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Hsieh MT, Aherne NJ, Ross W, Salindera S, Westhuyzen J, Winkley L, Shakespeare TP. Evaluation of apical clips placed during axillary dissection demonstrates potential under-coverage of axillary radiation therapy target volumes during breast cancer regional nodal irradiation. J Med Imaging Radiat Oncol 2021; 66:158-164. [PMID: 34821471 DOI: 10.1111/1754-9485.13349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Evidence-based Australian guidelines (eviQ) recommend adjuvant supraclavicular fossa irradiation after axillary lymph node dissection (ALND) in node-positive breast cancer patients. Disparity between surgically determined versus computed tomography (CT) determined nodal volumes may result in discontiguous nodal volumes and untreated nodal tissue. We examine the extent of untreated nodal tissue in women with breast cancer post-level II or III ALND and adjuvant radiation therapy (RT) using ESTRO contouring guidelines. METHODS Female breast cancer patients who underwent level II and III ALND with apical clip placement from 2016 to 2020 and CT simulated in supine position were included. CT-defined axillary level II-IV volumes were contoured using ESTRO guidelines. The distance between the apical clip and RT nodal volumes was measured to indicate extent of untreated tissue. RESULTS Of 34 eligible patients treated by 7 surgeons, 76% had level II ALND and 24% level III ALND. Only 5.9% of clips entirely encompassed the corresponding RT nodal volumes. 55.9% of clips fell within and 44.1% fell inferolaterally outside the corresponding RT nodal volumes. A median 3.6 cm (range 0-7.5 cm) of undissected nodal tissue would not be included within standard RT target volumes following eviQ recommendations. CONCLUSION There is a disparity between surgically determined versus CT determined axillary nodal volumes, leading to discontiguous nodal volumes and untreated axillary nodal tissue, despite following standard radiation contouring guidelines. Intraoperatively placed apical axillary clips may assist radiation oncologists to accurately delineate undissected nodal tissues at risk.
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Affiliation(s)
- Michael Ti Hsieh
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Noel J Aherne
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia.,School of Health and Human Sciences, Southern Cross University, Coffs Harbour, New South Wales, Australia.,RCS Faculty of Medicine, University of New South Wales, Coffs Harbour, New South Wales, Australia
| | - William Ross
- RCS Faculty of Medicine, University of New South Wales, Coffs Harbour, New South Wales, Australia.,Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Shehnarz Salindera
- Department of Surgery, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Lauren Winkley
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia
| | - Thomas P Shakespeare
- Department of Radiation Oncology, Mid North Coast Cancer Institute, Coffs Harbour Health Campus, Coffs Harbour, New South Wales, Australia.,RCS Faculty of Medicine, University of New South Wales, Coffs Harbour, New South Wales, Australia
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Dundas KL, Pogson EM, Batumalai V, Boxer MM, Yap ML, Delaney GP, Metcalfe P, Holloway L. Australian survey on current practices for breast radiotherapy. J Med Imaging Radiat Oncol 2015; 59:736-42. [PMID: 26269376 DOI: 10.1111/1754-9485.12348] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 06/21/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Detailed, published surveys specific to Australian breast radiotherapy practice were last conducted in 2002. More recent international surveys specific to breast radiotherapy practice include a European survey conducted in 2008/2009 and a Spanish survey conducted in 2009. Radiotherapy techniques continue to evolve, and the utilisation of new techniques, such as intensity-modulated radiation therapy (IMRT), is increasing. This survey aimed to determine current breast radiotherapy practices across Australia. METHOD An online survey was completed by 50 of the 69 Australian radiation therapy treatment centres. RESULTS Supine tangential beam whole breast irradiation remains the standard of care for breast radiotherapy in Australia. A growing number of institutions are exploring prone positioning and IMRT utilisation. This survey demonstrated a wide variation in the benchmarks used to limit and report organ at risk doses, prescribed dose regimen, and post-mastectomy bolus practices. This survey also indicated, when compared with international literature, that there may be less interest in or uptake of external beam partial breast irradiation, prone positioning, simultaneous integrated boost and breath hold techniques. These are areas where further review and research may be warranted to ensure Australian patients are receiving the best care possible based on the best evidence available. CONCLUSION This survey provides insight into the current radiotherapy practice for breast cancer in Australia.
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Affiliation(s)
- Kylie L Dundas
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Elise M Pogson
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Vikneswary Batumalai
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Miriam M Boxer
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mei Ling Yap
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - Geoff P Delaney
- Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, University of Western Sydney, Sydney, New South Wales, Australia
| | - Peter Metcalfe
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Lois Holloway
- Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Institute of Medical Physics, School of Physics, University of Sydney, Sydney, New South Wales, Australia
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Ung KA, Portillo M, Moran B, Kron T, Sawyer B, Herschtal A, Chua BH. The dosimetric impact of supraclavicular nodal irradiation on the thyroid gland in patients with breast cancer. Pract Radiat Oncol 2014; 3:e131-7. [PMID: 24674410 DOI: 10.1016/j.prro.2012.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 12/24/2012] [Accepted: 12/26/2012] [Indexed: 12/19/2022]
Abstract
PURPOSE The thyroid is not routinely considered an organ at risk in supraclavicular (SC) nodal radiation therapy (RT) for breast cancer. We compared the dosimetric impact of the following 2 RT planning techniques on the thyroid: (1) conventional single anterior field to encompass the SC nodal volume defined clinically; and (2) 3-dimensional conformal radiation therapy (3DCRT) planning to encompass the computed tomography (CT)-contoured SC nodal volume. METHODS AND MATERIALS The thyroid, SC nodal volumes, and organs at risk were contoured on the planning CT of 20 patients who received 50 Gy in 2-Gy daily fractions to the breast or chest wall, and SC nodes. Comparisons of dosimetric parameters between the techniques were performed: thyroid, mean and maximum dose, V5, V30, and V50 (percentage of thyroid receiving ≥5 Gy, ≥30 Gy, and ≥50 Gy, respectively); SC nodal volume, homogeneity index (HI, percentage volume receiving 95%-107% of prescribed dose); and maximum doses of spinal cord and brachial plexus. Anatomic characteristics that influenced the dose distributions were investigated. RESULTS The 3DCRT planning technique significantly increased all thyroid dosimetric measures (mean dose 17.2 Gy vs 26.7 Gy; maximum dose 48.5 Gy vs 51.9 Gy; V5 45.7% vs 64.9%; V30 33.7% vs 48%; and V50 0.6% vs 26.7%; P < .001). It improved HI for the SC nodal volumes (P < .001) but resulted in higher maximum doses to the spinal cord (6.1 Gy vs 30 Gy) and brachial plexus (43.2 Gy vs 51.4 Gy). The thyroid volume and depth of SC nodes did not influence the thyroid dose distribution. The depth of SC nodes impacted on the HI of SC nodal volumes in the conventional technique (P = .004). CONCLUSIONS The 3DCRT planning improved dosimetric coverage of the SC nodal volume but increased thyroid radiation doses. The potential adverse effects of incidental thyroid irradiation should be considered while improving dosimetric coverage in SC nodal irradiation for breast cancer.
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Affiliation(s)
- Kim Ann Ung
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.
| | - Maria Portillo
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Brigid Moran
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Tomas Kron
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Brooke Sawyer
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Alan Herschtal
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Boon H Chua
- Division of Radiation Oncology and Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Victoria, Australia
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Algara M, Arenas M, De Las Peñas Eloisa Bayo D, Muñoz J, Carceller JA, Salinas J, Moreno F, Martínez F, González E, Montero A. Radiation techniques used in patients with breast cancer: Results of a survey in Spain. Rep Pract Oncol Radiother 2012; 17:122-8. [PMID: 24377012 DOI: 10.1016/j.rpor.2012.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2011] [Revised: 02/05/2012] [Accepted: 03/14/2012] [Indexed: 10/28/2022] Open
Abstract
AIM To evaluate the resources and techniques used in the irradiation of patients with breast cancer after lumpectomy or mastectomy and the status of implementation of new techniques and therapeutic schedules in our country. BACKGROUND The demand for cancer care has increased among the Spanish population, as long as cancer treatment innovations have proliferated. Radiation therapy in breast cancer has evolved exponentially in recent years with the implementation of three-dimensional conformal radiotherapy, intensity modulated radiotherapy, image guided radiotherapy and hypofractionation. MATERIAL AND METHODS An original survey questionnaire was sent to institutions participating in the SEOR-Mama group (GEORM). In total, the standards of practice in 969 patients with breast cancer after surgery were evaluated. RESULTS The response rate was 70% (28/40 centers). In 98.5% of cases 3D conformal treatment was used. All the institutions employed CT-based planning treatment. Boost was performed in 56.4% of patients: electrons in 59.8%, photons in 23.7% and HDR brachytherapy in 8.8%. Fractionation was standard in 93.1% of patients. Supine position was the most frequent. Only 3 centers used prone position. The common organs of risk delimited were: homolateral lung (80.8%) and heart (80.8%). In 84% histograms were used. An 80.8% of the centers used isocentric technique. In 62.5% asymmetric fields were employed. CTV was delimited in 46.2%, PTV in 65% and both in 38.5%. A 65% of the centers checked with portal films. IMRT and hypofractionation were used in 1% and in 5.5% respectively. CONCLUSION In most of centers, 3D conformal treatment and CT-based planning treatment were used. IMRT and hypofractionation are currently poorly implemented in Spain.
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Affiliation(s)
- Manuel Algara
- Breast Cancer Radiation Oncology Spanish Group (GEORM), Spain
| | | | | | - Julia Muñoz
- Breast Cancer Radiation Oncology Spanish Group (GEORM), Spain
| | | | - Juan Salinas
- Breast Cancer Radiation Oncology Spanish Group (GEORM), Spain
| | - Ferran Moreno
- Breast Cancer Radiation Oncology Spanish Group (GEORM), Spain
| | | | | | - Angel Montero
- Breast Cancer Radiation Oncology Spanish Group (GEORM), Spain
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van der Laan HP, Hurkmans CW, Kuten A, Westenberg HA. Current technological clinical practice in breast radiotherapy; results of a survey in EORTC-Radiation Oncology Group affiliated institutions. Radiother Oncol 2010; 94:280-5. [PMID: 20116120 DOI: 10.1016/j.radonc.2009.12.032] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 12/09/2009] [Accepted: 12/29/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate the current technological clinical practice of radiation therapy of the breast in institutions participating in the EORTC-Radiation Oncology Group (EORTC-ROG). MATERIALS AND METHODS A survey was conducted between August 2008 and January 2009 on behalf of the Breast Working Party within the EORTC-ROG. The questionnaire comprised 32 questions on 4 main topics: fractionation schedules, treatment planning methods, volume definitions and position verification procedures. RESULTS Sixty-eight institutions out of 16 countries responded (a response rate of 47%). The standard fraction dose was generally 2Gy for both breast and boost treatment, although a 2.67 Gy boost fraction dose is routinely given in British institutions. The main boost modality was electrons in 55%, photons in 47% and brachytherapy in 3% of the institutions (equal use of photon and electron irradiation in 5% of the institutions). All institutions used CT-based treatment planning. Wide variations are seen in the definition of the breast and boost target volumes, with margins around the resection cavity, ranging from 0 to 30 mm. Inverse planned IMRT is available in 27% and breath-hold techniques in 19% of the institutions. The number of patients treated with IMRT and breath-hold varied per institution. Electronic portal imaging for patient set-up is used by 92% of the institutions. CONCLUSIONS This survey provides insight in the current practice of radiation technology used in the treatment of breast cancer among institutions participating in EORTC-ROG clinical trials.
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Affiliation(s)
- Hans Paul van der Laan
- Department of Radiation Oncology, University Medical Center Groningen/University of Groningen, Groningen, The Netherlands.
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