1
|
Prunaretty J, Lopez L, Cabaillé M, Bourgier C, Morel A, Azria D, Fenoglietto P. Evaluation of Ethos intelligent optimization engine for left locally advanced breast cancer. Front Oncol 2024; 14:1399978. [PMID: 39015493 PMCID: PMC11250590 DOI: 10.3389/fonc.2024.1399978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/13/2024] [Indexed: 07/18/2024] Open
Abstract
Purpose To evaluate the feasibility to use a standard Ethos planning template to treat left-sided breast cancer with regional lymph nodes. Material/Methods The tuning cohort of 5 patients was used to create a planning template. The validation cohort included 15 patients treated for a locally advanced left breast cancer randomly enrolled. The Ethos planning template was tuned using standard 3 partial arc VMAT and two collimator rotation configurations: 45/285/345° and 30/60/330°. Re-planning was performed automatically using the template without editing. The study was conducted with a schedule of 42.3 Gy in 18 fractions to the breast/chestwall, internal mammary chain (IMC) and regional lymph nodes ("Nodes"). The PTV was defined as a 3D extension of the CTV with a margin of 7 mm, excluding the 5mm below the skin. The manual treatment plans were performed using Eclipse treatment planning system with AAA and PO algorithms (v15.6) and a manual arc VMAT configuration and imported in Ethos TPS (v1.1) for a dose calculation with Ethos Acuros algorithm. The automated plans were compared with the manual plans using PTV and CTV coverage, homogeneity and conformity indices (HI and CN) and doses to organs at risk (OAR) via DVH metrics. For each plan, the patient quality assurance (QA) were performed using Mobius3D and gamma index. Finally, two breast radiation oncologists performed a blinded assessment of the clinical acceptability of each of the three plans (manual and automated) for each patient. Results The manual and automated plans provided suitable treatment planning as regards dose constraints. The dosimetric comparison showed the CTV_breast D99% were significantly improved with both automated plans (p< 0,002) while PTV coverage was comparable. The doses to the organs at risk were equivalent for the three plans. Concerning treatment delivery, the Ethos-45° and Ethos-30° plans led to an increase in MUs compared to the manual plans, without affecting the beam on time. The average gamma index pass rates remained consistently above 98% regardless of the type of plan utilized. In the blinded evaluation, clinicians 1 and 2 assessed 13 out of 15 plans for Ethos 45° and 11 out of 15 plans for Ethos 30° as clinically acceptable. Conclusion Using a standard planning template for locally advanced breast cancer, the Ethos TPS provided automated plans that were clinically acceptable and comparable in quality to manually generated plans. Automated plans also dramatically reduce workflow and operator variability.
Collapse
Affiliation(s)
- Jessica Prunaretty
- Radiotherapy Department, Montpellier Regional Cancer Institute, Montpellier, France
| | | | | | | | | | | | | |
Collapse
|
2
|
Zhang R, Xie Y, DiTusa C, Ohler R, Heins D, Bourgeois D, Guo B. Flattening Filter-Free Volumetric-Modulated Arc Radiotherapy for Left-Sided Whole-Breast, Partial-Breast, and Postmastectomy Irradiations. J Med Phys 2022; 47:166-172. [PMID: 36212208 PMCID: PMC9542989 DOI: 10.4103/jmp.jmp_146_21] [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: 11/29/2021] [Revised: 03/23/2022] [Accepted: 04/09/2022] [Indexed: 11/20/2022] Open
Abstract
Purpose: Unflattened photon beams exhibit many benefits over traditional flattened beams for radiotherapy (RT), but comprehensive evaluations of dosimetric results and beam-on time using flattening filter-free (FFF) beams for all types of breast irradiations are still lacking. The purpose of this study was to investigate if FFF RT can maintain equal or better dose coverage than standard flattened-beam RT while reducing doses to organs at risk (OARs) and beam-on time for various types of breast cancer irradiations. Methods and Materials: FFF volumetric-modulated arc therapy (FFF-VMAT) and standard VMAT (STD-VMAT) treatment plans were created for 15 whole-breast irradiation (WBI) patients with 50 Gy/25 fractions, 13 partial-breast irradiation (PBI) patients with 38.5 Gy/10 fractions, and 9 postmastectomy irradiation (PMI) patients with 50 Gy/25 fractions. Planning target volume (PTV) coverage and dose to OARs were evaluated. Results: Both techniques produced clinically acceptable plans for all three types of irradiations. For WBI, FFF-VMAT plans exhibited similar PTV and OARs evaluation metrics as STD-VMAT. For PBI, FFF-VMAT plans showed significantly lower mean and maximum doses for ipsilateral and contralateral lungs, contralateral breast, and heart. For PMI, FFF-VMAT plans showed significantly lower mean dose and V5 for contralateral breast but significantly higher Dmean, Dmax, and V20 for ipsilateral lung and significantly higher Dmean, V22.5, and V30 for heart. FFF-VMAT techniques significantly reduced beam-on time than STD-VMAT for all cases. Conclusion: This work has shown that FFF beams are most beneficial for small-field irradiation such as PBI, and breast cancer patients could potentially benefit from the shortened beam-on time.
Collapse
|
3
|
Breast cancer in the oldest old (≥ 89 years): Tumor characteristics, treatment choices, clinical outcomes and literature review. Eur J Surg Oncol 2020; 47:796-803. [PMID: 33097334 DOI: 10.1016/j.ejso.2020.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/04/2020] [Accepted: 10/07/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Risk of breast cancer increases with age and very few data are available in patients older than 89. METHODS A retrospective analysis on patients aged 89 and older treated between 2008 and 2019 at our certified breast center. The aim was to analyze clinical characteristics, decision-making, treatment, outcomes and open questions regarding this subpopulation for which there is a lack of guidelines. RESULTS 58 patients included. Tumor characteristics were analyzed, 85% patients underwent surgery of which 44% had a mastectomy. The median follow-up and overall survival were 20 and 76 months, respectively.The median survival of metastatic and non-metastatic patients were 14 and 50 months, respectively. Most patients did not receive any adjuvant treatment and among these 14% had a relapse. CONCLUSIONS Elderly patients should not be under or over-treated because of their age; they represent a large heterogeneous group deserving a sub-stratification for a better tailored treatment.
Collapse
|
4
|
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
|
5
|
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
|
6
|
External radiotherapy for breast cancer in the elderly. Aging Clin Exp Res 2017; 29:149-157. [PMID: 27837457 DOI: 10.1007/s40520-016-0655-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/12/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Breast cancer is the most common malignancy amongst elderly women and the main cause of mortality. A specific management for elderly woman is not clear because clinical trials are usually not customized for this subset of patients. AIMS The aim of this paper is to provide an overview of the available information on the main issues in the field of breast cancer radiotherapy in the elderly population. MATERIALS AND METHODS Authors discuss on different radiation treatments for breast cancer in the elderly, based on the data of the literature with a focus on new strategy: hypo-fractionation, accelerated partial breast irradiation, and the utility of a dose boost. DISCUSSION The treatment of breast cancer is not standardized in the elderly. The optimal management in this population often requires complex multidisciplinary supportive care due to multiple comorbidities to optimize their cancer care. CONCLUSIONS New options such as APBI or HyRT regimens should be taken into consideration and offered as a breach of duty to the elderly population. Furthermore, they should be extensively investigated through randomized clinical trials.
Collapse
|
7
|
Cabanne A, Schick U, Pradier O, Rivera S. [Establishing margins from CTV to PTV in breast cancer treatment]. Cancer Radiother 2016; 20:640-4. [PMID: 27614520 DOI: 10.1016/j.canrad.2016.07.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 07/24/2016] [Accepted: 07/28/2016] [Indexed: 12/25/2022]
Abstract
The benefit of postoperative radiotherapy for breast cancer both in terms of local control and overall survival is widely acknowledged. Today, technological advances in simulation imaging and positioning control enable the definition of new margins from CTV to PTV. Improvements in mathematical modeling of random and systematic errors impact the treatment plans. However, there is no universal absolute value to consistently determine the margins from CTV to PTV. It is down to each centre to assess and correct as much as possible uncertainties due to positioning and internal movements depending on techniques and methods used for the implementation of treatment and monitoring. IMRT and respiratory gating techniques for breast radiotherapy will be considered more systematically in the years to come.
Collapse
Affiliation(s)
- A Cabanne
- Service de radiothérapie, CHRU Morvan, 2, avenue Foch, 29200 Brest, France.
| | - U Schick
- Service de radiothérapie, CHRU Morvan, 2, avenue Foch, 29200 Brest, France
| | - O Pradier
- Service de radiothérapie, CHRU Morvan, 2, avenue Foch, 29200 Brest, France
| | - S Rivera
- Service A de radiothérapie, institut Gustave-Roussy, 114, rue Édouard-Vaillant, 94805 Villejuif cedex, France
| |
Collapse
|