1
|
Unterkirhere O, Stenger-Weisser A, Kaever A, Hoeng L, Jeller D, Logaritsch P, Glanzmann C, Studer G. Single-Institution Prospective Evaluation of Moderately Hypofractionated Whole-Breast Radiation Therapy With Simultaneous Integrated Boost With or Without Lymphatic Drainage Irradiation After Breast-Conserving Surgery. Adv Radiat Oncol 2023; 8:101270. [PMID: 38047219 PMCID: PMC10692289 DOI: 10.1016/j.adro.2023.101270] [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: 05/03/2023] [Accepted: 05/12/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose We report treatment outcomes for patients who received adjuvant moderate hypofractionated whole-breast radiation therapy with simultaneous integrated boost (SIB-mhWBRT) after breast-conserving surgery. Methods and Materials SIB-mhWBRT for patients with breast cancer was introduced in our department in July 2017. This prospective evaluation includes 424 consecutive patients treated with SIB-mhWBRT for stage I-III invasive breast cancer (n = 391) and/or ductal carcinoma in situ (n = 33) until December 2021. SIB-mhWBRT was applied with 40 Gy in 15 daily fractions over 3 weeks according to the START B trial, with an SIB dose to the tumor bed of 48 Gy according to Radiation Therapy Oncology Group 1005/UK-IMPORT-HIGH, delivered as 3-dinemsional conformal radiation therapy (RT; n = 402), intensity modulated RT (n = 4), or volumetric modulated arc therapy (n = 18). The mean patient age was 60 years (range, 27-88). Since May 2018, patients with indications for lymphatic pathway RT were included (n = 62). Baseline parameters and follow-up data were recorded and reported, including objective assessment of treatment-related outcomes and subjective patient-reported outcome measures (PROMs). Results Mean/median follow-up was 29/33 months (range, 2-60). Acute toxicity grade 0, 1, 2, and 3 was observed in 25.0%, 61.4%, 13.3%, and 0%, respectively, at the completion of RT. Data of 281, 266, 243, 172, and 58 patients were available for 6-month and 1-, 2-, 3-, and 4-year follow-up, respectively. Grade 2 late effects were identified in 8.5%, 6.0%, 4.9%, 2.2%, and 10.2% and grade 3 in 2.8%, 1.1%, 1.2%, 0%, and 0% of patients at 6-month and 1-, 2-, 3-, and 4-year follow-up, respectively. Medical treatment of breast edema was the only grade 3 late effect observed. PROM cosmesis results were evaluated as excellent-good, fair, and poor in 97.2%, 2.5%, and 0.4%; 96.5%, 3.1%, and 0.4%; 97.4%, 2.2%, and 0.4%; 97.5%, 2.5%, and 0%; and 96.5%, 3.5%, and 0.0% at 6 months and 1, 2, 3, and 4 years post-RT, respectively. For all patients, the 3-year overall, cancer-specific, and disease-free survival rates were 98.2%, 99.1%, and 95.9%, respectively. Three-year risk of any locoregional recurrence was 0.6%. No mortality or relapse was observed in patients with ductal carcinoma in situ. Conclusions SIB-mhWBRT demonstrated very favorable side effect profiles and cosmesis/PROMs. Three-year results demonstrate excellent locoregional control. This short-term regimen offers substantial patient comfort and improves institutional efficacy.
Collapse
Affiliation(s)
- Olga Unterkirhere
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Laura Hoeng
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | - David Jeller
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
| | | | | | - Gabriela Studer
- Radiation Oncology Department, Kantonsspital Luzern, Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| |
Collapse
|
2
|
Onal C, Bozca R, Oymak E, Guler OC. Comparison of helical and TomoDirect techniques with simultaneous integrated boost in early breast cancer patients. Rep Pract Oncol Radiother 2023; 28:541-550. [PMID: 37795226 PMCID: PMC10547420 DOI: 10.5603/rpor.a2023.0058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/14/2023] [Indexed: 10/06/2023] Open
Abstract
Background The aim of the study was to perform dosimetric comparisons of helical (H) and TomoDirect (TD) plans for whole-breast irradiation (WBI) with simultaneous integrated boost (SIB) in early-stage breast cancer patients undergoing breast conserving surgery. Materials and methods Fifty patients, 25 with left-side and 25 with right-side tumors, were determined for a treatment planning system for a total dose of 50.4Gy in 1.8Gy per fraction to WBI, with a SIB of 2.3Gy per fraction delivered to the tumor bed. The planning target volume (PTV) doses and the conformity (CI) and homogeneity indices (HI) for PTVbreast and PTVboost, as well as organ-at-risk (OAR) doses and treatment times, were compared between the H and TD plans. Results All plans met the PTV coverage criteria for the H plan, except for mean V107 of PTVbreast for TD plan. The H plan yielded better homogeneity and conformity of dose distribution compared to the TD plan. The ipsilateral mean lung doses were not significantly different between the two plans. The TD plans is advantageous for mean doses to the heart, contralateral breast and lung, spinal cord, and esophagus than the H plans. In both the H and TD plans, the right-sided breast patients had lower heart dose parameters than the left-sided breast patients. The TD plan is superior to the H plan in sparing the contralateral breast and lung by decreasing low-dose volumes. Conclusions While the OAR dose advantages of TD are appealing, shorter treatment times or improved dose homogeneity and conformity for target volume may be advantageous for H plan.
Collapse
Affiliation(s)
- Cem Onal
- Division of Radiation Oncology, Iskenderun Gelisim Hospital, Hatay, Türkiye
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Türkiye
- Department of Radiation Oncology, Baskent University Faculty of Medicine, Ankara, Türkiye
| | - Recep Bozca
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Türkiye
| | - Ezgi Oymak
- Division of Radiation Oncology, Iskenderun Gelisim Hospital, Hatay, Türkiye
| | - Ozan Cem Guler
- Department of Radiation Oncology, Baskent University Faculty of Medicine Adana Dr Turgut Noyan Research and Treatment Center, Adana, Türkiye
| |
Collapse
|
3
|
Tomatis S, Mancosu P, Reggiori G, Lobefalo F, Gallo P, Lambri N, Paganini L, La Fauci F, Bresolin A, Parabicoli S, Pelizzoli M, Navarria P, Franzese C, Lenoci D, Scorsetti M. Twenty Years of Advancements in a Radiotherapy Facility: Clinical Protocols, Technology, and Management. Curr Oncol 2023; 30:7031-7042. [PMID: 37504370 PMCID: PMC10378035 DOI: 10.3390/curroncol30070510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Hypo-fractionation can be an effective strategy to lower costs and save time, increasing patient access to advanced radiation therapy. To demonstrate this potential in practice within the context of temporal evolution, a twenty-year analysis of a representative radiation therapy facility from 2003 to 2022 was conducted. This analysis utilized comprehensive data to quantitatively evaluate the connections between advanced clinical protocols and technological improvements. The findings provide valuable insights to the management team, helping them ensure the delivery of high-quality treatments in a sustainable manner. METHODS Several parameters related to treatment technique, patient positioning, dose prescription, fractionation, equipment technology content, machine workload and throughput, therapy times and patients access counts were extracted from departmental database and analyzed on a yearly basis by means of linear regression. RESULTS Patients increased by 121 ± 6 new per year (NPY). Since 2010, the incidence of hypo-fractionation protocols grew thanks to increasing Linac technology. In seven years, both the average number of fractions and daily machine workload decreased by -0.84 ± 0.12 fractions/year and -1.61 ± 0.35 patients/year, respectively. The implementation of advanced dose delivery techniques, image guidance and high dose rate beams for high fraction doses, currently systematically used, has increased the complexity and reduced daily treatment throughput since 2010 from 40 to 32 patients per 8 h work shift (WS8). Thanks to hypo-fractionation, such an efficiency drop did not affect NPY, estimating 693 ± 28 NPY/WS8, regardless of the evaluation time. Each newly installed machine was shown to add 540 NPY, while absorbing 0.78 ± 0.04 WS8. The COVID-19 pandemic brought an overall reduction of 3.7% of patients and a reduction of 0.8 fractions/patient, to mitigate patient crowding in the department. CONCLUSIONS The evolution of therapy protocols towards hypo-fractionation was supported by the use of proper technology. The characteristics of this process were quantified considering time progression and organizational aspects. This strategy optimized resources while enabling broader access to advanced radiation therapy. To truly value the benefit of hypo-fractionation, a reimbursement policy should focus on the patient rather than individual treatment fractionation.
Collapse
Affiliation(s)
- Stefano Tomatis
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Pietro Mancosu
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Giacomo Reggiori
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Francesca Lobefalo
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Pasqualina Gallo
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Nicola Lambri
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Lucia Paganini
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Francesco La Fauci
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Andrea Bresolin
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Sara Parabicoli
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marco Pelizzoli
- Medical Physics Service, Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Pierina Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Ciro Franzese
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| | - Domenico Lenoci
- Development Strategic Initiatives Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Marta Scorsetti
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090 Milan, Italy
| |
Collapse
|
4
|
Salim N, Popodko A, Tumanova K, Stolbovoy A, Lagkueva I, Ragimov V. Cardiac dose in the treatment of synchronous bilateral breast cancer patients between three different radiotherapy techniques (VMAT, IMRT, and 3D CRT). Discov Oncol 2023; 14:29. [PMID: 36862205 PMCID: PMC9981832 DOI: 10.1007/s12672-023-00636-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/22/2023] [Indexed: 03/03/2023] Open
Abstract
PURPOSE Synchronous bilateral irradiation of both mammary glands and chest wall is a challenging task due to technical difficulties and limited evidence supporting an optimal technique to improve treatment outcomes. We studied and compared the dosimetry data of three radiotherapy techniques to select the most optimal one. METHODS We compared three-dimensional conformal radiation treatment (3D CRT), intensity-modulated radiation therapy (IMRT), and volumetric modulated arc therapy (VMAT) during irradiation of synchronous bilateral breast cancer in nine patients followed by examination of dose distribution to the cardiac conduction system (SA node, AV node and Bundle of His), myocardium, lungs, left anterior descending artery (LADA) and right coronary artery (RCA) . RESULTS VMAT is the most sparing technique for SBBC treatment. Even though doses to the SA node, AV node and Bundle of His were higher with VMAT (Dmean were 3.75 ± 0.62, 2.58 ± 0.83 and 3.03 ± 1.18 Gy respectively) compared with 3D CRT (Dmean were 2.61 ± 0.66, 1.52 ± 0.38 and 1.88 ± 0.70 Gy respectively), this difference is statistically insignificant. Doses to the right and left lung (average Dmean = 12.65 ± 3.20 Gy, V20Gy = 24.12 ± 6.25%), myocardium (Dmean = 5.33 ± 1.51 Gy, V10Gy = 9.80 ± 3.83%, V20Gy = 7.19 ± 3.15%, V25Gy = 6.20 ± 2.93%), and LADA (Dmean = 10.04 ± 4.92 Gy, V20Gy = 18.17 ± 13.24% and V25Gy = 15.41 ± 12.19%) were highest with 3D CRT. The highest Dmean in the cardiac conduction system (5.30 ± 2.23, 3.15 ± 1.61 and 3.89 ± 1.85 Gy respectively) was observed with IMRT, and a similar effect was noted in RCA (Dmean = 7.48 ± 2.11 Gy). CONCLUSION VMAT is the optimal and satisfactory radiation therapy technique for sparing organs at risk (OARs). With VMAT, a lower Dmean value was noted in the myocardium, LADA, and lungs. The use of 3D CRT significantly increases the dose of radiation reaching the lungs, myocardium, and LADA, which can subsequently cause cardiovascular and lung complications, but not in the cardiac conduction system.
Collapse
Affiliation(s)
- Nidal Salim
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
- Department of Radiation Oncology, Russian Medical Academy of Continuous Medical Education of the Ministry of Health, Moscow, Russia
| | - Alexey Popodko
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
| | - Kristina Tumanova
- Department of Radiation Oncology, European Medical Center, Moscow, Russia.
| | - Alexandr Stolbovoy
- Department of Radiation Oncology, European Medical Center, Moscow, Russia
- Department of Radiation Oncology, Russian Medical Academy of Continuous Medical Education of the Ministry of Health, Moscow, Russia
| | | | | |
Collapse
|
5
|
Quesada S, Fenoglietto P, Gourgou S, Lemanski C, Draghici R, Ailleres N, Prunaretty J, Azria D, Bourgier C. Efficacy, safety, and feasibility of volumetric modulated arc therapy for synchronous bilateral breast cancer management. Front Oncol 2022; 12:967479. [PMID: 36059658 PMCID: PMC9436014 DOI: 10.3389/fonc.2022.967479] [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: 06/12/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeVolumetric Modulated Arc Therapy (VMAT) exhibits potent advantages regarding target volume coverage and protection of organs at risk, notably in the context of anatomical constraints. Nevertheless, reports concerning VMAT for the treatment of synchronous bilateral breast cancers (SBBC) have been scarce to date. As such, we conducted this observational study to assess efficacy, safety and feasibility of VMAT in SBBC.Materials and MethodsFrom August 2011 to December 2017, 54 consecutive patients with SBBC with or without axillary nodes involvement underwent a treatment protocol containing radiotherapy using VMAT. A total dose (TD) of 52.2Gy in 29 fractions was delivered to breast and internal mammary chain (IMC) nodes Planning Target Volume (PTV) plus, if applicable, a TD of 49.3Gy in 29 fractions to the supra- and infra-clavicular nodes PTV and a TD of 63.22Gy in 29 fractions to tumor boost PTV. Lungs, heart, esophagus, trachea, liver, thyroid and spinal cord were considered as organs at risk. VMAT feasibility and organ at risk sparing were evaluated by treatments planning of the 20 first enrolled patients. Tolerance and patients’ outcome were prospectively monitored by acute/late toxicities records and by the analysis of overall survival (OS), locoregional recurrence-free survival (LRFS) and recurrence-free survival (RFS).ResultsBreast, supraclavicular nodes and boost PTV coverage was adequate with at least 98% of PTV encompassed by more than 95% of the prescribed dose. Less than 90% of IMC PTV was encompassed by 95% of the prescribed dose. Mean lung dose was 12.3Gy (range: 7.7 – 18.7); mean heart dose was 10.7Gy (range: 6.2 – 22.3). Concerning acute toxicities, only 2 patients experienced grade 3 skin toxicity (3.7%) and only 1 patient developed grade 1 pneumonitis. After a median follow-up of 5.3 years, grade 2 fibrosis and/or shrinking was observed in 5 patients (10%), and grade 3 fibrosis in 1 patients (2%). The 5-year LRFS-rate, RFS-rate and OS were 98% [95% CI= 86.12-99.70%], 96% [95% CI= 84.63-98.96%] and 100%, respectively.
Collapse
Affiliation(s)
- Stanislas Quesada
- Faculty of Medicine, University of Montpellier, Montpellier, France
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
| | - Pascal Fenoglietto
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
| | - Sophie Gourgou
- Institute of Cancer Research of Montpellier (IRCM), Montpellier, France
| | - Claire Lemanski
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
| | - Roxana Draghici
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
| | - Norbert Ailleres
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
| | - Jessica Prunaretty
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
| | - David Azria
- Faculty of Medicine, University of Montpellier, Montpellier, France
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
- Institute of Cancer Research of Montpellier (IRCM), Montpellier, France
| | - Céline Bourgier
- Faculty of Medicine, University of Montpellier, Montpellier, France
- Department of Radiation Oncology, Montpellier Cancer Institute (ICM), Montpellier, France
- Institute of Cancer Research of Montpellier (IRCM), Montpellier, France
- *Correspondence: Céline Bourgier,
| |
Collapse
|
6
|
Schmitt M, Menoux I, Chambrelant I, Hild C, Petit T, Mathelin C, Noël G. Adjuvant hypofractionated radiotherapy with simultaneous integrated boost after breast-conserving surgery: A systematic literature review. Transl Oncol 2022; 22:101456. [PMID: 35609442 PMCID: PMC9125620 DOI: 10.1016/j.tranon.2022.101456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/18/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022] Open
Abstract
PURPOSES Several studies have shown that simultaneous integrated boost provides better dose homogeneity, improves the biologically effective dose-volume histogram and reduces treatment time compared to sequential boost in breast cancer. PATIENTS AND METHODS We conducted a systematic review of published trials evaluating simultaneous integrated boost in hypofractionated radiotherapy to analyze the results in terms of overall survival, local control, early and late side effects, and radiotherapy techniques used. RESULTS Upon 9 articles, the prescribed dose to the whole breast varied from 40 to 46.8 Gy. The number of fractions varies from 15 to 20 fractions. The prescribed dose per fraction to the boost varied from 2.4 Gy per fraction to 3.4 Gy per fraction for a total boost dose from 48 to 52.8 Gy. CONCLUSIONS Simultaneous integrated boost seems effective and safe when given hypofractionated whole-breast irradiation but needs to be validated in prospective trials.
Collapse
Affiliation(s)
- Martin Schmitt
- Radiotherapy Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France.
| | - Inès Menoux
- Radiotherapy Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France
| | - Isabelle Chambrelant
- Radiotherapy Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France
| | - Carole Hild
- Breast Surgery Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France
| | - Thierry Petit
- Medical Oncology Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France
| | - Carole Mathelin
- Breast Surgery Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France
| | - Georges Noël
- Radiotherapy Department, Strasbourg Europe Cancer Institute, 17 Rue Albert Calmette, Strasbourg CEDEX 67200, France
| |
Collapse
|
7
|
Lertbutsayanukul C, Pitak M, Nantavithya C. Long-term oncological outcomes of hypofractionated versus conventional fractionated whole breast irradiation with simultaneous integrated boost in early-stage breast cancer. Radiat Oncol J 2022; 40:141-150. [PMID: 35796117 PMCID: PMC9262705 DOI: 10.3857/roj.2021.00927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 03/25/2022] [Indexed: 11/18/2022] Open
Abstract
Purpose For patients with early breast cancer who undergo breast-conserving surgery, adjuvant whole breast irradiation (WBI) with simultaneous integrated boost (SIB) results in lower radiotherapy fractions. Published studies have shown that both conventional fraction with SIB (C-SIB) and hypofractionation with SIB (H-SIB) seem to be safe and feasible. In this study, we sought to compare the oncologic outcomes between C-SIB and H-SIB in early-stage breast cancer. Materials and Methods Stage I–II breast cancer patients who received adjuvant WBI with SIB between January 2008 and December 2017 were retrospectively reviewed. The radiation dose in the C-SIB group was 50 Gy and 65 Gy in 25 daily fractions, while in the H-SIB group, it was 43.2 Gy and 52.8 Gy in 16 daily fractions to the whole breast and tumor bed, respectively. Results A total of 188 patients, 103 in the C-SIB group and 85 in the H-SIB group, were included. With a median follow-up time of 87 months, 7-year locoregional control of C-SIB was comparable to H-SIB (95.8% vs. 97.4%, p = 0.964). The 7-year distant metastasis-free survival rates of C-SIB and H-SIB were 89.9% and 95.9% (p = 0.111), while the 7-year disease-free survival rates were 84.2% and 95.4%, respectively (p = 0.176). In multivariate analysis, there was no significant prognostic factor associated with better overall survival. Conclusion H-SIB provided comparable locoregional control to C-SIB. With the advantage of a shorter radiotherapy course, H-SIB could be a favorable option for WBI in early-stage breast cancer.
Collapse
Affiliation(s)
- Chawalit Lertbutsayanukul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Manida Pitak
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Chonnipa Nantavithya
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Correspondence: Chonnipa Nantavithya Division of Radiation Oncology, Department of Radiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, 1873, Rama 4 Rd., Bangkok 10330, Thailand. Tel: +66-2564334 E-mail:
| |
Collapse
|
8
|
Franceschini D, Fogliata A, Spoto R, Dominici L, Lo Faro L, Franzese C, Comito T, Lobefalo F, Reggiori G, Cozzi L, Sagona A, Gentile D, Scorsetti M. Long term results of a phase II trial of hypofractionated adjuvant radiotherapy for early-stage breast cancer with volumetric modulated arc therapy and simultaneous integrated boost. Radiother Oncol 2021; 164:50-56. [PMID: 34537289 DOI: 10.1016/j.radonc.2021.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE to report toxicity and cosmetic outcome with a median follow-up of 6 years of a phase II trial of hypofractionated radiotherapy with volumetric modulated arc therapy (VMAT) and simultaneous integrated boost (SIB) for early-stage breast cancer after conservative surgery. MATERIALS AND METHODS From August 2010 to September 2014, patients requiring adjuvant radiotherapy for early-stage breast cancer were treated according to a phase I-II protocol with SIB to 40.5 and 48 Gy to the breast and the boost region, respectively, with VMAT technique. The primary endpoint evaluated the treatment feasibility regarding adherence to required dose constraints for target, heart and lungs. Acute and late toxicity, local and distant control were secondary endpoints. RESULTS 450 patients were included in the trial and analysed after a median follow-up of 6 years. Acute toxicity was already presented in a previous paper. Regarding late toxicity, 93% of patients had no skin alteration at five years, while 5.3% and 1.3% did record G1 and G2 residual toxicity, respectively. Cosmetic outcome was scored good or excellent in almost all cases (97.2%), fair only in 2.3% of patients. Residual tenderness in the irradiated breast was reported by 10% of patients. Cosmesis and breast pain improved during follow-up. Two cases of G2 pneumonitis and two cases of ischemic cardiopathy were registered during follow-up. Five cases presented local recurrence in the homolateral breast, four patients had a new primary cancer in the contralateral breast, while distant metastasis developed in 7 patients. CONCLUSION After more than six years, hypofractionated VMAT with SIB for adjuvant radiotherapy in early-stage breast cancer patients remains a safe and effective approach. Mature data on skin toxicity and cosmetic outcome are encouraging. However, longer follow-up is required to evaluate local control, cardiac toxicity and secondary carcinogenesis.
Collapse
Affiliation(s)
- D Franceschini
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - A Fogliata
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy.
| | - R Spoto
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - L Dominici
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - L Lo Faro
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - C Franzese
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| | - T Comito
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - F Lobefalo
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - G Reggiori
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy
| | - L Cozzi
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| | - A Sagona
- IRCCS Humanitas Research Hospital, Breast Unit, Milan-Rozzano, Italy
| | - D Gentile
- Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy; IRCCS Humanitas Research Hospital, Breast Unit, Milan-Rozzano, Italy
| | - M Scorsetti
- IRCCS Humanitas Research Hospital, Department of Radiotherapy and Radiosurgery, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Pieve Emanuele, Italy
| |
Collapse
|
9
|
Studer G, Glanzmann C. [Radiation Oncology - Recent Status]. PRAXIS 2021; 110:733-742. [PMID: 34583545 DOI: 10.1024/1661-8157/a003729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Radiation Oncology - Recent Status Abstract. We summarize the most important developments and innovations in the field over the past years and illustrate resulting external radiation treatment schedules and related treatment tolerance, focusing on hypofractionation.
Collapse
|
10
|
Breast boost vector: a new metric proposed to optimise isocentre location in an fIMRT–VMAT hybrid technique for a simultaneous integrated boost in breast radiotherapy. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396920000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractPurpose:Evaluating the improvements of placing the treatment isocentre at the boost centre of mass (CoM) in a hybrid treatment for breast cancer radiotherapy.Material and methods:Twenty-two patients were planned in two isocentre locations with two forward intensity-modulated radiation therapy (fIMRT) tangentials to the breast and a volumetric-modulated arc therapy (VMAT) to the boost. A simultaneous integrated boost technique was used. Breast Boost (BB) Vector was investigated as a criterion for selecting an appropriate isocentre placement. Various metrics for boost, breast and hybrid plans were analysed using analysis of variance statistics.Results:Comparing hybrid plans at the boost CoM vs. hybrid plans at the breast CoM, no significant differences were found. Analysis of relative variations of planning target volume (PTV) boost coverage vs. BB Vector indicated an upgrade in boost CoM isocentre strategy. Dose to organs at risk was comparable: V5Gy (26·24 vs. 25·69%, p = 0·8), V20Gy (14·66 vs. 14·58%, p = 0·959) and the mean dose (7·37 Gy vs. 7·26 Gy, p = 0·879) to ipsilateral lung; V5Gy (15·60 vs. 15·22%, p = 0·903), and the mean dose (4·91 Gy vs. 4·86 Gy, p = 0·950) to heart and dose to free breast of boost (46·71 Gy vs. 46·62 Gy, p = 0·408).Findings:The hybrid fIMRT–VMAT technique centred at the boost CoM resulted equivalent to plans centred at the breast CoM, while benefiting from an enhancement in PTV boost coverage for patients with BB Vector superior to 5.
Collapse
|
11
|
Two-year toxicity of simultaneous integrated boost in hypofractionated prone breast cancer irradiation: Comparison with sequential boost in a randomized trial. Radiother Oncol 2021; 158:62-66. [PMID: 33617910 DOI: 10.1016/j.radonc.2021.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/29/2021] [Accepted: 02/09/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A simultaneous integrated boost (SIB) leads to less acute toxicity. Less is known for late toxicity due to SIB. In this first and only randomized trial, two-years toxicity is analysed. MATERIALS AND METHODS Physician-assessed toxicity, using the LENT SOMA scale, and photographs, analysed with the BCCT.core software, was examined for 150 patients, randomized between SIB and sequential boost (SEB). RESULTS Differences in physician-assessed two-years toxicity and photographic analysis between SIB and SEB are very small and not significant. CONCLUSION There is no indication that a SIB leads to an excess in toxicity or worse cosmetic outcome at 2 years.
Collapse
|
12
|
Dicuonzo S, Leonardi MC, Raimondi S, Corrao G, Bagnardi V, Gerardi MA, Morra A, Zerella MA, Zaffaroni M, Pansini F, Cattani F, Luraschi R, Fodor C, Veronesi P, Orecchia R, Rojas DP, Jereczek-Fossa BA. Acute and intermediate toxicity of 3-week radiotherapy with simultaneous integrated boost using TomoDirect: prospective series of 287 early breast cancer patients. Clin Transl Oncol 2021; 23:1415-1428. [PMID: 33537865 DOI: 10.1007/s12094-020-02538-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/27/2020] [Indexed: 11/26/2022]
Abstract
AIMS To report toxicity of a hypofractionated scheme of whole-breast (WB) intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to the tumor bed (TB) using Tomotherapy® with Direct modality. METHODS Patients with early breast cancer, undergoing radiotherapy (RT) in 15 daily fractions to WB (prescription dose 40.05 Gy) and SIB to the TB (48 Gy), between 2013 and 2017, was analyzed. Primary endpoint was acute and intermediate toxicity assessed at the end and within 6 months from RT, according to Radiation Therapy Oncology Group (RTOG) scale. Secondary endpoints included early chronic toxicity at 12-months follow-up, using the Late Effects Normal Tissue Task Subjective, Objective, Management, and Analytic (LENT-SOMA) scale, and cosmesis using Harvard criteria. RESULTS The study population was of 287 patients. Acute and intermediate toxicity was collected among 183 patients with data available at the end of RT and within 6 months, 85 (46%) experienced G2 toxicity and 84 (46%) G1 toxicity, while 14 (8%) did not report toxicity at any time. A significant reduction of any grade toxicity was observed between the two time points, with the majority of patients reporting no clinically relevant toxicity at 6 months. At univariate analysis, age < 40 years, breast volume > 1000 cm3 and Dmax ≤ 115% of prescription dose were predictive factors of clinically relevant acute toxicity (G ≥ 2) at any time. At multivariable analysis, only age and breast volume were confirmed as predictive factors, with Relative Risks (95% Confidence Intervals): 2.02 (1.13-3.63) and 1.84 (1.26-2.67), respectively. At 12-month follow-up, 113 patients had complete information on any toxicity with 53% of toxicity G < 2, while cosmetic evaluation, available for 102 patients, reported a good-excellent result for 86% of patients. CONCLUSIONS Hypofractionated WB IMRT with a SIB to the TB, delivered with TomoDirect modality, is safe and well-tolerated. Most patients reported no toxicity after 6 months and good-excellent cosmesis. Predictive factors of clinically relevant toxicity might be considered during treatment planning in order to further reduce side effects.
Collapse
Affiliation(s)
- S Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M C Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - S Raimondi
- Molecular and Pharmaco-Epidemiology Unit, Department of Experimental Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - G Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - V Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - M A Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - A Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M A Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - M Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - F Pansini
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - F Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - R Luraschi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - C Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - P Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - R Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - D P Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
| | - B A Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| |
Collapse
|
13
|
Rago M, Placidi L, Polsoni M, Rambaldi G, Cusumano D, Greco F, Indovina L, Menna S, Placidi E, Stimato G, Teodoli S, Mattiucci GC, Chiesa S, Marazzi F, Masiello V, Valentini V, De Spirito M, Azario L. Evaluation of a generalized knowledge-based planning performance for VMAT irradiation of breast and locoregional lymph nodes-Internal mammary and/or supraclavicular regions. PLoS One 2021; 16:e0245305. [PMID: 33449952 PMCID: PMC7810311 DOI: 10.1371/journal.pone.0245305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/24/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To evaluate the performance of eleven Knowledge-Based (KB) models for planning optimization (RapidPlantm (RP), Varian) of Volumetric Modulated Arc Therapy (VMAT) applied to whole breast comprehensive of nodal stations, internal mammary and/or supraclavicular regions. METHODS AND MATERIALS Six RP models have been generated and trained based on 120 VMAT plans data set with different criteria. Two extra-structures were delineated: a PTV for the optimization and a ring structure. Five more models, twins of the previous models, have been created without the need of these structures. RESULTS All models were successfully validated on an independent cohort of 40 patients, 30 from the same institute that provided the training patients and 10 from an additional institute, with the resulting plans being of equal or better quality compared with the clinical plans. The internal validation shows that the models reduce the heart maximum dose of about 2 Gy, the mean dose of about 1 Gy and the V20Gy of 1.5 Gy on average. Model R and L together with model B without optimization structures ensured the best outcomes in the 20% of the values compared to other models. The external validation observed an average improvement of at least 16% for the V5Gy of lungs in RP plans. The mean heart dose and for the V20Gy for lung IPSI were almost halved. The models reduce the maximum dose for the spinal canal of more than 2 Gy on average. CONCLUSIONS All KB models allow a homogeneous plan quality and some dosimetric gains, as we saw in both internal and external validation. Sub-KB models, developed by splitting right and left breast cases or including only whole breast with locoregional lymph nodes, have shown good performances, comparable but slightly worse than the general model. Finally, models generated without the optimization structures, performed better than the original ones.
Collapse
Affiliation(s)
- Maria Rago
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lorenzo Placidi
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mattia Polsoni
- Fatebenefratelli Isola Tiberina, Ospedale San Giovanni Calibita, Rome, Italy
- Amethyst Radioterapia Italia, Isola Tiberina, Rome, Italy
| | - Giulia Rambaldi
- Fatebenefratelli Isola Tiberina, Ospedale San Giovanni Calibita, Rome, Italy
- Amethyst Radioterapia Italia, Isola Tiberina, Rome, Italy
| | - Davide Cusumano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Greco
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Indovina
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sebastiano Menna
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Elisa Placidi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Stefania Teodoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Silvia Chiesa
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabio Marazzi
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valeria Masiello
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vincenzo Valentini
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco De Spirito
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Azario
- Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| |
Collapse
|
14
|
Freedman GM, Taunk NK. Hypofractionated Whole Breast Radiotherapy and Boost in Early-Stage Breast Cancer. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00386-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
15
|
Hybrid planning techniques for hypofractionated whole-breast irradiation using flattening filter-free beams. Strahlenther Onkol 2019; 196:376-385. [PMID: 31863154 DOI: 10.1007/s00066-019-01555-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 11/21/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to assess the feasibility of flattening filter-free (FFF) photon beams in hybrid intensity-modulated radiation therapy (H-IMRT) and hybrid volumetric modulated arc therapy (H-VMAT) for left-sided whole-breast radiation therapy with a boost volume (RT) using a hypofractionated dose regimen. PATIENTS AND METHODS RT plans of 25 patients with left-sided early-stage breast cancer were created with H‑IMRT and H‑VMAT techniques under breath-hold conditions using 6‑MV FFF beams. In hybrid techniques, three-dimensional conformal radiotherapy (3DCRT) plans were kept as base-dose plans for the VMAT and IMRT plans. In addition, H‑IMRT in step-and-shoot mode was also calculated to assess its achievability with FFF beams. RESULTS All hybrid plans achieved the expected target coverage. H‑VMAT showed better coverage and homogeneity index results for the boost target (p < 0.002), while H‑IMRT presented better results for the whole-breast target (p < 0.001). Mean doses to normal tissues were comparable between both plans, while H‑IMRT reduced the low-dose levels to heart and ipsilateral lung (p < 0.05). H‑VMAT revealed significantly better results with regard to monitor units (MU) and treatment time (p < 0.001). CONCLUSION The 6‑MV FFF beam technique is feasible for large-field 3DCRT-based hybrid planning in whole-breast and boost planning target volume irradiation. For breath-hold patients, the H‑VMAT plan is superior to H‑IMRT for hypofractionated dose regimens, with reduced MU and treatment delivery time.
Collapse
|
16
|
Hypofractionated volumetric modulated arc therapy with SIB adjuvant to breast preservation surgery: retrospective experience from a Regional Cancer Centre in Eastern India. JOURNAL OF RADIOTHERAPY IN PRACTICE 2019. [DOI: 10.1017/s1460396919000165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AbstractBackground:The incidence of breast cancer has surpassed cervical cancer in India and it has now become the most common cancer in women. Multiple randomised studies have reported low α/β value in the range of 3–4 for breast cancer, which predict a potential radiobiological advantage for hypofractionated radiotherapy resulting in such schedules becoming standard in many centers with reduction in overall treatment time. Volumetric modulated arc therapy (VMAT) is a novel technique of delivering radiotherapy that reduces treatment delivery time, requires less monitor units (MU) and offers good conformity. The mean dose to normal tissue may be minimised using this technique although there will be inferior sparing if we consider the low-dose volume such as V5, the effect of which is not quantifiable yet.Aim:Reporting acute toxicity, cosmetic effects, and quality of life in patients of early breast cancer treated with adjuvant hypofractionated VMAT with SIB.Material and Methods:The records of 44 patients registered at the hospital between August 2014 and December 2015 were included in this analysis. Acute toxicities were analysed using CTCAE v4.03. Cosmetic outcomes were assessed using Harvard scale, while quality of life outcomes were assessed using EORTC scales and Health Related quality of life (HRQOL) questionnaires (QLQ-C30 and QLQ-BR23).Results:No grade ≥2 skin toxicities were recorded. Breast pain was recorded as Grade 1 in 13·8% patients and Grade 1 fatigue in 18·2%. The maximum haematological abnormality grade recorded was Grade 1. Cosmesis was assessed at the baseline, 6 months, 1 year and 2 years. A total of 88·6% of the patients had an Excellent or good cosmesis at the baseline, which was similar even at 6 months, at 88·7%, improved further at 1 year to 90·9%. At 6 months post radiotherapy, high functional scale QOL scores were noted.Conclusion:The technique is associated with minimum acute toxicity, good to excellent cosmesis and acceptable quality of life.
Collapse
|
17
|
Russo S, Esposito M, Hernandez V, Saez J, Rossi F, Paoletti L, Pini S, Bastiani P, Reggiori G, Nicolini G, Vanetti E, Tomatis S, Scorsetti M, Mancosu P. Does deep inspiration breath hold reduce plan complexity? Multicentric experience of left breast cancer radiotherapy with volumetric modulated arc therapy. Phys Med 2019; 59:79-85. [PMID: 30928069 DOI: 10.1016/j.ejmp.2019.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/14/2019] [Accepted: 02/20/2019] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Volumetric modulated arc therapy (VMAT) for left breast treatments allows heart sparing without compromising PTV coverage. However, this technique may require highly complex plans. Deep Inspiration Breath Hold (DIBH) procedure increases the heart-to-breast distance, facilitating the dose sparing of the heart. The aim of the present work was to investigate if the cardiac-sparing benefits of the DIBH technique were achieved with lower plan modulation and complexity than Free Breathing (FB) treatments. METHODS AND MATERIALS Ten left side breast cases were considered by two centers with different treatment planning systems (TPS) and Linacs. VMAT plans were elaborated in FB and DIBH according to the same protocol. Plan complexity was evaluated by scoring several complexity indices. A new global score index accounting for both plan quality and dosimetric parameters was defined. Pre-treatment QA was performed for all VMAT plans using EPID and Epiqa software. RESULTS DIBH-VMAT plans were associated with significant PTV coverage improvement and mean heart dose reduction (p < 0.003), increasing the resulting global score index. All the evaluated complexity indices showed lower plan complexity for DIBH plans than FB ones, but only in few cases the results were statistically significant. All plans passed the gamma analysis with the selected criteria. CONCLUSIONS The DIBH technique is superior to the FB technique when the heart needs further sparing, allowing a reduction of the doses to OARs with a slightly lower degree of plan complexity and without compromising plan deliverability. These benefits were achieved regardless of the technological scenarios adopted.
Collapse
Affiliation(s)
| | - Marco Esposito
- Medical Physics Unit, AUSL Toscana Centro, Florence, Italy
| | - Victor Hernandez
- Department of Medical Physics, Hospital Universitari Sant Joan de Reus, Tarragona, Spain
| | - Jordi Saez
- Radiation Oncology Department, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Lisa Paoletti
- Radiotherapy Unit, AUSL Toscana Centro, Florence, Italy
| | - Silvia Pini
- Medical Physics Unit, AUSL Toscana Centro, Florence, Italy
| | | | - Giacomo Reggiori
- Medical Physicist Group of Radiotherapy and Radiosurgery Dept., Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Giorgia Nicolini
- Medical Physics Team, Radiqa Developments, Bellinzona, Switzerland
| | - Eugenio Vanetti
- Medical Physics Team, Radiqa Developments, Bellinzona, Switzerland
| | - Stefano Tomatis
- Medical Physicist Group of Radiotherapy and Radiosurgery Dept., Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Dept, Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Pietro Mancosu
- Medical Physicist Group of Radiotherapy and Radiosurgery Dept., Humanitas Clinical and Research Hospital IRCCS, Milan-Rozzano, Italy
| |
Collapse
|
18
|
Ippolito E, Rinaldi CG, Silipigni S, Greco C, Fiore M, Sicilia A, Trodella L, D’Angelillo RM, Ramella S. Hypofractionated radiotherapy with concomitant boost for breast cancer: a dose escalation study. Br J Radiol 2019; 92:20180169. [PMID: 30433824 PMCID: PMC6541174 DOI: 10.1259/bjr.20180169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 10/04/2018] [Accepted: 11/02/2018] [Indexed: 12/25/2022] Open
Abstract
METHODS: Patients with breast cancer with pathological stage pT 1-2 and at least one risk factor for local recurrence such as N1 disease, lymphovascular invasion, extensive intraductal component, close margins, non-hormone sensitive disease, grading G3 were enrolled. Patients were treated with hypofractionated RT to whole breast with a dose of 40.05 Gy in 15 fractions. The dose was escalated to the tumour bed through a daily concomitant boost technique at three dose levels: 48 Gy (3.2 Gy/die), 50.25 Gy(3.35 Gy/die) and 52.5 Gy (3.5 Gy/die). Dose escalation to a higher step was carried out if all patients of the lower dose had completed the treatment without dose limiting toxicity (DLT). Skin toxicity, cosmetic evaluation and quality of life was evaluated at baseline, at treatment end and at 3 and 12 months after RT end. RESULTS: Three patients for each dose level were enrolled. No DLT occurred. The maximum toxicity collected during RT was G2 skin toxicity in 3 (33.3%) patients, one for each dose level. No G2 toxicity at 3 and 12 months was collected. At median follow up of 21.8 months (range: 13.5 - 40.9 months), no G2 late toxicity was recorded. CONCLUSION: The 3 week course of post-operative RT with dose escalation to the tumour bed to 52.5 Gy has been achieved without dose limiting toxicities and can be tested in Phase II trials. ADVANCES IN KNOWLEDGE: In our study, we tested the highest dose level to the tumour bed ever reported in studies using accelerated hypofractionation with concomitant boost in high risk patients.
Collapse
Affiliation(s)
- Edy Ippolito
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Sonia Silipigni
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Carlo Greco
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | - Michele Fiore
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Lucio Trodella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| | | | - Sara Ramella
- Radiotherapy Unit, Campus Bio-Medico University, Rome, Italy
| |
Collapse
|
19
|
Fiorentino A, Gregucci F, Mazzola R, Figlia V, Ricchetti F, Sicignano G, Giajlevra N, Ruggieri R, Fersino S, Naccarato S, Massocco A, Corradini S, Alongi F. Intensity-modulated radiotherapy and hypofractionated volumetric modulated arc therapy for elderly patients with breast cancer: comparison of acute and late toxicities. LA RADIOLOGIA MEDICA 2018; 124:309-314. [PMID: 30547358 DOI: 10.1007/s11547-018-0976-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the differences between conventional fractionated intensity-modulated radiotherapy (IMRT) and hypofractionated (HypoRT) volumetric modulated arc therapy (VMAT) in elderly women affected by early-stage breast cancer (BC) in terms of RT-related acute/late side effect. MATERIALS AND METHODS Between October 2011 and July 2015, 80 consecutive elderly BC patients were treated with IMRT for 5 weeks (40 patients) or HypoRT-VMAT for 3 weeks (40 patients). Inclusion criteria were: age ≥ 70 years, early BC (pT1-2 pN0-1), no prior neoadjuvant chemotherapy and non-metastatic disease. For patients receiving IMRT or HypoRT-VMAT, a total dose of 50 Gy (25 fractions) or 40.5 Gy (15 fractions) was prescribed to the whole ipsilateral breast, respectively. All patients received a simultaneously integrated boost up to a total dose of 60 Gy for IMRT and 48 Gy for HypoRT-VMAT. Acute and late side effects were evaluated using the RTOG/EORTC radiation morbidity scoring system. RESULTS With a median follow-up of 45 months, acute skin toxicity was overall very low, with grade 1 in 25 cases (62.5%) of the IMRT group and 21 cases (52.5%) of the HypoRT-VMAT group, while grade 2 toxicity was reported in 10 IMRT patients (25%) and 1 HypoRT-VMAT patient (2.5%) (p = 0.001). Regarding late adverse events, only grade 1 skin toxicity was recorded. CONCLUSION The present study showed that whole breast IMRT and HypoRT-VMAT are feasible and well tolerated in early-stage BC elderly patients and that HypoRT-VMAT is affected by lower risk of acute and late RT-related side effects.
Collapse
Affiliation(s)
- Alba Fiorentino
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Fabiana Gregucci
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - Rosario Mazzola
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Vanessa Figlia
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Francesco Ricchetti
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Gianluisa Sicignano
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Niccolo Giajlevra
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Ruggero Ruggieri
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Sergio Fersino
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Stefania Naccarato
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Alberto Massocco
- Breast Unit, Cancer Care Center, Ospedale Sacro Cuore don Calabria, Negrar, Verona, Italy
| | - Stefanie Corradini
- Radiation Oncology, Ludwig-Maximilians University of Munich, Munich, Germany
| | - Filippo Alongi
- Radiation Oncology, Cancer Care Center, Ospedale Sacro Cuore don Calabria, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
- University of Brescia, Brescia, Italy
| |
Collapse
|
20
|
Kammerer E, Fenoglietto P, Bourgier C. [Modalities and advantages of image guided radiation therapy of breast cancer in adjuvant setting]. Cancer Radiother 2018; 22:581-585. [PMID: 30145089 DOI: 10.1016/j.canrad.2018.07.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 07/07/2018] [Indexed: 11/18/2022]
Abstract
In adjuvant setting, breast cancer radiotherapy volumes include whole mammary gland or chest wall, and when indicated, nodal area such as axilla, supraclavicular, and internal mammary chain. An accurate patients positioning is required due to some geometric complexity of target volumes closed to organs at risk as heart and lung. Image guided radiation therapy allows such accuracy. Here we propose a review on image guided radiotherapy for breast cancer.
Collapse
Affiliation(s)
- E Kammerer
- Centre François-Baclesse, 3, avenue du Général-Harris, 14000 Caen, France
| | - P Fenoglietto
- Institut régional du cancer de Montpellier (ICM), Val d'Aurelle, 208, avenue des Apothicaires, 34298 Montpellier, France
| | - C Bourgier
- Institut régional du cancer de Montpellier (ICM), Val d'Aurelle, 208, avenue des Apothicaires, 34298 Montpellier, France; Inserm U1194, 641, avenue du Doyen Gaston-Giraud, 34000 Montpellier, France; Faculté de médecine, université de Montpellier, 641, avenue du Doyen Gaston-Giraud, 34000 Montpellier, France.
| |
Collapse
|
21
|
Mo JC, Huang J, Gu WD, Gao M, Ning ZH, Mu JM, Li QL, Pei HL. A dosimetric comparison of double-arc volumetric arc therapy, step-shoot intensity modulated radiotherapy and 3D-CRT for left-sided breast cancer radiotherapy after breast-conserving surgery. Technol Health Care 2018; 25:851-858. [PMID: 29103057 DOI: 10.3233/thc-160746] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the dosimetric and efficiency differences for left-sided breast cancer radiotherapy after breast-conserving surgery among three different planning techniques: double-arc volumetric-modulate arc therapy (VMAT), step-shoot intensity-modulated radiotherapy (sIMRT) and three-dimensional conformal radiation therapy (3D-CRT). MATERIALS AND METHODS A total of 17 female patients with left-sided breast cancer who underwent breast-conserving surgery were selected; the prescription doses were 50 Gy in 25 fractions. For every patient VMAT, sIMRT and 3D-CRT plans were generated within the Monaco treatment planning system for an Axesse™ accelerator equipped with the Agility MLC. The Conformity Index (CI), the Homogeneity Index (HI), the dose volume histogram (DVH) parameters for the organs at risk and the delivery efficiency were evaluated. RESULTS The VMAT plans showed on average higher CI of PTV (0.77 ± 0.03) than both sIMRT (0.68 ± 0.02) and 3D-CRT (0.55 ± 0.04) plans (P< 0.05). The HI values in the VMAT, sIMRT and 3D-CRT plans were 0.10 ± 0.01 0.09 ± 0.01 and 0.13 ± 0.01 (P> 0.05), respectively, and the differences among the three techniques were not statistically significant. In the ipsilateral lung, the VMAT plans showed lower Dmean, V30, V20, and V10 than the sIMRT and 3D-CRT (P< 0.05); however, there was no significant difference in V5. In the heart, the VMAT plans had lower V30 and V20 than the sIMRT and 3D-CRT plans (P< 0.05), but there was no significant difference in the Dmean and V5. In the contralateral lung, the VMAT plans showed higher Dmean and V5 than sIMRT and 3D-CRT (P< 0.05). In the contralateral breast, the VMAT plans had a higher V5 than the sIMRT and 3D-CRT plans (P< 0.05). The VMAT plans had higher MU's than sIMRT and 3D-CRT, while the treatment times were lower than that of sIMRT. CONCLUSION For left-sided breast cancer radiotherapy after breast-conserving surgery, the VMAT plans had a better CI than the sIMRT and 3D-CRT plans. The VMAT and the sIMRT plans had better HI than the 3D-CRT plans, but no significant difference was observed between VMAT and sIMRT.
Collapse
|
22
|
Tyran M, Tallet A, Resbeut M, Ferre M, Favrel V, Fau P, Moureau-Zabotto L, Darreon J, Gonzague L, Benkemouche A, Varela-Cagetti L, Salem N, Farnault B, Acquaviva MA, Mailleux H. Safety and benefit of using a virtual bolus during treatment planning for breast cancer treated with arc therapy. J Appl Clin Med Phys 2018; 19:463-472. [PMID: 29959819 PMCID: PMC6123145 DOI: 10.1002/acm2.12398] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 12/19/2022] Open
Abstract
Purpose This study evaluates the benefit of a virtual bolus method for volumetric modulated arc therapy (VMAT) plan optimization to compensate breast modifications that may occur during breast treatment. Methods Ten files were replanned with VMAT giving 50 Gy to the breast and 47 Gy to the nodes within 25 fractions. The planning process used a virtual bolus for the first optimization, then the monitors units were reoptimized without bolus, after fixing the segments shapes. Structures and treatment planning were exported on a second scanner (CT) performed during treatment as a consequence to modifications in patient's anatomy. The comparative end‐point was clinical target volume's coverage. The first analysis compared the VMAT plans made using the virtual bolus method (VB‐VMAT) to the plans without using it (NoVB‐VMAT) on the first simulation CT. Then, the same analysis was performed on the second CT. Finally, the level of degradation of target volume coverage between the two CT using VB‐VMAT was compared to results using a standard technique of forward‐planned multisegment technique (Tan‐IMRT). Results Using a virtual bolus for VMAT does not degrade dosimetric results on the first CT. No significant result in favor of the NoVB‐VMAT plans was noted. The VB‐VMAT method led to significant better dose distribution on a second CT with modified anatomies compared to NoVB‐VMAT. The clinical target volume's coverage by 95% (V95%) of the prescribed dose was 98.9% [96.1–99.6] on the second CT for VB‐VMAT compared to 92.6% [85.2–97.7] for NoVB‐VMAT (P = 0.0002). The degradation of the target volume coverage for VB‐VMAT is not worse than for Tan‐IMRT: the median differential of V95% between the two CT was 0.9% for VMAT and 0.7% for Tan‐IMRT (P = 1). Conclusion This study confirms the safety and benefit of using a virtual bolus during the VMAT planning process to compensate potential breast shape modifications.
Collapse
Affiliation(s)
- Marguerite Tyran
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Agnes Tallet
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Michel Resbeut
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Marjorie Ferre
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Veronique Favrel
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Pierre Fau
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Julien Darreon
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Laurence Gonzague
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Ahcene Benkemouche
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Naji Salem
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | - Bertrand Farnault
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| | | | - Hugues Mailleux
- Department of Radiation-Oncology, Institut Paoli-Calmettes, Marseille, France
| |
Collapse
|
23
|
Pazos M, Schönecker S, Reitz D, Rogowski P, Niyazi M, Alongi F, Matuschek C, Braun M, Harbeck N, Belka C, Corradini S. Recent Developments in Radiation Oncology: An Overview of Individualised Treatment Strategies in Breast Cancer. Breast Care (Basel) 2018; 13:285-291. [PMID: 30319331 DOI: 10.1159/000488189] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Radiation therapy (RT) for breast cancer has dramatically changed over the past years, leading to individualized risk-adapted treatment strategies. Historically, the choice of RT regimen was limited to conventional fractionation protocols using standard tangential fields. Nowadays, technological and technical improvements in modern RT have added a variety of other RT modalities, different fractionation schedules, and individualised treatment volumes to the portfolio of breast RT. This review aims to give a short overview on the main topics which have recently found their way into clinical practice: hypofractionated treatment protocols, accelerated partial breast irradiation (APBI) for low-risk patients, deep inspiration breath hold (DIBH) for maximal heart protection, extent of regional nodal irradiation for high-risk patients, and the implementation of new radiation techniques such as intensity modulated RT (IMRT) and volumetric modulated RT (VMAT).
Collapse
Affiliation(s)
- Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Schönecker
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Reitz
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Paul Rogowski
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Department of Radiation Oncology, Sacro Cuore Don Calbria Negrar, Verona, Italy.,University of Brescia, Brescia, Italy
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, Düsseldorf, Germany
| | - Michael Braun
- Department of Gynecology and Obstetrics, Red Cross Hospital, Munich, Germany
| | - Nadia Harbeck
- Breast Center, Department of Gynecology and Obstetrics, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
24
|
Mancosu P, Nicolini G, Goretti G, De Rose F, Franceschini D, Ferrari C, Reggiori G, Tomatis S, Scorsetti M. Applying Lean-Six-Sigma Methodology in radiotherapy: Lessons learned by the breast daily repositioning case. Radiother Oncol 2018. [DOI: 10.1016/j.radonc.2018.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
25
|
De Rose F, Fogliata A, Franceschini D, Iftode C, Torrisi R, Masci G, Sagona A, Tinterri C, Testori A, Gatzemeier W, Fernandes B, Rahal D, Cozzi L, Santoro A, Scorsetti M. Hypofractionated volumetric modulated arc therapy in ductal carcinoma in situ: toxicity and cosmetic outcome from a prospective series. Br J Radiol 2018; 91:20170634. [PMID: 29322827 DOI: 10.1259/bjr.20170634] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Hypofractionated radiotherapy in early stage breast cancer is an effective adjuvant treatment, but there is a lack of randomized data for patients with ductal carcinoma in situ (DCIS). The aim of this study is the evaluation of skin toxicity and cosmesis, and early clinical outcome of DCIS patients enrolled in an institutional Phase II trial of hypofractionated breast irradiation. METHODS 137 DCIS patients were enrolled in the trial. All patients underwent volumetric modulated arc therapy (VMAT) to the whole breast with a total dose of 40.5 Gy in 15 fractions over 3 weeks, without tumour bed boost. Acute and late skin toxicities were recorded. Cosmetic outcomes were assessed as excellent/good or fair/poor. Early clinical outcome was reported. RESULTS Median age was 58 y.o. (range 30-86). The median follow-up time was 22 months (range 6-45). At the end of the radiotherapy, skin toxicity was grade G1 in 56% of the patients, G2 in 15%, no patients presented G3 toxicity. In the range of 3-9 months of follow-up, the skin toxicity was G1 in 28% of patients, no G2-G3 cases; cosmetic outcome was good/excellent in 95% of patients. In the follow-up interval of 9-24 months, the skin toxicity was G1 in 12% of patients, no G2-G3 toxicity; cosmetic outcome was good/excellent in 96% of patients. After an early evaluation of clinical outcomes, 5 patients (3.6%) presented an in-breast recurrence. CONCLUSION Hypofractionated radiotherapy using VMAT is a viable option for DCIS. A longer follow-up is needed to assess clinical outcomes and late toxicity. Advances in knowledge: The use of hypofractionated VMAT is dosimetrically feasible for treating breast DCIS.
Collapse
Affiliation(s)
- Fiorenza De Rose
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Antonella Fogliata
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Davide Franceschini
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Cristina Iftode
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Rosalba Torrisi
- 2 Department of Medical Oncology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Giovanna Masci
- 2 Department of Medical Oncology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Andrea Sagona
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Corrado Tinterri
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Alberto Testori
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Wolfgang Gatzemeier
- 3 Department of Breast Surgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Bethania Fernandes
- 4 Department of Pathology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Daoud Rahal
- 4 Department of Pathology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Luca Cozzi
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy.,5 Department of Biomedical Sciences, Humanitas University , Milan, Rozzano , Italy
| | - Armando Santoro
- 2 Department of Medical Oncology, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy
| | - Marta Scorsetti
- 1 Department of Radiotherapy and Radiosurgery, Humanitas Research Hospital and Cancer Center , Milan, Rozzano , Italy.,5 Department of Biomedical Sciences, Humanitas University , Milan, Rozzano , Italy
| |
Collapse
|
26
|
Cozzi L, Lohr F, Fogliata A, Franceschini D, De Rose F, Filippi AR, Guidi G, Vanoni V, Scorsetti M. Critical appraisal of the role of volumetric modulated arc therapy in the radiation therapy management of breast cancer. Radiat Oncol 2017; 12:200. [PMID: 29258539 PMCID: PMC5735809 DOI: 10.1186/s13014-017-0935-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023] Open
Abstract
Background The aim of this review is the critical appraisal of the current use of volumetric modulated arc therapy for the radiation therapy management of breast cancer. Both clinical and treatment planning studies were investigated. Material and methods A Pubmed/MEDLINE search of the National Library of Medicine was performed to identify VMAT and breast related articles. After a first order rejection of the irrelevant findings, the remaining articles were grouped according to two main categories: clinical vs. planning studies and to some sub-categories (pointing to significant technical features). Main areas of application, dosimetric and clinical findings as well as areas of innovations were defined. Results A total of 131 articles were identified and of these, 67 passed a first order selection. Six studies reported clinical results while 61 treatment dealed with treatment planning investigations. Among the innovation lines, the use of high intensity photon beams (flattening filter free), altered fractionation schemes (simultaneous integrated boost, accelerated partial breast irradiation, single fraction), prone positioning and modification of standard VMAT (use of dynamic trajectories or hybrid VMAT methods) resulted among the main relevant fields of interest. Approximately 10% of the publications reported upon respiratory gating in conjunction with VMAT. Conclusions The role of VMAT in the radiation treatment of breast cancer seems to be consolidated in the in-silico arena while still limited evidence and only one phase II trial appeared in literature from the clinical viewpoint. More clinical reports are needed to fully proove the expected dosimetric benefits demonstrated in the planning investigations.
Collapse
Affiliation(s)
- Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy. .,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.
| | - Frank Lohr
- Radiation Oncology Department, Ospedaliero-Universitaria, Modena, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy
| | - A R Filippi
- Department of Radiation Oncology, Osp. S. Luigi Gonzaga University Hospital, Torino, Italy
| | - Gabriele Guidi
- Medical Physics Department, Az. Ospedaliero-Universitaria, Modena, Italy
| | | | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano-Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Rozzano, Italy
| |
Collapse
|
27
|
Xi D, Ding Y, Hu R, Gu W, Mu J, Li Q. Advantages of a technique using two 50 degree arcs in simultaneous integrated boost radiotherapy for left-sidebreast cancer. Sci Rep 2017; 7:14748. [PMID: 29116237 PMCID: PMC5677093 DOI: 10.1038/s41598-017-15307-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/25/2017] [Indexed: 11/26/2022] Open
Abstract
This study evaluated radiotherapy techniques with 15 cases for simultaneous integrated boost to treat whole left breast and tumor bed following breast conserving surgery. Treatment plans were generated using three techniques: volumetric modulated arc therapy (VMAT) with a partial arc of 190° (1ARC), VMAT with two tangential mini-arcs of 50° each (2TARC) and intensity modulated radiation therapy with four fixed angle fields (4IMRT). Dosimetric parameters for the whole breast (Target), the boost tumor bed (Boost), and surrounding normal organs were compared. Chair Index (CHI) was introduced to evaluate the dose homogeneity in Target given the two levels of prescription dose. The dose coverage in Target was better in 1ARC and 2TARC than that in 4IMRT. The mean CHI in 1ARC (2.47) and 2TARC (2.62) were higher than that in 4IMRT (1.71, p < 0.05), and this indicated the dose homogeneity of Target was better in 1ARC and 2TARC than that in 4IMRT. The mean doses to right lung, and contralateral breast in 4IMRT were lower than those in 2TARC but the differences between them were small. 2TARC was better than 4IMRT with respect to the dose to ipsilateral lung and heart. Overall, 2TARC was optimal among three techniques.
Collapse
Affiliation(s)
- Dan Xi
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Yun Ding
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Rui Hu
- Department of Radiation Oncology, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, 213003, China
| | - Wendong Gu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Jinming Mu
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China
| | - Qilin Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Soochow University, The First Peoples' Hospital of Changzhou, Changzhou, 213003, China.
| |
Collapse
|
28
|
Which simultaneous-integrated boost (SIB) intensity-modulated radiotherapy (IMRT) technique is dosimetrically superior in the treatment of breast cancer; volumetric-modulated arc therapy (VMAT) or fixed field (ff) IMRT? JOURNAL OF RADIOTHERAPY IN PRACTICE 2017. [DOI: 10.1017/s1460396917000164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground and purposeTo determine which concomitant boost technique is dosimetrically superior in the treatment of breast cancer; volumetric-modulated arc therapy (VMAT) or fixed field intensity-modulated radiotherapy (ff-IMRT).Materials and methodsIn total, 30 breast patients were re-planned with both VMAT and fixed field concomitant boost intensity-modulated radiotherapy techniques. A hybrid technique was used delivering 80% of the dose through tangential beams and 20% through an integrated boost. A two-tailed t-test sample for means was used to compare the dosimetric differences between the techniques.ResultsMaximum dose was statistically lower for VMAT; 103·2 versus 103·7% for ff-IMRT along with statistically lower V2 Gy doses to the contralateral lung (0·7 versus 1·6%) and heart for both left- (19·0%/22·6%), and right- (5·5%/8·8%) sided patients, respectively. ff-IMRT boasted significantly lower ipsilateral lung V20, V18 and V10 Gy (7·9/8·6/13·1 versus 8·1/8·8/13·4%) than VMAT, respectively. No differences were found with minimum coverage, mean dose and V5 Gy to all organs at risk (OARs).ConclusionVMAT and ff-IMRT techniques demonstrate excellent target coverage and OAR sparing facilitated by the hybrid planning technique and deep inspiration breath hold. There is no obvious dosimetrically superior option between the two techniques. Reduced treatment times with VMAT make it more desirable to implement clinically.
Collapse
|
29
|
Fiorentino A, Mazzola R, Giaj Levra N, Fersino S, Ricchetti F, Di Paola G, Gori S, Massocco A, Alongi F. Comorbidities and intensity-modulated radiotherapy with simultaneous integrated boost in elderly breast cancer patients. Aging Clin Exp Res 2017; 30:533-538. [DOI: 10.1007/s40520-017-0802-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/14/2017] [Indexed: 12/11/2022]
|
30
|
Macchia G, Deodato F, Cilla S, Cammelli S, Guido A, Ferioli M, Siepe G, Valentini V, Morganti AG, Ferrandina G. Volumetric modulated arc therapy for treatment of solid tumors: current insights. Onco Targets Ther 2017; 10:3755-3772. [PMID: 28794640 PMCID: PMC5538686 DOI: 10.2147/ott.s113119] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Aim This article discusses the current use of volumetric modulated arc therapy (VMAT) techniques in clinical practice and reviews the available data from clinical outcome studies in different clinical settings. An overview of available literature about clinical outcomes with VMAT stereotactic/radiosurgical treatment is also reported. Materials and methods All published manuscripts reporting the use of VMAT in a clinical setting from 2009 to November 2016 were identified. The search was carried out in December 2016 using the National Library of Medicine (PubMed/Medline). The following words were searched: “volumetric arc therapy”[All Fields] OR “vmat”[All Fields] OR “rapidarc”[All Fields], AND “radiotherapy”[All Fields] AND “Clinical Trial”[All Fields]. Results Overall, 37 studies (21 prospective and 16 retrospective) fulfilling inclusion criteria and thus included in the review evaluated 2,029 patients treated with VMAT; of these patients, ~30.8% had genitourinary (GU) tumors (81% prostate, 19% endometrial), 26.2% head-and-neck cancer (H&NC), 13.9% oligometastases, 11.2% had anorectal cancer, 10.6% thoracic neoplasms (81% breast, 19% lung), and 7.0% brain metastases (BMs). Six different clinical scenarios for VMAT use were identified: 1) BMs, 2) H&NC, 3) thoracic neoplasms, 4) GU cancer, 5) anorectal tumor, and 6) stereotactic body radiation therapy (SBRT) performed by VMAT technique in the oligometastatic patient setting. Conclusion The literature addressing the clinical appropriateness of VMAT is scarce. Current literature suggests that VMAT, especially when used as simultaneous integrated boost or SBRT strategy, is an effective safe modality for all cancer types.
Collapse
Affiliation(s)
| | | | - Savino Cilla
- Medical Physics Unit, "Giovanni Paolo II" Foundation, Catholic University of the Sacred Heart, Campobasso
| | - Silvia Cammelli
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Alessandra Guido
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Martina Ferioli
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Giambattista Siepe
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Vincenzo Valentini
- Department of Radiation Oncology, Catholic University of the Sacred Heart, Rome
| | - Alessio Giuseppe Morganti
- Radiation Oncology Unit, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi Hospital, Bologna
| | - Gabriella Ferrandina
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome.,Department of Health Sciences and Medicine, University of Molise, Campobasso, Italy
| |
Collapse
|
31
|
Taylor C, Correa C, Duane FK, Aznar MC, Anderson SJ, Bergh J, Dodwell D, Ewertz M, Gray R, Jagsi R, Pierce L, Pritchard KI, Swain S, Wang Z, Wang Y, Whelan T, Peto R, McGale P. Estimating the Risks of Breast Cancer Radiotherapy: Evidence From Modern Radiation Doses to the Lungs and Heart and From Previous Randomized Trials. J Clin Oncol 2017; 35:1641-1649. [PMID: 28319436 PMCID: PMC5548226 DOI: 10.1200/jco.2016.72.0722] [Citation(s) in RCA: 488] [Impact Index Per Article: 69.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Purpose Radiotherapy reduces the absolute risk of breast cancer mortality by a few percentage points in suitable women but can cause a second cancer or heart disease decades later. We estimated the absolute long-term risks of modern breast cancer radiotherapy. Methods First, a systematic literature review was performed of lung and heart doses in breast cancer regimens published during 2010 to 2015. Second, individual patient data meta-analyses of 40,781 women randomly assigned to breast cancer radiotherapy versus no radiotherapy in 75 trials yielded rate ratios (RRs) for second primary cancers and cause-specific mortality and excess RRs (ERRs) per Gy for incident lung cancer and cardiac mortality. Smoking status was unavailable. Third, the lung or heart ERRs per Gy in the trials and the 2010 to 2015 doses were combined and applied to current smoker and nonsmoker lung cancer and cardiac mortality rates in population-based data. Results Average doses from 647 regimens published during 2010 to 2015 were 5.7 Gy for whole lung and 4.4 Gy for whole heart. The median year of irradiation was 2010 (interquartile range [IQR], 2008 to 2011). Meta-analyses yielded lung cancer incidence ≥ 10 years after radiotherapy RR of 2.10 (95% CI, 1.48 to 2.98; P < .001) on the basis of 134 cancers, indicating 0.11 (95% CI, 0.05 to 0.20) ERR per Gy whole-lung dose. For cardiac mortality, RR was 1.30 (95% CI, 1.15 to 1.46; P < .001) on the basis of 1,253 cardiac deaths. Detailed analyses indicated 0.04 (95% CI, 0.02 to 0.06) ERR per Gy whole-heart dose. Estimated absolute risks from modern radiotherapy were as follows: lung cancer, approximately 4% for long-term continuing smokers and 0.3% for nonsmokers; and cardiac mortality, approximately 1% for smokers and 0.3% for nonsmokers. Conclusion For long-term smokers, the absolute risks of modern radiotherapy may outweigh the benefits, yet for most nonsmokers (and ex-smokers), the benefits of radiotherapy far outweigh the risks. Hence, smoking can determine the net effect of radiotherapy on mortality, but smoking cessation substantially reduces radiotherapy risk.
Collapse
Affiliation(s)
- Carolyn Taylor
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Candace Correa
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Frances K. Duane
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Marianne C. Aznar
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Stewart J. Anderson
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Jonas Bergh
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - David Dodwell
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Marianne Ewertz
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Richard Gray
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Reshma Jagsi
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Lori Pierce
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Kathleen I. Pritchard
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Sandra Swain
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Zhe Wang
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Yaochen Wang
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Tim Whelan
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Richard Peto
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Paul McGale
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - for the Early Breast Cancer Trialists’ Collaborative Group
- Carolyn Taylor, Frances K. Duane, David Dodwell, Richard Gray, Zhe Wang, Yaochen Wang, Richard Peto, and Paul McGale, University of Oxford, Oxford, United Kingdom; Candace Correa, Regional Cancer Center, Utica, NY; Marianne C. Aznar, Rigshospitalet, Copenhagen; Marianne Ewertz, Odense University Hospital, Odense, Denmark; Stewart J. Anderson, University of Pittsburgh, Pittsburgh, PA; Jonas Bergh, Karolinska Institutet and University Hospital, Stockholm, Sweden; Reshma Jagsi and Lori Pierce, University of Michigan, Ann Arbor MI; Kathleen I. Pritchard, Sunnybrook Odette Cancer Centre, Toronto; Tim Whelan, Juravinski Cancer Centre and McMaster University, Hamilton, Ontario, Canada; and Sandra Swain, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| |
Collapse
|
32
|
Mondal D, Julka PK, Sharma DN, Jana M, Laviraj MA, Deo SVS, Roy S, Guleria R, Rath GK. Accelerated hypofractionated adjuvant whole breast radiation with simultaneous integrated boost using volumetric modulated arc therapy for early breast cancer: A phase I/II dosimetric and clinical feasibility study from a tertiary cancer care centre of India. J Egypt Natl Canc Inst 2017; 29:39-45. [DOI: 10.1016/j.jnci.2017.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 11/26/2022] Open
|
33
|
Fiorentino A, Mazzola R, Naccarato S, Giaj-Levra N, Fersino S, Sicignano G, Tebano U, Ricchetti F, Ruggieri R, Alongi F. Synchronous bilateral breast cancer irradiation: clinical and dosimetrical issues using volumetric modulated arc therapy and simultaneous integrated boost. Radiol Med 2017; 122:464-471. [PMID: 28224401 DOI: 10.1007/s11547-017-0741-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/06/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The aim of the present retrospective analysis was to evaluate dosimetric parameters, feasibility and outcome for Synchronous Bilateral Breast Cancer (SBBC) patients treated with adjuvant radiotherapy (RT) by Volumetric Modulated Arc Therapy (VMAT). METHODS From September 2011 to April 2016, 1100 Breast Cancer (BC) patients were referred to our institution to receive adjuvant breast RT, and those with SBBC were selected for the present analysis. A total of 16 patients were identified. A total dose of 50 Gy in 25 fractions was prescribed to the Planning Target Volume of the whole bilateral breast (PTVBN) with or without the supraclavicular and infraclavicular nodes, while a total dose of 60 Gy in 25 fractions was prescribed to the surgical bed (PTVboost). Several V xGy and Dx% parameters were analyzed for the PTVs, together with Conformity and Homogeneity indexes (CI, HI), and for the critical Organs at risk (OARs), lungs and heart first. RESULTS With a median follow-up of 24 months, no acute or late side effects more than grade 2 were observed. All patients are alive without any sign of disease. For target dose coverage, our observed inter-patients averages (±1 sd) were V 95% Dp = 96.7 ± 1.6% (96.3 ± 1.8%) to the left (right) PTVBN, V 95% Dp = 98.6 ± 2.7% (99.4 ± 0.9%) to the left (right) PTVboost, and D 2% = 64.4 ± 1.8 Gy (65.0 ± 2.0 Gy) to the left (right) PTVboost, respectively. With regard to the heart, the inter-patient average of D mean was 8.3 ± 3.3 Gy. For the lungs, the inter-patient average of D mean, V 5 Gy and V 20 Gy were 11.8 ± 2.3 Gy, 78.9 ± 15.3% and 15.7 ± 5%, respectively. CONCLUSIONS The present retrospective analysis showed the feasibility, tolerability and safety of VMAT in the treatment of SBBC patients. Further studies are necessary to confirm these preliminary data.
Collapse
Affiliation(s)
- Alba Fiorentino
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Rosario Mazzola
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy.
| | - Stefania Naccarato
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Niccolò Giaj-Levra
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Sergio Fersino
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Gianluisa Sicignano
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Umberto Tebano
- Radiation Oncology School, University of Padua, Padua, Italy
| | - Francesco Ricchetti
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Ruggero Ruggieri
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| | - Filippo Alongi
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, via Don Sempreboni 5, 37034, Negrar, Verona, Italy
| |
Collapse
|
34
|
Fogliata A, Seppälä J, Reggiori G, Lobefalo F, Palumbo V, De Rose F, Franceschini D, Scorsetti M, Cozzi L. Dosimetric trade-offs in breast treatment with VMAT technique. Br J Radiol 2017; 90:20160701. [PMID: 27885857 DOI: 10.1259/bjr.20160701] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE Breast planning with volumetric modulated arc therapy (VMAT) has been explored, especially for left-sided breast treatments, with the primary intent of lowering the heart dose and improving target dose homogeneity. As a trade-off, larger healthy tissue volumes would receive low dose levels, with the potential risk of increasing late toxicities and secondary cancer induction, although no clinical data are available today to confirm the risk level. The scope of this work is to explore the dosimetric trade-offs using two different VMAT plans. METHODS Two planning strategies for dual-partial-arc VMAT, RA_avoid and RA_full, with and without avoidance sectors, were explored in a cohort of 20 patients, for whole left breast irradiation for 40.05 Gy to the mean target dose in 15 fractions. Common dose objectives included a stringent dose homogeneity, mean dose to the heart <5 Gy, ipsilateral lung (Ilung) <8 Gy, contralateral lung (Clung) <2 Gy and contralateral breast (Cbreast) <3 Gy. RESULTS RA_full showed a better dose conformity, lower high-dose spillage in the healthy tissue and lower skin dose. RA_avoid presented a reduction of the mean doses for all critical structures: 51% to the heart, 12% to the Ilung, 81% to the Clung and 73% to the Cbreast. All differences were significant with p < 0.0001. CONCLUSION The adaptation of VMAT options to planning objectives reduced significantly the healthy tissue dose levels at the price of some high-dose spillage. Evaluation of the trade-offs for application to the different critical structures should drive in improving the usage of the VMAT technique for breast cancer treatment. Advances in knowledge: Different planning strategies in the same VMAT technique could give significant variations in dose distributions. The choice of the trade-offs would affect the possible future late toxicity and secondary cancer induction risk.
Collapse
Affiliation(s)
- Antonella Fogliata
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Jan Seppälä
- 2 Radiotherapy Department, Cancer Center, Kuopio University Hospital, Kuopio, Finland
| | - Giacomo Reggiori
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Francesca Lobefalo
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Valentina Palumbo
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Fiorenza De Rose
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Davide Franceschini
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Marta Scorsetti
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,3 Biomedical Science Department, Humanitas University, Milan-Rozzano, Italy
| | - Luca Cozzi
- 1 Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,3 Biomedical Science Department, Humanitas University, Milan-Rozzano, Italy
| |
Collapse
|
35
|
Paelinck L, Gulyban A, Lakosi F, Vercauteren T, De Gersem W, Speleers B, Monten C, Mulliez T, Berkovic P, van Greveling A, Decoster F, Coucke P, De Neve W, Veldeman L. Does an integrated boost increase acute toxicity in prone hypofractionated breast irradiation? A randomized controlled trial. Radiother Oncol 2017; 122:30-36. [PMID: 28062087 DOI: 10.1016/j.radonc.2016.12.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 12/15/2016] [Accepted: 12/19/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The safety of a simultaneous integrated boost (SIB) in combination with prone hypofractionated whole-breast irradiation (WBI) was investigated. MATERIALS AND METHODS 167 patients were randomized between WBI with a sequential boost (SeB) or SIB. All patients were treated in prone position to 40.05Gy in 15 fractions to the whole breast. In the control arm, a SeB of 10Gy in 4 fractions (negative surgical margins) or 14.88Gy in 6 fractions (transsection) was prescribed. In the experimental arm a SIB of 46.8 or 49.95Gy (negative and positive surgical margins, respectively) was prescribed. RESULTS Patient age was the only significantly different parameter between treatment arms with patients in the SIB arm being slightly older. In both arms, 6/83 patients developed moist desquamation. Grade 2/3 dermatitis was significantly more frequent in the SeB arm (38/83vs 24/83 patients, p=0.037). In the SIB and SeB arm, respectively, 36 patients (43%) and 51 patients (61%) developed pruritus (p=0.015). The incidence of oedema was lower in the SIB arm (59vs 68 patients), but not statistically significant (p=0.071). CONCLUSIONS The primary endpoint, moist desquamation, was not significantly different between treatment arms.
Collapse
Affiliation(s)
- Leen Paelinck
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium
| | - Akos Gulyban
- Dept. of Radiation Oncology, Liège University Hospital, Belgium
| | - Ferenc Lakosi
- Dept. of Radiation Oncology, Liège University Hospital, Belgium
| | - Tom Vercauteren
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium
| | - Werner De Gersem
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium; Dept. of Radiotherapy and Experimental Cancer Research, Ghent University, Belgium
| | - Bruno Speleers
- Dept. of Radiotherapy and Experimental Cancer Research, Ghent University, Belgium
| | - Christel Monten
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium; Dept. of Radiotherapy and Experimental Cancer Research, Ghent University, Belgium
| | - Thomas Mulliez
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium
| | | | | | | | - Philippe Coucke
- Dept. of Radiation Oncology, Liège University Hospital, Belgium
| | - Wilfried De Neve
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium; Dept. of Radiotherapy and Experimental Cancer Research, Ghent University, Belgium
| | - Liv Veldeman
- Dept. of Radiation Oncology, Ghent University Hospital, Belgium; Dept. of Radiotherapy and Experimental Cancer Research, Ghent University, Belgium.
| |
Collapse
|
36
|
Simultaneous integrated bilateral breast and nodal irradiation with volumetric arc therapy: case report and literature review. TUMORI JOURNAL 2016; 102:B295489C-37AA-4F8C-9614-317D2FB3B83F. [PMID: 27716877 DOI: 10.5301/tj.5000568] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2016] [Indexed: 11/20/2022]
Abstract
AIM For simultaneous bilateral breast cancer (SBBC) treatment, conventional radiotherapy (RT) has a number of critical shortcomings. Thus, the usefulness of volumetric arc therapy (VMAT) for SBBC is undeniable. CASE REPORT A 34-year-old woman with SBBC received neoadjuvant chemotherapy followed by breast-conserving surgery and bilateral lymph node dissection. Given the conservative surgery and the nodal involvement after neoadjuvant chemotherapy, bilateral adjuvant RT to the breasts and regional nodes with doses of 50 Gy in 25 fractions and a simultaneous integrated boost (SIB) of 60 Gy to the surgical bed was proposed. Monoisocentric VMAT using 2 pairs of arcs was performed with adequate target dose coverage and low doses to the organs at risk. The results of this case were compared with those of previous studies in terms of RT technique and irradiated volumes. CONCLUSIONS VMAT is feasible and safe in the treatment of SBBC with SIB and nodal irradiation.
Collapse
|
37
|
Three-dimensional conformal versus intensity modulated radiotherapy in breast cancer treatment: is necessary a medical reversal? Radiol Med 2016; 122:146-153. [DOI: 10.1007/s11547-016-0700-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
|
38
|
De Rose F, Fogliata A, Franceschini D, Navarria P, Villa E, Iftode C, D'Agostino G, Cozzi L, Lobefalo F, Mancosu P, Tomatis S, Scorsetti M. Phase II trial of hypofractionated VMAT-based treatment for early stage breast cancer: 2-year toxicity and clinical results. Radiat Oncol 2016; 11:120. [PMID: 27639373 PMCID: PMC5027088 DOI: 10.1186/s13014-016-0701-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/13/2016] [Indexed: 01/28/2023] Open
Abstract
Background To report toxicity and early clinical outcomes of hypofractionated simultaneous integrated boost (SIB) approach with Volumetric Modulated Arc Therapy (VMAT) as adjuvant treatment after breast-conserving surgery. Methods Patients presenting early-stage breast cancer were enrolled in a phase II trial. Eligibility criteria: age > 18 years old, invasive cancer or ductal carcinoma in situ (DCIS), Stage I-II (T < 3 cm and N ≤ 3), breast-conserving surgery without oncoplastic reconstruction. Any systemic therapy was allowed in neoadjuvant or adjuvant setting. All patients underwent VMAT-SIB technique to irradiate the whole breast and the tumor bed. Doses to whole breast and surgical bed were 40.5 Gy and 48 Gy, respectively, delivered in 15 fractions over 3 weeks. Acute and late skin toxicities were recorded. Cosmetic outcome was assessed as excellent/good or fair/poor. Results The present study focused on results of a cohort of 144 patients with a minimum follow-up of 24 months (median 37, range 24–55 months). Median age was 62 years old (range 30–88). All patients had an invasive carcinoma (no patients with DCIS were present in this subset). At one year, the highest reported skin toxicity was G1, in 14 % of the patients; this data dropped to 4 % at the last follow-up, after more than 2 years. Breast pain was recorded in 21.6 % of the patients 6 months after treatment, while it was present in 3.5 % of the patients at the last follow-up, showing a significant improvement with time. Correlation between liponecrosis and boost target volume was found not significant. Breast pain was correlated with breast volume. No pulmonary or cardiological toxicities were recorded. After an early evaluation of clinical outcomes, only one case presented disease relapse, as liver metastases. Conclusions The 3-week VMAT-SIB course as adjuvant treatment after breast-conserving surgery showed to be well tolerated and was associated with optimal local control. Long-term follow-up data are needed to assess late toxicity and clinical outcomes.
Collapse
Affiliation(s)
- Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.
| | - Davide Franceschini
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Piera Navarria
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Elisa Villa
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Cristina Iftode
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Giuseppe D'Agostino
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Research Hospital and Cancer Center, Milan-Rozzano, Italy.,Department of Biomedical Sciences, Humanitas University, Milan-Rozzano, Italy
| |
Collapse
|
39
|
Mondal D, Sharma DN. External beam radiation techniques for breast cancer in the new millennium: New challenging perspectives. J Egypt Natl Canc Inst 2016; 28:211-218. [PMID: 27595191 DOI: 10.1016/j.jnci.2016.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/26/2016] [Accepted: 08/01/2016] [Indexed: 11/17/2022] Open
Abstract
Radiation therapy in breast cancer has evolved dramatically over the past century. It has traveled a long path touching different milestones and taking unprecedented turns. At the end, a fine tune of clinical understanding, skill, technological advancement and translation of radiobiological understanding to clinical outcome has taken place. What all these have given is better survival with quality survivorship. It is thus prudent to understand breast irradiation in a new perspective suitable for the current millennium.
Collapse
Affiliation(s)
- Dodul Mondal
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India.
| | - Daya Nand Sharma
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi 110029, India
| |
Collapse
|
40
|
Calvo-Ortega JF, Moragues S, Pozo M, Casals J. Dosimetric feasibility of an "off-breast isocenter" technique for whole-breast cancer radiotherapy. Rep Pract Oncol Radiother 2016; 21:500-507. [PMID: 27698590 DOI: 10.1016/j.rpor.2016.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/26/2016] [Indexed: 11/17/2022] Open
Abstract
AIM To investigate the viability of placing the treatment isocenter at the patient midline for breast cancer radiotherapy in order to avoid the risk of collisions during image-guided setup and treatment delivery. BACKGROUND The use of kilovoltage orthogonal setup images has spread in last years in breast radiotherapy. There is a potential risk of an imaging system-patient collision when the isocenter is laterally placed. MATERIALS AND METHODS Twenty IMRT plans designed by placing the isocenter within the breast volume ("plan_ref"), were retrospectively replanned by shifting the isocenter at the patient's midline ("plan_off-breast"). An integrated simultaneous boost (SIB) technique was used. Multiple metrics for the planning target volumes (PTVs) and organs at risk (OARs) were compared for both approaches using a paired t test. RESULTS Comparing plan_ref vs. plan_off-breast, no significant differences in PTV coverage (V95%) were found (96.5% vs. 96.2%; p = 0.361 to PTVbreast; 97.0% vs. 97.0%; p = 0.977 to PTVtumor_bed). With regard to OARs, no substantial differences were observed in any analyzed metric: V5Gy (30.3% vs. 31.4%; p = 0.486), V20Gy (10.3% vs. 10.3%; p = 0.903) and mean dose (7.1 Gy vs. 7.1 Gy; p = 0.924) to the ipsilateral lung; V5Gy (11.2% vs. 10.0%; p = 0.459), V30Gy (0.7% vs. 0.6%; p = 0.251) and mean dose (2.3 Gy vs. 2.2 Gy; p = 0.400) to the heart; and average dose to the contralateral breast (0.4 Gy vs. 0.5 Gy; p = 0.107). CONCLUSIONS The off-breast isocenter solution resulted in dosimetrically comparable plans as the reference technique, avoiding the collision risk during the treatment session.
Collapse
Affiliation(s)
- Juan-Francisco Calvo-Ortega
- Servicio de Oncología Radioterápica, Hospital Quirón Barcelona, Plaza Alfonso Comín, 5, 08023 Barcelona, Spain
| | - Sandra Moragues
- Servicio de Oncología Radioterápica, Hospital Quirón Barcelona, Plaza Alfonso Comín, 5, 08023 Barcelona, Spain
| | - Miquel Pozo
- Servicio de Oncología Radioterápica, Hospital Quirón Barcelona, Plaza Alfonso Comín, 5, 08023 Barcelona, Spain
| | - Joan Casals
- Servicio de Oncología Radioterápica, Hospital Quirón Barcelona, Plaza Alfonso Comín, 5, 08023 Barcelona, Spain
| |
Collapse
|
41
|
Hamilton DG, Bale R, Jones C, Fitzgerald E, Khor R, Knight K, Wasiak J. Impact of tumour bed boost integration on acute and late toxicity in patients with breast cancer: A systematic review. Breast 2016; 27:126-35. [PMID: 27113229 DOI: 10.1016/j.breast.2016.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/24/2016] [Accepted: 03/11/2016] [Indexed: 01/13/2023] Open
Abstract
The purpose of this systematic review was to summarise the evidence from studies investigating the integration of tumour bed boosts into whole breast irradiation for patients with Stage 0-III breast cancer, with a focus on its impact on acute and late toxicities. A comprehensive systematic electronic search through the Ovid MEDLINE, EMBASE and PubMed databases from January 2000 to January 2015 was conducted. Studies were considered eligible if they investigated the efficacy of hypo- or normofractionated whole breast irradiation with the inclusion of a daily concurrent boost. The primary outcomes of interest were the degree of observed acute and late toxicity following radiotherapy treatment. Methodological quality assessment was performed on all included studies using either the Newcastle-Ottawa Scale or a previously published investigator-derived quality instrument. The search identified 35 articles, of which 17 satisfied our eligibility criteria. Thirteen and eleven studies reported on acute and late toxicities respectively. Grade 3 acute skin toxicity ranged from 1 to 7% whilst moderate to severe fibrosis and telangiectasia were both limited to 9%. Reported toxicity profiles were comparable to historical data at similar time-points. Studies investigating the delivery of concurrent boosts with whole breast radiotherapy courses report safe short to medium-term toxicity profiles and cosmesis rates. Whilst the quality of evidence and length of follow-up supporting these findings is low, sufficient evidence has been generated to consider concurrent boost techniques as an alternative to conventional sequential techniques.
Collapse
Affiliation(s)
- Daniel George Hamilton
- Epworth Radiation Oncology Research Centre, Epworth Richmond, 32 Erin St, Richmond VIC 3121, Australia; Epworth Radiation Oncology, Epworth Richmond, 32 Erin St, Richmond VIC 3121, Australia.
| | | | - Claire Jones
- Epworth Radiation Oncology, Epworth Richmond, 32 Erin St, Richmond VIC 3121, Australia
| | - Emma Fitzgerald
- Epworth Radiation Oncology, Epworth Richmond, 32 Erin St, Richmond VIC 3121, Australia
| | - Richard Khor
- Austin Health, Austin Hospital, 145 Studley Road, Heidelberg VIC 3121, Australia
| | - Kellie Knight
- Department of Medical Imaging & Radiation Sciences, School of Biomedical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton VIC 3800, Australia
| | - Jason Wasiak
- Epworth Radiation Oncology Research Centre, Epworth Richmond, 32 Erin St, Richmond VIC 3121, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| |
Collapse
|
42
|
Bahrainy M, Kretschmer M, Jöst V, Kasch A, Würschmidt F, Dahle J, Lorenzen J. Treatment of breast cancer with simultaneous integrated boost in hybrid plan technique : Influence of flattening filter-free beams. Strahlenther Onkol 2016; 192:333-41. [PMID: 26972086 DOI: 10.1007/s00066-016-0960-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/10/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The present study compares in silico treatment plans using hybrid plan technique during hypofractionated radiation of mammary carcinoma with simultaneous integrated boost (SIB). The influence of 6 MV photon radiation in flattening filter free (FFF) mode against the clinical standard flattening filter (FF) mode is to be examined. PATIENTS AND METHODS RT planning took place with FF and FFF radiation plans for 10 left-sided breast cancer patients. Hybrid plans were realised with two tangential IMRT fields and one VMAT field. The dose prescription was in line with the guidelines in the ARO-2010-01 study. The dosimetric verification took place with a manufacturer-independent measurement system. RESULTS Required dose prescriptions for the planning target volumes (PTV) were achieved for both groups. The average dose values of the ipsi- and contralateral lung and the heart did not differ significantly. The overall average incidental dose to the left anterior descending artery (LAD) of 8.24 ± 3.9 Gy in the FFF group and 9.05 ± 3.7 Gy in the FF group (p < 0.05) were found. The dosimetric verifications corresponded to the clinical requirements. FFF-based RT plans reduced the average treatment time by 17 s/fraction. CONCLUSION In comparison to the FF-based hybrid plan technique the FFF mode allows further reduction of the average LAD dose for comparable target volume coverage without adverse low-dose exposure of contralateral structures. The combination of hybrid plan technique and 6 MV photon radiation in the FFF mode is suitable for use with hypofractionated dose schemes. The increased dose rate allows a substantial reduction of treatment time and thus beneficial application of the deep inspiration breath hold technique.
Collapse
Affiliation(s)
- Marzieh Bahrainy
- Radiologische Allianz, Mörkenstrasse 47, 22767, Hamburg, Germany.
| | | | - Vincent Jöst
- Radiologische Allianz, Mörkenstrasse 47, 22767, Hamburg, Germany
| | - Astrid Kasch
- Radiologische Allianz, Mörkenstrasse 47, 22767, Hamburg, Germany
| | | | - Jörg Dahle
- Radiologische Allianz, Mörkenstrasse 47, 22767, Hamburg, Germany
| | - Jörn Lorenzen
- Radiologische Allianz, Mörkenstrasse 47, 22767, Hamburg, Germany
| |
Collapse
|
43
|
Aly MMOM, Abo-Madyan Y, Jahnke L, Wenz F, Glatting G. Comparison of breast sequential and simultaneous integrated boost using the biologically effective dose volume histogram (BEDVH). Radiat Oncol 2016; 11:16. [PMID: 26830843 PMCID: PMC4736177 DOI: 10.1186/s13014-016-0590-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 01/18/2016] [Indexed: 12/03/2022] Open
Abstract
Purpose A method is presented to radiobiologically compare sequential (SEQ) and simultaneously integrated boost (SIB) breast radiotherapy. Methods The method is based on identically prescribed biologically effective dose (iso-BED) which was achieved by different prescribed doses due to different fractionation schemes. It is performed by converting the calculated three-dimensional dose distribution to the corresponding BED distribution taking into consideration the different number of fractions for generic α/β ratios. A cumulative BED volume histogram (BEDVH) is then derived from the BED distribution and is compared for the two delivery schemes. Ten breast cancer patients (4 right-sided and 6 left-sided) were investigated. Two tangential intensity modulated whole breast beams with two other oblique (with different gantry angles) beams for the boost volume were used. The boost and the breast target volumes with either α/β = 10 or 3 Gy, and ipsi-lateral and contra-lateral lungs, heart, and contra-lateral breast as organs at risk (OARs) with α/β = 3 Gy were compared. Results Based on the BEDVH comparisons, the use of SIB reduced the biological breast mean dose by about 3 %, the ipsi-lateral lung and heart by about 10 %, and contra-lateral breast and lung by about 7 %. Conclusion BED based comparisons should always be used in comparing plans that have different fraction sizes. SIB schemes are dosimetrically more advantageous than SEQ in breast target volume and OARs for equal prescribed BEDs for breast and boost.
Collapse
Affiliation(s)
- Moamen M O M Aly
- Medical Radiation Physics/Radiation Protection, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .,Department of Radiotherapy and Nuclear Medicine, South Egypt Cancer Institute, Assiut University, Assiut, Egypt.
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .,Department of Radiation Oncology and Nuclear Medicine (NEMROCK), Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Lennart Jahnke
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Gerhard Glatting
- Medical Radiation Physics/Radiation Protection, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .,Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| |
Collapse
|
44
|
Fogliata A, Nicolini G, Bourgier C, Clivio A, De Rose F, Fenoglietto P, Lobefalo F, Mancosu P, Tomatis S, Vanetti E, Scorsetti M, Cozzi L. Performance of a Knowledge-Based Model for Optimization of Volumetric Modulated Arc Therapy Plans for Single and Bilateral Breast Irradiation. PLoS One 2015; 10:e0145137. [PMID: 26691687 PMCID: PMC4686991 DOI: 10.1371/journal.pone.0145137] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/26/2015] [Indexed: 11/19/2022] Open
Abstract
Purpose To evaluate the performance of a model-based optimisation process for volumetric modulated arc therapy, VMAT, applied to whole breast irradiation. Methods and Materials A set of 150 VMAT dose plans with simultaneous integrated boost were selected to train a model for the prediction of dose-volume constraints. The dosimetric validation was done on different groups of patients from three institutes for single (50 cases) and bilateral breast (20 cases). Results Quantitative improvements were observed between the model-based and the reference plans, particularly for heart dose. Of 460 analysed dose-volume objectives, 13% of the clinical plans failed to meet the constraints while the respective model-based plans succeeded. Only in 5 cases did the reference plans pass while the respective model-based failed the criteria. For the bilateral breast analysis, the model-based plans resulted in superior or equivalent dose distributions to the reference plans in 96% of the cases. Conclusions Plans optimised using a knowledge-based model to determine the dose-volume constraints showed dosimetric improvements when compared to earlier approved clinical plans. The model was applicable to patients from different centres for both single and bilateral breast irradiation. The data suggests that the dose-volume constraint optimisation can be effectively automated with the new engine and could encourage its application to clinical practice.
Collapse
Affiliation(s)
- Antonella Fogliata
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| | - Giorgia Nicolini
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Celine Bourgier
- Radiotherapy Department, ICM-Val d'Aurelle, Montpellier, France
| | | | - Fiorenza De Rose
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| | | | - Francesca Lobefalo
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| | - Pietro Mancosu
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| | - Stefano Tomatis
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| | - Eugenio Vanetti
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Marta Scorsetti
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| | - Luca Cozzi
- Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center, Milan-Rozzano, Italy
| |
Collapse
|
45
|
Avanzo M, Chiovati P, Boz G, Sartor G, Dozza F, Capra E. Image-guided volumetric arc radiotherapy of pancreatic cancer with simultaneous integrated boost: Optimization strategies and dosimetric results. Phys Med 2015; 32:169-75. [PMID: 26626610 DOI: 10.1016/j.ejmp.2015.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 08/28/2015] [Accepted: 11/07/2015] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To introduce volumetric modulated arc therapy treatments (VMAT) with simultaneous integrated boost (SIB) for pancreatic cancer and describe dosimetric results on a large patient series. METHODS AND MATERIALS 45 patients with pancreatic malignancies were treated with 18 MV single-arc VMAT. Image guidance was performed with daily online kilo-volt cone-beam computed tomography (CBCT). The conformity index (CI) and homogeneity index (HI) to the target volumes, PTV45Gy and PTV54Gy, and dose-volume indices to OARs from the QUANTEC task group were reported. The risk of clinical nephritis was evaluated using normal tissue complication probability (NTCP). Treatments were verified in-phantom with the Delta4 system. RESULTS Average CI was 1.06 with 95% confidence intervals (95% CI) of 0.97-1.22 for PTV45Gy and 1.17 (0.66-1.61) for PTV54Gy. HI of PTV54Gy was 1.06 (1.04-1.10). OAR constraints were achieved in all patients, except for kidneys V12Gy of 48 (35.4-72.3)%. NTCP of the kidneys was 0.98 (0.6-1.7)%. Kidneys V12Gy and V20Gy were inversely related to PTV54Gy CI and maximum dose. All in-phantom tests had gamma pass rates exceeding 95% with global 3% dose difference and 3 mm distance to agreement. Patient shifts measured with CBCT had 95% CI of -0.8, +0.8 in the RL, -0.7, +0.8 in the SI, and -0.8, +0.7 cm in the AP directions. CONCLUSIONS Dosimetric results of VMAT were excellent on PTVs and organs at risk. The kidneys represent the dose-limiting organ at risk for this technique. NTCP indicates that this technique is safe from radiation-induced side effects to the kidneys.
Collapse
Affiliation(s)
- Michele Avanzo
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy.
| | - Paola Chiovati
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Giovanni Boz
- Radiation Oncology Department, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Giovanna Sartor
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Francesca Dozza
- Radiation Oncology Department, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| | - Elvira Capra
- Medical Physics Unit, Centro di Riferimento Oncologico, 33081 Aviano, Italy
| |
Collapse
|
46
|
Lee HH, Hou MF, Chuang HY, Huang MY, Tsuei LP, Chen FM, Ou-Yang F, Huang CJ. Intensity modulated radiotherapy with simultaneous integrated boost vs. conventional radiotherapy with sequential boost for breast cancer - A preliminary result. Breast 2015; 24:656-60. [PMID: 26371691 DOI: 10.1016/j.breast.2015.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/19/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE This study was aimed to assess the acute dermatological adverse effect from two distinct RT techniques for breast cancer patients. We compared intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) and conventional radiotherapy followed by sequential boost (CRT-SB). METHODS The study population was composed of 126 consecutive female breast cancer patients treated with breast conserving surgery. Sixty-six patients received IMRT-SIB to 2 dose levels simultaneously. They received 50.4 Gy at 1.8 Gy per fraction to the whole breast and 60.2 Gy at 2.15 Gy per fraction to the tumor bed by integral boost. Sixty patients in the CRT-SB group received 50 Gy in 25 fractions to the whole breast followed by a boost irradiation to tumor bed in 5-7 fractions to a total dose of 60-64 Gy. Acute skin toxicities were documented in agreement with the Common Terminology Criteria for Adverse Events version 3 (CTCAE v.3.0). RESULTS Ninety-eight patients had grade 1 radiation dermatitis while 14 patients had grade 2. Among those with grade 2, there were 3 patients in IMRT-SIB group (4.5%) while 11 in CRT-SB group (18.3%). (P = 0.048) There was no patient with higher than grade 2 toxicity. Three year local control was 99.2%, 3-year disease free survival was 97.5% and 3-year overall survival was 99.2%. CONCLUSIONS A significant reduction in the severity of acute radiation dermatitis from IMRT-SIB comparing with CRT-SB is demonstrated.
Collapse
Affiliation(s)
- Hsin-Hua Lee
- Division of Radiation Oncology, Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Radiation Oncology, Antai Tian-Sheng Memorial Hospital, Pingtung, Taiwan
| | - Ming-Feng Hou
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of General Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; National Sun Yat-Sen University-Kaohsiung Medical University Joint Research Center, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Hung-Yi Chuang
- Faculty of Department of Public Health, College of Health Science, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Ming-Yii Huang
- Division of Radiation Oncology, Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Le-Ping Tsuei
- Division of Radiation Oncology, Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Radiation Oncology, Antai Tian-Sheng Memorial Hospital, Pingtung, Taiwan
| | - Fang-Ming Chen
- Department of General Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Fu Ou-Yang
- Department of General Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Jen Huang
- Division of Radiation Oncology, Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| |
Collapse
|
47
|
Wang CW, Zhou Y, Bai JP, Liu H, Liu Y, Shi GL, Ding JJ, Ma DH, Li WT, Xie PM, Yan Y. Application of Volumetric Modulated Arc Therapy and Simultaneous Integrated Boost Techniques to Prepare "Safe Margin" in the Rabbit VX2 Limb Tumor Model. Med Sci Monit 2015; 21:2397-405. [PMID: 26280694 PMCID: PMC4544349 DOI: 10.12659/msm.894909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background In this study, we aimed to establish the rabbit VX2 limb tumor model, and then prepare a “necrotic zone” as a safe margin by volumetric modulated arc therapy and simultaneous integrated boost (VMAT-SIB) technique applied in the areas where the tumor is located adjacent to the bone (GTVboost area). Material/Methods Rabbits in the control group (n=10) were not treated, while those in the test group (n=10) were treated with the SIB schedule delivering a dose of 40Gy, 35Gy, 30Gy, and 25Gy to the GTVboost, GTV (gross tumor volume), CTV (clinical target volume), and PTV (planning target volume) in 10 fractions. Magnetic resonance diffusion-weighted imaging (MRDWI), 3-dimensional power Doppler angiography (3D-PDA), and histological changes were observed after radiotherapy. Results After radiotherapy, the two groups showed a significant difference in the GTVboost area. In the test group, the tumor necrosis showed a significantly low signal in DWI and high signal in apparent diffusion coefficient (ADC) maps. The 3D-PDA observation showed that tumor vascular structures decreased significantly. Histological analysis demonstrated that a necrotic zone could be generated in the GTVboost area, and microscopic examination observed cell necrosis and fibroplasia. Conclusions This studies demonstrated the feasibility of using VMAT-SIB technique in the rabbit VX2 limb tumor model. The formation of a necrotic zone can be effectively defined as safe margin in the GTVboost area. showing potential clinical applicability.
Collapse
Affiliation(s)
- Chong-Wen Wang
- Department of Bone and Soft Tissue, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Yang Zhou
- Department of Bone and Soft Tissue, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Jing-Ping Bai
- Department of Bone and Soft Tissue, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Hao Liu
- Department of Radiotherapy, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Yan Liu
- Department of Magnetic Resonance Imaging, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Guang-Li Shi
- Department of Bone and Soft Tissue, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Jiao-Jiao Ding
- Department of Ultrasound, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Dong-Hui Ma
- Department of Radiotherapy, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Wen-Ting Li
- Department of Pathology, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Peng-Ming Xie
- Department of Bone and Soft Tissue, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| | - Yue Yan
- Department of Bone and Soft Tissue, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China (mainland)
| |
Collapse
|
48
|
|
49
|
Nitsche M, Dunst J, Carl UM, Hermann RM. Emerging Role of Hypofractionated Radiotherapy with Simultaneous Integrated Boost in Modern Radiotherapy of Breast Cancer. Breast Care (Basel) 2015; 10:320-4. [PMID: 26688679 DOI: 10.1159/000436951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Hypofractionated radiotherapy for breast cancer is becoming increasingly important. The scientific background of this development as well as the introduction of the simultaneous integrated boost to the primary tumor region in this context are discussed here.
Collapse
Affiliation(s)
- Mirko Nitsche
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Juergen Dunst
- Klinik für Strahlentherapie, Karl-Lennert-Krebscentrum, Universität Kiel, Germany
| | - Ulrich M Carl
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany
| | - Robert M Hermann
- Zentrum für Strahlentherapie und Radioonkologie, Bremen/Westerstede, Germany ; Abteilung Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Germany
| |
Collapse
|
50
|
Aly MMOM, Glatting G, Jahnke L, Wenz F, Abo-Madyan Y. Comparison of breast simultaneous integrated boost (SIB) radiotherapy techniques. Radiat Oncol 2015; 10:139. [PMID: 26156086 PMCID: PMC4495684 DOI: 10.1186/s13014-015-0452-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 07/02/2015] [Indexed: 12/18/2022] Open
Abstract
Purpose To dosimetrically evaluate different breast SIB techniques with respect to target coverage and organs at risk (OARs) doses. Methods Four IMRT techniques were compared in 12 patients. Three techniques employ tangential whole breast irradiation with either two coplanar fields (T-2F), or four non-coplanar fields (T-NC), or one Volumetric Modulated Arc Therapy (T-VMAT) for the boost volume. The fourth technique is a fully-modulated VMAT technique (f-VMAT). Dosimetric parameters were compared for the boost and breast target volumes as well as OARs. Delivery efficiency was analysed based on number of monitor units (MUs) and estimated delivery time. Results T-VMAT and f-VMAT ranked highest with respect to integral assessment of boost and breast treatment quality measures. T-VMAT significantly outperformed f-VMAT with respect to ipsi-lateral lung and left-sided patients’ heart volumes ≥ 5 Gy (35 % ± 5 % vs. 52 % ± 6 % and 11 % ± 5 % vs. 22 % ± 6 %, respectively). f-VMAT significantly outperformed T-VMAT with respect to ipsi-lateral lung volume ≥ 20 Gy (13 % ± 2 % vs. 15 % ± 3 %) and heart volume ≥ 30 Gy in left breast cancer (0 % ± 0 % vs. 1 % ± 1 %). T-VMAT and f-VMAT needed 442 ± 58 and 1016 ± 152 MUs, respectively. Conclusions The hybrid T-VMAT is considered the technique of choice due to its balance of quality, efficiency and dose to OARs.
Collapse
Affiliation(s)
- Moamen M O M Aly
- Medical Radiation Physics/Radiation Protection, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .,Department of Radiotherapy and Nuclear Medicine, South Egypt Cancer Institute, Assiut University, Assiut, Egypt.
| | - Gerhard Glatting
- Medical Radiation Physics/Radiation Protection, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .,Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Lennart Jahnke
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Frederik Wenz
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany. .,Department of Radiation Oncology and Nuclear Medicine (NEMROCK), Faculty of Medicine, Cairo University, Cairo, Egypt.
| |
Collapse
|