distributions, dose-volume histograms (DVH) and plan quality indices clinically used for plan evaluation, as well as radiobiological parameters. RESULTS TG-43 overestimation of target DVH parameters is statistically significant but small (less than 2% for the target coverage indices and 4% for homogeneity indices, on average). Significant dose differences (>5%) were observed close to the skin and at relatively large distances from the implant leading to a TG-43 dose overestimation for the organs at risk. These differences correspond to low dose regions (<50% of the prescribed dose), being less than 2% of the prescribed dose. Detected dosimetric differences did not induce clinically significant differences in calculated tumor control probabilities (mean absolute difference <0.2%) and normal tissue complication probabilities. CONCLUSION While TG-43 shows a statistically significant overestimation of most indices used for plan evaluation, differences are small and therefore not clinically significant. Improved MBDCA dosimetry could be important for re-irradiation, technique inter-comparison and/or the assessment of secondary cancer induction risk, where accurate dosimetry in the whole patient anatomy is of the essence.
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Affiliation(s)
- V Peppa
- Medical Physics Laboratory, Medical School, National and Kapodistrian University of Athens, Greece
| | - E P Pappas
- Medical Physics Laboratory, Medical School, National and Kapodistrian University of Athens, Greece
| | - P Karaiskos
- Medical Physics Laboratory, Medical School, National and Kapodistrian University of Athens, Greece
| | - T Major
- National Institute of Oncology, Budapest, Hungary
| | - C Polgár
- National Institute of Oncology, Budapest, Hungary
| | - P Papagiannis
- Medical Physics Laboratory, Medical School, National and Kapodistrian University of Athens, Greece.
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16
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Neligan PC, Kung TA, Maki JH. MR lymphangiography in the treatment of lymphedema. J Surg Oncol 2016; 115:18-22. [DOI: 10.1002/jso.24337] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/12/2016] [Indexed: 12/21/2022]
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17
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Caban ME, Freeman JL, Zhang DD, Jansen C, Ostir G, Hatch SS, Goodwin JS. The relationship between depressive symptoms and shoulder mobility among older women: assessment at one year after breast cancer diagnosis. Clin Rehabil 2016; 20:513-22. [PMID: 16892933 DOI: 10.1191/0269215506cr966oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To examine the association between depressive symptoms and shoulder range of motion at one year after breast cancer diagnosis, controlling for patient characteristics, tumour stage and cancer therapy (surgery, axillary node dissection and radiation). Design: Prospective trial of nurse case management involving 187 older women with complete data, age 60 years and older, newly diagnosed with breast cancer, from 1 November, 1993 to 31 October, 1996 in south-eastern Texas. Depressive symptoms, sociodemographic characteristics and breast cancer treatment were measured at two months and shoulder range of motion at 12 months. The relationship among the variables was evaluated with bivariate chi-square statistics and logistic regression analysis. All logistic models also included a variable indicating whether or not the woman received nurse case management, to control for intervention status. Results: Increasing depressive symptoms at baseline were associated with lower arm mobility at 12 months following breast cancer diagnosis. Each unit increase in depressive symptoms at baseline was associated with an 8% decreased odds of having full range of motion of the shoulder (odds ratio (OR) 0.92, 95% confidence interval (CI) 0.87, 0.97), after controlling for relevant patient and treatment factors. Conclusion(s): Older women with depressive symptoms have an elevated risk of not fully recovering shoulder mobility after being treated for breast cancer. Future studies are needed to assess benefits from early intervention with psychological and or physical interventions in the presence of depressive symptoms on shoulder mobility.
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Affiliation(s)
- Mabel E Caban
- Department of Orthopedics and Rehabilitation, Route 0165, University of Texas Medical Branch, Galveston, TX 77555, USA.
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18
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van Heijst TCF, van Asselen B, Pijnappel RM, Cloos-van Balen M, Lagendijk JJW, van den Bongard D, Philippens MEP. MRI sequences for the detection of individual lymph nodes in regional breast radiotherapy planning. Br J Radiol 2016; 89:20160072. [PMID: 27164032 DOI: 10.1259/bjr.20160072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE In regional radiotherapy (RT) for patients with breast cancer, lymph node (LN) targets are delineated on CT, defined by anatomical boundaries. By identifying individual LNs, MRI-based delineations may reduce target volumes and thereby toxicity. We optimized MRI sequences for this purpose. Our aim was to evaluate the techniques for LN delineation in RT planning. METHODS Supine MRI was explored at 1.5 T in RT position (arms in abduction). 5 MRI techniques were optimized in 10 and evaluated in 12 healthy female volunteers. The scans included one T1 weighted (T1w), three T2 weighted (T2w) and a diffusion-weighted imaging (DWI) technique. Quantitative evaluation was performed by scoring LN numbers per volunteer and per scan. Qualitatively, scans were assessed on seven aspects, including LN contrast, anatomical information and insensitivity to motion during acquisition. RESULTS Two T2w fast spin-echo (FSE) methods showed the highest LN numbers (median 24 axillary), high contrast, excellent fat suppression and relative insensitivity to motion during acquisition. A third T2w sequence and DWI showed significantly fewer LNs (14 and 10) and proved unsuitable due to motion sensitivity and geometrical uncertainties. T1w MRI showed an intermediate number of LNs (17), provided valuable anatomical information, but lacked LN contrast. CONCLUSION Explicit LN imaging was achieved, in supine RT position, using MRI. Two T2w FSE techniques had the highest detection rates and were motion insensitive. T1w MRI showed anatomical information. MRI enables direct delineation of individual LNs. ADVANCES IN KNOWLEDGE Our optimized MRI scans enable accurate target definition in MRI-guided regional breast RT and development of personalized treatments.
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Affiliation(s)
| | - Bram van Asselen
- 1 Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Ruud M Pijnappel
- 2 Department of Radiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Jan J W Lagendijk
- 1 Department of Radiotherapy, University Medical Centre Utrecht, Utrecht, Netherlands
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Głowacka I, Nowikiewicz T, Siedlecki Z, Hagner W, Nowacka K, Zegarski W. The Assessment of the Magnitude of Frontal Plane Postural Changes in Breast Cancer Patients After Breast-Conserving Therapy or Mastectomy – Follow-up Results 1 Year After the Surgical Procedure. Pathol Oncol Res 2015; 22:203-8. [DOI: 10.1007/s12253-015-9995-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
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20
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de Abreu Junior GF, Pitta GBB, Araújo M, Castro ADA, de Azevedo Junior WF, Miranda Junior F. Ultrasonografic changes in the axillary vein of patients with lymphedema after mastectomy. Rev Col Bras Cir 2015; 42:81-92. [PMID: 26176673 DOI: 10.1590/0100-69912015002004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 08/15/2014] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To determine the prevalence of sonographic abnormalities (SA) in the axillary vein of patients with and without post-mastectomy lymphedema. METHODS We studied a sample of 80 women, divided into two equal groups, with and without lymphedema, with B mode ultrasound, color and pulsed Doppler. The primary variable, SA, is defined as change in the venous diameter, parietal thickening, intraluminal images, compressibility, parietal collapse at inspiration and feature of the axillary venous flow on the operated side. Secondary variables were: stage of lymphedema, surgical technique, number of radio and chemotherapy sessions, limb volume, weight and age. The differences between the proportions in the groups were determined using the Chi-square test and / or Fisher's test. For continuous variables, we used the Mann-Whitney Test. To estimate the magnitude of the associations, we used the prevalence rate of SA in both groups as a measure of frequency, and as a measure of association, the prevalence ratio (PR) obtained as a function of relative risk (RR) and estimated by the test Mantel-Haenszel homogeneity test. We adopted the statistical significance level of 5% (p < 0.05). RESULTS only the criterion "parietal thickening" was strongly associated with the lymphedema group (p = 0.001). The prevalence of SA was 55% in patients with lymphedema and 17.5% in the group without it, with difference in prevalence of 37.5%. CONCLUSION the prevalence of SA was higher in patients undergoing mastectomy with lymphedema than in those without lymphedema.
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Affiliation(s)
| | | | - Marcelo Araújo
- Department of Health Sciences, Universidade Estadual de Santa Cruz, Ilheus, BA, Brazil
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21
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The changing role of axillary treatment in breast cancer: Who will remain at risk for developing arm morbidity in the future? Breast 2015; 24:543-7. [PMID: 26051795 DOI: 10.1016/j.breast.2015.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/26/2015] [Accepted: 04/18/2015] [Indexed: 11/23/2022] Open
Abstract
Primary aim is to give an overview of changes in axillary staging and treatment of breast cancer patients. Secondly, we aim to identify patients with a high arm/shoulder morbidity risk, and describe a strategy to improve early detection and treatment. Recent and initiated studies on axillary staging and treatment were evaluated and clustered for clinically node negative and clinically node positive breast cancer patients, together with studies on pathology, detection and (surgical) prevention and treatment of lymphedema. For clinically node negative patients, the indication for axillary lymph node dissection in sentinel node positive patients is fading. On the contrary, clinically node positive patients are routinely subjected to an axillary lymph node dissection, in combination with other therapies associated with an increased lymphedema risk, such as mastectomy, adjuvant radiation- and (taxane-based) chemotherapy. Techniques for prevention, early detection and (surgical) treatment of lymphedema are being developed. Axillary staging and treatment in breast cancer patients with a clinically node negative status will become less invasive, thereby reducing the incidence of morbidity. Nevertheless, in patients with a clinically node positive status, aggressive treatment will still be required for oncologic control. For these patients, a surveillance program should be implemented in order to apply (curative) surgical treatment for lymphedema.
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22
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Cariati M, Bains SK, Grootendorst MR, Suyoi A, Peters AM, Mortimer P, Ellis P, Harries M, Van Hemelrijck M, Purushotham AD. Adjuvant taxanes and the development of breast cancer-related arm lymphoedema. Br J Surg 2015; 102:1071-8. [PMID: 26040263 DOI: 10.1002/bjs.9846] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 02/24/2015] [Accepted: 04/07/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite affecting approximately one-quarter of all patients undergoing axillary lymph node dissection, the pathophysiology of breast cancer-related lymphoedema (BCRL) remains poorly understood. More extensive locoregional treatment and higher body mass index have long been identified as major risk factors. This study aimed to identify risk factors for BCRL with a specific focus on the potential impact of chemotherapy on the risk of BCRL. METHODS This was a retrospective analysis of a cohort of consecutive patients with breast cancer treated at a major London regional teaching hospital between 1 January 2010 and 31 December 2012. All patients had node-positive disease and underwent axillary lymph node dissection. Data regarding tumour-, patient- and treatment-related characteristics were collected prospectively. The diagnosis of BCRL was based on both subjective and objective criteria. Multivariable Cox proportional hazards regression was used to assess the association between treatment and risk of BCRL. RESULTS Some 27.1 per cent of all patients (74 of 273) developed BCRL over the study period. Administration of taxanes showed a strong association with the development of BCRL, as 52 (33.5 per cent) of 155 patients who received taxanes developed BCRL. Multivariable Cox regression analysis demonstrated that patients who received taxanes were nearly three times more likely to develop BCRL than patients who had no chemotherapy (hazard ratio 2.82, 95 per cent c.i. 1.31 to 6.06). No such increase was observed when taxanes were administered in the neoadjuvant setting. CONCLUSION The present findings suggest that adjuvant taxanes play a key role in the development of BCRL after surgery. This may support the use of taxanes in a neoadjuvant rather than adjuvant setting.
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Affiliation(s)
- M Cariati
- Section of Research Oncology, King's College London, London, UK.,Directorate of Haematology and Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S K Bains
- Section of Research Oncology, King's College London, London, UK
| | | | - A Suyoi
- Directorate of Haematology and Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A M Peters
- Department of Nuclear Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - P Mortimer
- Department of Clinical Sciences, St George's, University of London, London, UK
| | - P Ellis
- Section of Research Oncology, King's College London, London, UK.,Directorate of Haematology and Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M Harries
- Section of Research Oncology, King's College London, London, UK.,Directorate of Haematology and Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - M Van Hemelrijck
- School of Medicine, Cancer Epidemiology Group, Division of Cancer Studies, King's College London, London, UK
| | - A D Purushotham
- Section of Research Oncology, King's College London, London, UK.,Directorate of Haematology and Oncology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Yang X, Yoshida E, Cassidy RJ, Beitler JJ, Yu DS, Curran WJ, Liu T. Quantitative Ultrasonic Nakagami Imaging of Neck Fibrosis After Head and Neck Radiation Therapy. Int J Radiat Oncol Biol Phys 2015; 92:407-14. [PMID: 25817529 PMCID: PMC4431929 DOI: 10.1016/j.ijrobp.2015.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/08/2014] [Accepted: 01/07/2015] [Indexed: 01/14/2023]
Abstract
PURPOSE To investigate the feasibility of ultrasound Nakagami imaging to quantitatively assess radiation-induced neck fibrosis, a common sequela of radiation therapy (RT) to the head and neck. METHODS AND MATERIALS In a pilot study, 40 study participants were enrolled and classified into 3 subgroups: (1) a control group of 12 healthy volunteers; (2) an asymptomatic group of 11 patients who had received intensity modulated RT for head and neck cancer and had experienced no neck fibrosis; and (3) a symptomatic group of 17 post-RT patients with neck fibrosis. Each study participant underwent 1 ultrasound study in which scans were performed in the longitudinal orientation of the bilateral neck. Three Nakagami parameters were calculated to quantify radiation-induced tissue injury: Nakagami probability distribution function, shape, and scaling parameters. Physician-based assessments of the neck fibrosis were performed according to the Radiation Therapy Oncology Group late morbidity scoring scheme, and patient-based fibrosis assessments were rated based on symptoms such as pain and stiffness. RESULTS Major discrepancies existed between physician-based and patient-based assessments of radiation-induced fibrosis. Significant differences in all Nakagami parameters were observed between the control group and 2 post-RT groups. Moreover, significant differences in Nakagami shape and scaling parameters were observed among asymptomatic and symptomatic groups. Compared with the control group, the average Nakagami shape parameter value increased by 32.1% (P<.001), and the average Nakagami scaling parameter increased by 55.7% (P<.001) for the asymptomatic group, whereas the Nakagami shape parameter increased by 74.1% (P<.001) and the Nakagami scaling parameter increased by 83.5% (P<.001) for the symptomatic group. CONCLUSIONS Ultrasonic Nakagami imaging is a potential quantitative tool to characterize radiation-induced asymptomatic and symptomatic neck fibrosis.
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Affiliation(s)
- Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Emi Yoshida
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Richard J Cassidy
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jonathan J Beitler
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David S Yu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia.
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van Roozendaal LM, Schipper RJ, Smit LHM, Brans BT, Beets-Tan RGH, Lobbes MBI, Boersma LJ, Smidt ML. Three-Dimensional Breast Radiotherapy and the Elective Radiation Dose at the Sentinel Lymph Node Site in Breast Cancer. Ann Surg Oncol 2015; 22:3824-30. [PMID: 25707492 PMCID: PMC4595528 DOI: 10.1245/s10434-015-4413-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Indexed: 11/19/2022]
Abstract
Background Several trials are presently randomizing clinically node-negative breast cancer patients treated with breast-conserving therapy (BCT) to sentinel lymph node biopsy (SLNB) or watchful waiting. We aimed to investigate the elective radiation dose at the sentinel lymph node (SLN) site while evaluating two techniques for SLN localization, in breast cancer patients treated with lumpectomy and three-dimensional (3D) whole-breast radiotherapy. Methods The SLN site of consecutive Tis-2N0 breast cancer patients undergoing lumpectomy and forward intensity-modulated whole-breast radiotherapy was determined by the location of the hotspot on preoperative single-photon emission computed tomography (SPECT)/computed tomography (CT) and by a surgical clip placed at the removed SLN(s) during SLNB. The radiation dose at the SLN site was subsequently determined on the postoperative radiotherapy planning CT. An elective radiation dose to the SLN site was defined as at least 95 % of the breast dose. Results Of the 42 included patients, the mean percentage of the breast dose on the SLN site was 90 % (standard deviation 26, range 7–132, median 99), with a non-significant difference between the two techniques (surgical clip or SPECT/CT) (p = 0.608). In 32/42 patients (76 %) the SLN site received an elective radiation dose. Conclusions A surgical clip placed at the removed SLN(s) during SLNB proved to be an adequate method of determining the radiation dose at the SLN site when compared with using SPECT/CT. With the use of 3D radiotherapy, the site of the SLN is treated with an elective radiation dose in the majority of patients who are treated with BCT.
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Affiliation(s)
- Lori M van Roozendaal
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands. .,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands. .,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Robert-Jan Schipper
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Leonie H M Smit
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Boudewijn T Brans
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Regina G H Beets-Tan
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Liesbeth J Boersma
- Department of Radiation Oncology, Maastricht University Medical Center (MAASTRO Clinic), Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marjolein L Smidt
- Department of Surgical Oncology, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Montero A, Sanz X, Hernanz R, Cabrera D, Arenas M, Bayo E, Moreno F, Algara M. Accelerated hypofractionated breast radiotherapy: FAQs (Frequently Asked Questions) and facts. Breast 2014; 23:299-309. [DOI: 10.1016/j.breast.2014.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 01/14/2014] [Accepted: 01/19/2014] [Indexed: 10/25/2022] Open
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Nguyen NTA, Roberge D, Freeman CR, Wong C, Hines J, Turcotte RE. Skin elasticity as a measure of radiation fibrosis: is it reproducible and does it correlate with patient and physician-reported measures? Technol Cancer Res Treat 2013; 13:469-76. [PMID: 24000984 PMCID: PMC4527462 DOI: 10.7785/tcrtexpress.2013.600257] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Current means of measuring RT-induced fibrosis are subjective. We evaluated the DermaLab suction cup system to measure objectively skin deflection as a surrogate for fibrosis. Sixty-nine patients with E-STS were treated with limb-sparing surgery and 50-66 Grays (Gy) of RT. Using a “scleroderma” DermaLab Suction Cup, the skin stiffness was measured by two clinicians. The National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE) scale, the Musculoskeletal Tumor Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) questionnaires were completed for each patient. Levels of agreement between measurers were estimated using the Kappa (κ) coefficient and the concordance correlation coefficient (CCC). All sixty-nine patients were included. The level of agreement between measurers for NCI-CTCAE grading was moderate (range κ = 0.41-0.59). The CCC for the elasticity measurements were higher, with CCC = 0.82 for fibrotic skin and CCC = 0.84 for normal skin. The elasticity measurements were significantly higher when MSTS scores were <30 and or TESS scores were <90. Suction Cup measurement of skin elasticity is more reproducible than CTCAE grading and shows promise in generating reproducible measurements for radiation-induced skin fibrosis. Furthermore, it correlates well with the MSTS and TESS.
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Affiliation(s)
- Nhu-Tram A Nguyen
- Division of Radiation Oncology, McMaster University, Juravinski Regional Cancer Centre, 699 Concession Street, Hamilton, ON, L8V 5C2, Canada.
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Pichon B, Thureau S, Delpon G, Barillot I, Mahé MA. [Obesity and radiation: technical difficulties, toxicity and efficacy]. Cancer Radiother 2013; 17:543-8. [PMID: 23969243 DOI: 10.1016/j.canrad.2013.06.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 06/18/2013] [Indexed: 01/10/2023]
Abstract
The number of obese patients has increased in France over the last two decades, which has had an impact on the incidence of numerous types of cancer. The treatment of cancer by radiotherapy is impacted by obesity as a result of the physical, technical and dosimetric constraints, the acute and late toxicity, local control and the survival of patients.
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Affiliation(s)
- B Pichon
- Service de radiothérapie, institut de cancérologie de l'Ouest René-Gauducheau, boulevard Jacques-Monod, 44805 Saint-Herblain, France.
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Cheville AL, Brinkmann DH, Ward SB, Durski J, Laack NN, Yan E, Schomberg PJ, Garces YI, Suman VJ, Petersen IA. The addition of SPECT/CT lymphoscintigraphy to breast cancer radiation planning spares lymph nodes critical for arm drainage. Int J Radiat Oncol Biol Phys 2013; 85:971-7. [PMID: 23452455 DOI: 10.1016/j.ijrobp.2012.08.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND This prospective cohort study was designed to determine whether the amount of radiation delivered to the nonpathological lymph nodes (LNs) that drain the arm can be significantly reduced by integrating single-photon emission computed tomography (SPECT)/computed tomography (CT) scans into radiation treatment planning. METHODS SPECT-CT scans were acquired for the 28 patients with stage I or II breast cancer and fused with the routinely obtained radiation oncology planning CT scans. Arm-draining LNs were contoured with 0.5-cm margins automatically using a threshold of 50% maximum intensity. Two treatment plans were generated: 1 per routine clinical practice (standard; STD) and the second (modified; MOD) with treatment fields modified to minimize dose to the arm-draining LNs visible on SPECT/CT images without interfering with the dosage delivered to target tissues. Participants were treated per the MOD plans. Arm volumes were measured prior to radiation and thereafter at least three subsequent 6-month intervals. RESULTS Sixty-eight level I-III arm-draining LNs were identified, 57% of which were inside the STD plan fields but could be blocked in the MOD plan fields. Sixty-five percent of arm-draining LNs in the STD versus 16% in the MOD plans received a mean of ≥10 Gy, and 26% in the STD versus 4% in the MOD plans received a mean of ≥40 Gy. Mean LN radiation exposure was 23.6 Gy (standard deviation 18.2) with the STD and 7.7 Gy (standard deviation 11.3) with the MOD plans (P<.001). No participant developed lymphedema. CONCLUSIONS The integration of SPECT/CT scans into breast cancer radiation treatment planning reduces unnecessary arm-draining LN radiation exposure and may lessen the risk of lymphedema.
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Affiliation(s)
- Andrea L Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA.
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Oncology Section Task Force on Breast Cancer Outcomes: An Introduction to the EDGE Task Force and Clinical Measures of Upper Extremity Function. REHABILITATION ONCOLOGY 2013. [DOI: 10.1097/01893697-201331010-00003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adriaenssens N, Vinh-Hung V, Miedema G, Versmessen H, Lamote J, Vanhoeij M, Lievens P, van Parijs H, Storme G, Voordeckers M, De Ridder M. Early contralateral shoulder-arm morbidity in breast cancer patients enrolled in a randomized trial of post-surgery radiation therapy. BREAST CANCER-BASIC AND CLINICAL RESEARCH 2012; 6:79-93. [PMID: 22904635 PMCID: PMC3418149 DOI: 10.4137/bcbcr.s9362] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Shoulder/arm morbidity is a common complication of breast cancer surgery and radiotherapy (RT), but little is known about acute contralateral morbidity. METHODS Patients were 118 women enrolled in a RT trial. Arm volume and shoulder mobility were assessed before and 1-3 months after RT. Correlations and linear regression were used to analyze changes affecting ipsilateral and contralateral arms, and changes affecting relative interlimb differences (RID). RESULTS Changes affecting one limb correlated with changes affecting the other limb. Arm volume between the two limbs correlated (R = 0.57). Risk factors were weight increase and axillary dissection. Contralateral and ipsilateral loss of abduction strongly correlated (R = 0.78). Changes of combined RID exceeding 10% affected the ipsilateral limb in 25% of patients, and the contralateral limb in 18%. Aromatase inhibitor therapy was significantly associated with contralateral loss of abduction. CONCLUSIONS High incidence of early contralateral arm morbidity warrants further investigations.
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Affiliation(s)
- Nele Adriaenssens
- Breast Clinic, Oncological Surgery, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
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McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW. A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues. Cancer 2012; 118:2226-36. [PMID: 22488697 DOI: 10.1002/cncr.27468] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Appropriate and timely rehabilitation is vital in the recovery from breast cancer surgeries, including breast conserving surgery, mastectomy, axillary lymph node dissection (ALND), and breast reconstruction. This article describes the incidence, prevalence, risk factors and time course for early postoperative effects and the role of prospective surveillance as a rehabilitation strategy to prevent and mitigate them. The most common early postoperative effects include wound issues such as cellulitis, flap necrosis, abscess, dehiscence, hematoma, and seroma. Appropriate treatment is necessary to avoid delay in wound healing that may increase the risk of long-term morbidity, unduly postpone systemic and radiation therapy, and delay rehabilitation. The presence of upper quarter dysfunction (UQD), defined as restricted upper quarter mobility, pain, lymphedema, and impaired sensation and strength, has been reported in over half of survivors after treatment for breast cancer. Moreover, evidence suggests that survivors who undergo breast reconstruction may be at higher risk of UQD. Ensuring the survivor's optimum functioning in the early postoperative time period is critical in the overall recovery from breast cancer. The formal collection of objective measures along with patient-reported outcome measures is recommended for the early detection of postoperative morbidity. Prospective surveillance, including preoperative assessment and structured surveillance, allows for early identification and timely rehabilitation. Early evidence supports a prospective approach to address and minimize postoperative effects.
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Affiliation(s)
- Margaret L McNeely
- Department of Physical Therapy and Oncology, University of Alberta and Cross Cancer Institute, Edmonton, Alberta, Canada.
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Binkley JM, Harris SR, Levangie PK, Pearl M, Guglielmino J, Kraus V, Rowden D. Patient perspectives on breast cancer treatment side effects and the prospective surveillance model for physical rehabilitation for women with breast cancer. Cancer 2012; 118:2207-16. [PMID: 22488695 DOI: 10.1002/cncr.27469] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Women's experience of breast cancer is complex, affecting all aspects of life during and after treatment. Patients' perspectives about common impairments and functional limitations secondary to breast cancer treatment, including upper extremity motion restriction, lymphedema, fatigue, weight gain, pain, and chemotherapy-induced peripheral neuropathy, are addressed. Women often report being uninformed regarding these side effects and surprised that they do not always disappear after treatment, but remain part of their lives. Breast cancer patients express strong, unmet needs for education, information, and intervention for these side effects. Evidence suggests that rehabilitation and exercise are effective in preventing and managing many physical side effects of breast cancer treatment. Nevertheless, few women are referred to rehabilitation during or after treatment, and fewer receive baseline assessments of impairment and function to facilitate early detection of impairment and functional limitations. The prospective surveillance model of rehabilitation will serve the needs of women with breast cancer by providing education and information about treatment side effects, reducing the incidence and burden of side effects through early identification and treatment, and enhancing access to timely rehabilitation. Integration of exercise as a component of the model benefits patients at every phase of survivorship, by addressing individual concerns about exercise during and after treatment and highlighting the important contribution of exercise to overall health and survival. The prospective surveillance model of rehabilitation can meet the evident and often expressed needs of survivors for information, guidance, and intervention--thus addressing, and potentially improving, overall quality of life for individuals diagnosed with and treated for breast cancer.
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Affiliation(s)
- Jill M Binkley
- TurningPoint Women's Healthcare, Alpharetta, Georgia 30022, USA.
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Radiothérapie des aires ganglionnaires sus- et sous-claviculaire dans les cancers du sein : état des lieux. Cancer Radiother 2012; 16:237-42; quiz 243. [DOI: 10.1016/j.canrad.2012.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 02/06/2012] [Accepted: 02/17/2012] [Indexed: 11/23/2022]
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Three-dimensional scapula kinematics and shoulder function examined before and after surgical treatment for breast cancer. Hum Mov Sci 2012; 31:408-18. [DOI: 10.1016/j.humov.2011.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 03/22/2011] [Accepted: 04/11/2011] [Indexed: 11/20/2022]
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Ben Salah H, Bahri M, Jbali B, Guermazi M, Frikha M, Daoud J. Lymphœdème du membre supérieur après traitement du cancer du sein. Cancer Radiother 2012; 16:123-7. [DOI: 10.1016/j.canrad.2011.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 09/08/2011] [Accepted: 10/12/2011] [Indexed: 11/16/2022]
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Das IJ, Cheville AL, Scheuermann J, Srinivas SM, Alavi A, Solin LJ. Use of lymphoscintigraphy in radiation treatment of primary breast cancer in the context of lymphedema risk reduction. Radiother Oncol 2011; 100:293-8. [DOI: 10.1016/j.radonc.2010.09.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 09/07/2010] [Accepted: 09/20/2010] [Indexed: 11/28/2022]
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Kim YM, Kim DY, Chun MH, Jeon JY, Yun GJ, Lee MS. Cancer rehabilitation: experience, symptoms, and needs. J Korean Med Sci 2011; 26:619-24. [PMID: 21532851 PMCID: PMC3082112 DOI: 10.3346/jkms.2011.26.5.619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 03/07/2011] [Indexed: 11/20/2022] Open
Abstract
The aim of this study was to examine the experience of cancer patients undergoing rehabilitation, to identify symptoms associated with rehabilitation from cancer, and to assess the need for rehabilitation services for cancer patients. Cancer patients (n = 402) at the Asan Medical Center (Seoul, Korea) were enrolled from June to September 2008. A chart review was used to collect demographic and clinical data, including type of cancer, current treatment, time from initial diagnosis to screening, and cancer stage. Each participant provided informed consent and was then given a questionnaire that asked about experience with rehabilitation, symptoms associated with rehabilitation, and the need for different types of rehabilitation services. Clinicians recommended rehabilitation for 8.5% of patients, and 6.7% underwent rehabilitation. Among study patients, 83.8% had one or more symptoms associated with rehabilitation, and 71.6% of patients with symptoms wanted rehabilitation management. The need for rehabilitation was associated with the presence of metastasis, advanced cancer stage, time to diagnosis, and type of current treatment. Our results provide specific information about particular functional symptoms and the rehabilitative needs of subgroups of cancer patients. It is suggested to develop and implement rehabilitation programs for cancer patients.
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Affiliation(s)
- Yong Mi Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Yul Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Ho Chun
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Yong Jeon
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi Jeong Yun
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Moo Song Lee
- Department of Preventive Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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A qualitative assessment of upper quarter dysfunction reported by physical therapists treated for breast cancer or treating breast cancer sequelae. Support Care Cancer 2010; 19:1367-78. [DOI: 10.1007/s00520-010-0959-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 07/12/2010] [Indexed: 12/24/2022]
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Abstract
BACKGROUND Pain after breast cancer therapy is a recognized complication found to have an adverse impact on patient's quality of life, increasing psychosocial distress. In recent years, case reports about myofascial pain syndrome are emerging in thoracic surgery as a cause of postsurgery pain. Myofascial pain syndrome is a regional pain syndrome characterized by myofascial trigger points in palpable taut bands of skeletal muscle that refers pain a distance, and that can cause distant motor and autonomic effects. OBJECTIVE The objective of this study was to assess the incidence of myofascial pain syndrome prospectively 12 months after breast cancer surgery. METHODS Each participant was assessed preoperatively, postoperatively between day 3 and day 5, and at 1, 3, 6, and 12 months after surgery. A physical therapist, expert in the diagnosis of myofascial pain syndrome, performed follow-up assessments. Pain descriptions by the patients and pain pattern drawings in body forms guided the physical examination. The patients were not given any information concerning myofascial pain or other muscle pain syndromes. RESULTS One year follow-up was completed by 116 women. Of these, 52 women developed myofascial pain syndrome (44.8%, 95% confidence interval: 35.6, 54.3). CONCLUSION Myofascial pain syndrome is a common source of pain in women undergoing breast cancer surgery that includes axillary lymph node dissection at least during the first year after surgery. Myofascial pain syndrome is one potential cause of chronic pain in breast cancer survivors who have undergone this kind of surgery.
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Springer BA, Levy E, McGarvey C, Pfalzer LA, Stout NL, Gerber LH, Soballe PW, Danoff J. Pre-operative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Res Treat 2010; 120:135-47. [PMID: 20054643 DOI: 10.1007/s10549-009-0710-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2009] [Accepted: 12/22/2009] [Indexed: 10/20/2022]
Abstract
In order to determine the extent and time course of upper limb impairment and dysfunction in women being treated for breast cancer (BC), and followed prospectively, a novel physical therapy surveillance model post-treatment was used. Subjects included adult women with newly diagnosed, untreated, unilateral, Stage I to III BC, and normal physiological and biomechanical shoulder function. Subjects were excluded if they had a previous history of BC, or prior injury or surgery of the affected upper limb. Measurements included body weight, shoulder ranges of motion (ROM), manual muscle tests, pain levels, upper limb volume, and an upper limb disability questionnaire (ULDQ). Measurements were taken at baseline (pre-surgery), and 1, 3-6, and 12 months post-surgery. All subjects received pre-operative education and exercise instruction and specific physical therapy (PT) protocol after surgery including ROM and strengthening exercises. All measures of function were significantly reduced 1 month post-surgery, but most recovered to baseline levels by 1-year post-surgery. Some subjects developed signs of lymphedema 3-12 months post-surgery, but this did not compromise function. Shoulder abduction, flexion, and external rotation, but not internal rotation ROM, were associated with the ULDQ. Most women in this cohort undergoing surgery for BC who receive PT intervention may expect a return to baseline ROM and strength by 3 months. Those who do not reach baseline, often continue to improve and reach their pre-operative levels by 1-year post-surgery. Lymphedema develops independently of shoulder function 3-12 months post-surgery, necessitating continued monitoring. A prospective physical therapy model of surveillance allows for detection of early and later onset of impairment following surgery for BC in this specific cohort of patients.
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Affiliation(s)
- Barbara A Springer
- Proponency Office for Rehabilitation and Reintegration, Office of the Surgeon General, 5109 Leesburg Pike, Suite 684, Falls Church, VA 22041-3258, USA.
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Yang EJ, Park WB, Seo KS, Kim SW, Heo CY, Lim JY. Longitudinal change of treatment-related upper limb dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study. J Surg Oncol 2010; 101:84-91. [PMID: 19924721 DOI: 10.1002/jso.21435] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES To investigate the prevalence of upper limb dysfunction (ULD) and subtypes after breast cancer surgery and to identify factors associated with late ULD. METHODS Among 191 enrolled patients, 191 were evaluated at 3 months, 187 at 6 months, and 183 at 12 months after surgery. Pain, shoulder range of motion, muscle strength, and arm circumference were assessed. Based on symptoms and physical examinations, the types of ULD common after breast cancer treatment were diagnosed and categorized. RESULTS The prevalence of ULD after surgery were 24.6%, 20.9%, and 26.8% at 3, 6, and 12 months, respectively. The most common types of ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Patients with pectoralis tightness or lymphedema at 3 or 6 months showed a higher prevalence of rotator cuff disease at 12 months compared with those without early pectoralis tightness or lymphedema. CONCLUSIONS The major post-operative ULD were pectoralis tightness at 3 and 6 months and lymphedema at 12 months. Late ULD such as rotator cuff disease were associated with pectoral tightness or lymphedema at earlier stages. Diagnosis and treatment of ULD should take place as soon as possible after surgery.
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Affiliation(s)
- Eun Joo Yang
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do 463-707, Republic of Korea
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The lateral decubitus breast boost: description, rationale, and efficacy. Int J Radiat Oncol Biol Phys 2010; 76:100-3. [PMID: 19394161 DOI: 10.1016/j.ijrobp.2009.01.053] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 01/14/2009] [Accepted: 01/20/2009] [Indexed: 11/22/2022]
Abstract
PURPOSE To describe and evaluate the modified lateral decubitus boost, a breast irradiation technique. Patients are repositioned and resimulated for electron boost to minimize the necessary depth for the electron beam and optimize target volume coverage. METHODS AND MATERIALS A total of 2,606 patients were treated with post-lumpectomy radiation at our institution between January 1, 2000, and February 1, 2008. Of these, 231 patients underwent resimulation in the lateral decubitus position with electron boost. Distance from skin to the maximal depth of target volume was measured in both the original and boost plans. Age, body mass index (BMI), boost electron energy, and skin reaction were evaluated. RESULTS Resimulation in the lateral decubitus position reduced the distance from skin to maximal target volume depth in all patients. Average depth reduction by repositioning was 2.12 cm, allowing for an average electron energy reduction of approximately 7 MeV. Mean skin entrance dose was reduced from about 90% to about 85% (p < 0.001). Only 14 patients (6%) experienced moist desquamation in the boost field at the end of treatment. Average BMI of these patients was 30.4 (range, 17.8-50.7). BMI greater than 30 was associated with more depth reduction by repositioning and increased risk of moist desquamation. CONCLUSIONS The lateral decubitus position allows for a decrease in the distance from the skin to the target volume depth, improving electron coverage of the tumor bed while reducing skin entrance dose. This is a well-tolerated regimen for a patient population with a high BMI or deep tumor location.
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Moran MS, Haffty BG. Radiation techniques and toxicities for locally advanced breast cancer. Semin Radiat Oncol 2009; 19:244-55. [PMID: 19732689 DOI: 10.1016/j.semradonc.2009.05.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Radiation therapy is used in the management of locally advanced breast cancer in the postmastectomy or neoadjuvant chemotherapy and breast-conservation setting to improve local-regional control and survival. Using modern-day technology, the therapeutic ratio has increased and the potential morbidity has decreased. This article reviews the technical aspects of radiation therapy for locally advanced breast cancer with emphasis on 3-dimensional radiotherapy techniques and discusses potential toxicities and how to reduce them.
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Affiliation(s)
- Meena S Moran
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT 06520-8040, USA.
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A multicentre cross-sectional study of arm lymphedema four or more years after breast cancer treatment in Iranian patients. Breast Cancer 2009; 17:281-5. [DOI: 10.1007/s12282-009-0165-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2009] [Accepted: 07/20/2009] [Indexed: 10/20/2022]
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Blomqvist L, Stark B, Engler N, Malm M. Evaluation of arm and shoulder mobility and strength after modified radical mastectomy and radiotherapy. Acta Oncol 2009; 43:280-3. [PMID: 15244252 DOI: 10.1080/02841860410026170] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Seventy-five women, of whom 30 had received postoperative radiotherapy, were tested for range of motion (ROM) and shoulder strength with a goniometer and an isokinetic device (Orthotron II), respectively. On the individual level, irradiated patients exhibited significantly reduced range of motion (varying from p < 0.05 to p < 0.001) for all movements compared with the non-operated side. In contrast, in the non-irradiated patients only flexion was significantly reduced (p < 0.05). The same individual pattern was evident for shoulder strength where all movements except external rotation were significantly reduced in irradiated patients (varying from p < 0.05 to p < 0.001). Non-irradiated patients exhibited a significant reduction in shoulder strength for flexion and abduction (p < 0.05), whereas other movements were less affected. The observed differences in ROM and strength were less pronounced when analyzed on a group level, but were still significant for ROM (p < 0.001) for flexion and abduction. Group level analysis also showed reduced shoulder strength for all movements but only rotation was significantly (p < 0.01) impaired.
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Affiliation(s)
- Lennart Blomqvist
- Plastic Surgery Unit, Center for Surgical Sciences, Karolinska Institutet and Huddinge University Hospital, Stockholm, Sweden.
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Magnitude of late effects of breast cancer treatments on shoulder function: a systematic review. Breast Cancer Res Treat 2008; 116:1-15. [DOI: 10.1007/s10549-008-0246-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 10/31/2008] [Indexed: 10/21/2022]
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Hwang JH, Chang HJ, Shim YH, Park WH, Park W, Huh SJ, Yang JH. Effects of supervised exercise therapy in patients receiving radiotherapy for breast cancer. Yonsei Med J 2008; 49:443-50. [PMID: 18581595 PMCID: PMC2615347 DOI: 10.3349/ymj.2008.49.3.443] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Postoperative radiotherapy for breast cancer has a number of associated complications. This study examined whether supervised moderate-intensity exercise could mitigate the complications that occur during radiotherapy. PATIENTS AND METHODS Forty women were randomized before radiotherapy after various operations for breast cancer. Seventeen patients who were assigned to the exercise group performed supervised moderate-intensity exercise therapy for 50 min 3 times per week for 5 weeks. Twenty-three patients in the control group were asked to perform self-shoulder stretching exercise. The World Health Organization Quality of Life-BREF (WHOQOL-BREF), brief fatigue inventory (BFI), range of motion (ROM) of the shoulder, and pain score were assessed before and after radiotherapy. RESULTS There were no significant differences noted at baseline between groups. In the exercise group, there was an increase in the WHOQOL-BREF and shoulder ROM and decrease in BFI and pain score after radiotherapy. On the other hand, patients in the control group showed decrease in the WHOQOL-BREF and shoulder ROM and increase in BFI and pain score after radiotherapy. There were statistically significant differences in the changes in the WHOQOL, BFI, shoulder ROM, and pain score between the groups. CONCLUSION Patients receiving radiotherapy for breast cancer may benefit in physical and psychological aspects from supervised moderate-intensity exercise therapy.
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Affiliation(s)
- Ji Hye Hwang
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Jung Chang
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Hun Shim
- Division of Sports Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Hah Park
- Division of Sports Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Hyun Yang
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Bergmann A, Mattos IE, Koifman RJ. Fatores de risco para linfedema após câncer de mama: uma revisão da literatura. FISIOTERAPIA E PESQUISA 2008. [DOI: 10.1590/s1809-29502008000200016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O linfedema representa uma das principais seqüelas do câncer de mama. Esta revisão da literatura visou discutir os principais fatores associados ao linfedema após o tratamento do câncer de mama. Foram selecionados 26 artigos publicados entre janeiro de 2000 e março de 2008 nas bases Medline e Lilacs, utilizando os descritores breast neoplasms, lymphedema, upper extremity, arm e risk factors. Sua revisão permitiu discutir os fatores relacionados ao linfedema, quanto a: clínica e paciente (tabagismo, escolaridade, etnia, comorbidades, hipertensão arterial, diabetes melito, menopausa, idade, peso corporal, índice de massa corporal, atividade física, membro dominante, restrição articular, infecção, seroma e trauma no membro superior); tratamento do câncer de mama (cirurgia, reconstrução mamária, número de linfonodos retirados, nível da linfadenectomia axilar, radioterapia, quimioterapia, hormonioterapia e tempo transcorrido após o tratamento); tumor (tamanho, grau, localização, comprometimento dos linfonodos axilares e estadiamento). A revisão feita indica que a linfadenectomia axilar, a radioterapia em cadeias de drenagem e a obesidade são fatores preponderantes do risco para desenvolvimento do linfedema.
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Purushotham AD, Bennett Britton TM, Klevesath MB, Chou P, Agbaje OF, Duffy SW. Lymph node status and breast cancer-related lymphedema. Ann Surg 2007; 246:42-5. [PMID: 17592289 PMCID: PMC1899199 DOI: 10.1097/01.sla.0000259390.51203.7b] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study examines the association between nodal positivity and risk of developing breast cancer-related lymphedema (BCRL) in patients who underwent axillary lymph node dissection (ALND). SUMMARY BACKGROUND DATA The pathophysiology of BCRL is poorly understood. It has been assumed that one of the factors predisposing to the development of BCRL is nodal positivity, although retrospective series have produced contradictory findings. As these studies have included treatment regimens known to cause BCRL, such as axillary radiotherapy, any relationship between nodal positivity and the development of BCRL remains speculative. METHODS A total of 212 patients who had undergone ALND for invasive breast cancer had arm volume measurements preoperatively, and at intervals postoperatively. No patient received axillary radiotherapy. Arm volumes were obtained by measuring serial arm circumferences every 4 cm up the arm and then calculated by using the formula for the volume of a truncated cone. Robust regression techniques were used to analyze the effects of node positivity, age, preoperative body mass index, and wound infection on arm volume excess. RESULTS In all, 64 of 212 (30%) patients were node positive. Contrary to previous assumptions, positive node status was significantly inversely associated with arm volume after adjusting for tumor size, time since operation, and allowing for correlated observations within subjects. Furthermore, the number of positive nodes also correlated inversely with arm volume. CONCLUSION These results are counterintuitive to the conventional understanding of the pathophysiology of BCRL. A possible explanation is that patients who develop disease in axillary lymph nodes and subsequently undergo ALND have more time and ability to develop lymphatic collaterals, which may provide adequate lymphatic drainage following surgery, thereby reducing the risk of developing BCRL.
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Fogarty GB, Cassumbhoy R, Martin JM, Fay M, Ainslie J. Technique for axillary radiotherapy using computer-assisted planning for high-risk skin cancer. ACTA ACUST UNITED AC 2007; 51:267-75. [PMID: 17504320 DOI: 10.1111/j.1440-1673.2007.01729.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High-risk skin cancer arising on the upper limb or trunk can cause axillary nodal metastases. Previous studies have shown that axillary radiotherapy improves regional control. There is little published work on technique. Technique standardization is important in quality assurance and comparison of results especially for trials. Our technique, planned with CT assistance, is presented. To assess efficacy, an audit of patients treated in our institution over a 15-month period was conducted. Of 24 patients treated, 13 were treated with radical intent, 11 with this technique. With a follow up of over 2 years, the technique had more than a 90% (10/11) regional control in this radical group. Both of the radical patients who were not treated according to the technique had regional failure. One case of late toxicity was found, of asymptomatic lymphoedema in a radically treated patient. This technique for axillary radiotherapy for regional control of skin cancer is acceptable in terms of disease control and toxicity as validated by audit at 2 years.
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Affiliation(s)
- G B Fogarty
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
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