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Behzadi ST, Moser R, Kiesl S, Nano J, Peeken JC, Fischer JC, Fallenberg EM, Huber T, Haller B, Klein E, Kiechle M, Combs SE, Borm KJ. Tumor Contact With Internal Mammary Perforator Vessels as Risk Factor for Gross Internal Mammary Lymph Node Involvement in Patients With Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 119:1455-1463. [PMID: 38458496 DOI: 10.1016/j.ijrobp.2024.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/10/2024]
Abstract
PURPOSE The identification of internal mammary lymph node metastases and the assessment of associated risk factors are crucial for adjuvant regional lymph node irradiation in patients with breast cancer. The current study aims to investigate whether tumor contact with internal mammary perforator vessels is associated with gross internal mammary lymph node involvement. METHODS AND MATERIALS We included 297 patients with primary breast cancer and gross internal mammary (IMN+) and/or axillary metastases as well as 230 patients without lymph node metastases. Based on pretreatment dynamic contrast-enhanced magnetic resonance imaging, we assessed contact of the tumor with the internal mammary perforating vessels (IMPV). RESULTS A total of 59 patients had ipsilateral IMN+ (iIMN+), 10 patients had contralateral IMN+ (cIMN+), and 228 patients had ipsilateral axillary metastases without IMN; 230 patients had node-negative breast cancer. In patients with iIMN+, 100% of tumors had contact with ipsilateral IMPV, with 94.9% (n = 56) classified as major contact. In iIMN- patients, major IMPV contact was observed in only 25.3% (n = 116), and 36.2% (n = 166) had no IMPV contact at all. Receiver operating characteristic analysis revealed that "major IMPV contact" was more accurate in predicting iIMN+ (area under the curve, 0.85) compared with a multivariate model combining grade of differentiation, tumor site, size, and molecular subtype (area under the curve, 0.65). Strikingly, among patients with cIMN+, 100% of tumors had contact with a crossing contralateral IMPV, whereas in cIMN- patients, IMPVs to the contralateral side were observed in only 53.4% (iIMN+) and 24.8% (iIMN-), respectively. CONCLUSIONS Tumor contact with the IMPV is highly associated with risk of gross IMN involvement. Further studies are warranted to investigate whether this identified risk factor is also associated with microscopic IMN involvement and whether it can assist in the selection of patients with breast cancer for irradiation of the internal mammary lymph nodes.
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Affiliation(s)
- Sophie T Behzadi
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Rebecca Moser
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Sophia Kiesl
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Jana Nano
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Jan C Peeken
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Julius C Fischer
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Eva M Fallenberg
- Department of Radiology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Thomas Huber
- Department of Radiology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Bernhard Haller
- Institute of AI and Informatics in Medicine, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Evelyn Klein
- Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Marion Kiechle
- Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany; Deutsches Konsortium für translationale Krebsforschung (DKTK) - Partner Site Munich, Munich, Germany; Institute of Radiation Medicine, Helmholtz Zentrum München, Munich, Germany
| | - Kai J Borm
- Department of Radiation Oncology, TUM School of Medicine and Health, Technical University Munich (TUM), Klinikum rechts der Isar, Munich, Germany.
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Trampetti I, Cuenin M, Gérard K, Salleron J, Peiffert D, Charra-Brunaud C. Can we predict the cardiac benefit of deep inspiration breath hold for left breast and regional nodal irradiation? Cancer Radiother 2023; 27:407-412. [PMID: 37541798 DOI: 10.1016/j.canrad.2023.06.004] [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: 05/14/2023] [Accepted: 06/13/2023] [Indexed: 08/06/2023]
Abstract
PURPOSE Deep inspiration breath hold (DIBH) is used to decrease the dose of radiotherapy delivered to the heart. There is a need to define criteria to select patients with the potential to derive a real clinical benefit from DIBH treatment. Our study's main goal was to investigate whether two CT-scan cardiac anatomical parameters, cardiac contact distance in the parasagittal plane (CCDps) and lateral heart-to-chest distance (HCD), were predictive of unmet dosimetric cardiac constraints for left breast and regional nodal irradiation (RNI). MATERIALS AND METHODS This retrospective single-institution dosimetric study included 62 planning CT scans of women with left-sided breast cancer (BC) from 2016 to 2021. Two independent radiation oncologists measured HCD and CCDps twice to assess inter- and intra-observer reproducibility. Dosimetric constraints to be respected were defined, and dosimetric parameters of interest were collected for each patient. RESULTS Mean heart dose was 7.9Gy. Inter-rater reproducibility between the two readers was considered excellent. The mean heart dose constraint<8Gy was not achieved in 25 patients (40%) and was achieved in 37 patients (60%). There was a significant correlation between mean heart dose and HCD (rs=-0.25, P=0.050) and between mean heart dose and CCDps (rs=0.25, P=0.047). The correlation between HCD and CCDps and unmet cardiac dosimetric constraints was not statistically significant. CONCLUSION Our dosimetric analysis did not find that the cardiac anatomical parameters HCD and CCDps were predictive of unmet dosimetric cardiac constraints, nor that they were good predictors for cardiac exposure in left-sided BC radiotherapy comprising RNI.
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Affiliation(s)
- I Trampetti
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France; Faculté de médecine de Nancy, université de Lorraine, 9, avenue de la Forêt de Haye, 54505 Vandoeuvre-lès-Nancy, France.
| | - M Cuenin
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - K Gérard
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - J Salleron
- Unité de biostatistiques, institut de cancérologie de Lorraine, 54519 Vandoeuvre-lès-Nancy, France
| | - D Peiffert
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
| | - C Charra-Brunaud
- Département de radiothérapie, institut de cancérologue de Lorraine, 6, avenue de Bourgogne, 54519 Vandoeuvre-lès-Nancy, France
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Qi WX, Cao L, Xu C, Cai G, Chen J. The optimal regional irradiation volume for breast cancer patients: A comprehensive systematic review and network meta-analysis of published studies. Front Oncol 2023; 13:1081201. [PMID: 36798812 PMCID: PMC9927229 DOI: 10.3389/fonc.2023.1081201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
Background Currently, the optimal adjuvant regional nodal irradiation (RNI) volume for breast cancer (BC) remained controversial. We aimed to define the optimal RNI treatment volume for BC by using a comprehensive network meta-analysis (NMA) of published studies. Materials and methods PubMed, Embase, Medline, and Cochrane Central Register of Controlled Trials were searched from database inception to 30 May 2022. Studies assessing different adjuvant RNI volumes for BC were eligible for inclusion. The primary outcome was overall survival (OS), and secondary outcome was disease-free survival (DFS) and distant-metastasis-free survival (DMFS). Results A total of 29,640 BC patients from twenty studies were included. The pooled hazard ratio demonstrated that internal mammary node irradiation (IMNI) in BC patients significantly improved OS giving HR (hazard ratio) of 0.87 (95%CI: 0.83-0.91, p<0.001), DFS with HR of 0.78 (95%CI: 0.68-0.90, p<0.01), and DMFS with HR of 0.87 (95%CI: 0.79-0.97, p<0.01) when compared to controls. Sub-group analysis indicated that RNI with IMNI significantly improved OS (HR 0.87, 95%CI: 0.81-0.93, p<0.01), DFS (HR 0.65, 95%CI: 0.56-0.77, p<0.01), and DMFS (HR 0.90, 95%CI: 0.82-0.98, p=0.02) when compared to RNI without IMNI. NMA showed that CW/WB (chest wall/whole breast) + RNI with IMNI significantly improved DFS (HR 0.93, 95%CI: 0.86-1.00) and DMFS (HR 0.90, 95%CI: 0.81-0.99), but not for OS (HR 0.93, 95%CI: 0.84-1.03) when compared to CW/WB alone. Based on the analysis of the treatment ranking, CW/WB+RNI with IMNI appeared as the best treatment approach for BC patients. Conclusions Our pooled results demonstrated that RNI with IMNI yielded a significant survival advantage for BC patients. NMA showed that CW/WB+RNI with IMNI was the optimal radiation volume for BC patients.
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Affiliation(s)
| | | | | | | | - Jiayi Chen
- *Correspondence: Wei-Xiang Qi, ; Jiayi Chen,
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Sun GY, Wen G, Zhang YJ, Tang Y, Jing H, Fang H, Wang JY, Zhang JH, Zhao XR, Chen SY, Song YW, Jin J, Liu YP, Tang Y, Qi SN, Li N, Chen B, Lu NN, Li YX, Wang SL. Risk factors to identify the indication for regional nodal irradiation in T1-2N1M0 breast cancer: A joint analysis of 4,243 real-world cases from two institutions. Front Oncol 2022; 12:955381. [PMID: 36605447 PMCID: PMC9807655 DOI: 10.3389/fonc.2022.955381] [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: 05/28/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose The aim of this study is to evaluate the role of regional nodal irradiation (RNI) in patients with T1-2N1M0 breast cancer and to identify the subgroup that could benefit from RNI. Methods and materials A total of 4,243 women with pT1-2N1M0 breast cancer treated at two institutions in China were retrospectively reviewed. Survival rates were calculated by the Kaplan-Meier method and compared by the log-rank test. The association of risk factors with survival outcomes was evaluated using multivariable proportional hazards regression. Results A total of 932 patients (22.0%) received RNI. At a median follow-up of 5.9 years, the 5-year locoregional recurrence (LRR), distant metastasis (DM), disease-free survival (DFS), and overall survival (OS) rates were 4.0% and 7.2% (P = 0.001), 13.2% and 10.6% (P = 0.465), 85.0% and 84.7% (P = 0.131), and 93.9% and 92.8% (P = 0.004) in the RNI and non-RNI groups, respectively. Multivariate analysis revealed that RNI was an independent prognostic factor for lower LRR (P = 0.001) and longer DFS (P = 0.013). Patients were stratified into low-, intermediate-, and high-risk groups based on the eight non-therapeutic risk factors. RNI significantly decreased the 5-year LRR (2.2% vs. 7.0%, P = 0.001) and improved the 5-year DFS (88.8% vs. 84.9%, P = 0.015) and OS (95.8% vs. 93.9%, P = 0.010) in the intermediate-risk group. However, neither the low-risk group nor the high-risk group had survival benefit from RNI. Conclusion T1-2N1M0 breast cancer is a heterogeneous disease. We found that RNI only improved survival in the intermediate-risk group. It might be omitted in low-risk patients, and the role of RNI in high-risk patients needs further study.
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Affiliation(s)
- Guang-Yi Sun
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ge Wen
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, China,Department of Radiation Oncology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yu-Jing Zhang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, Guangdong, China
| | - Yu Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hao Jing
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Fang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Yang Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang-Hu Zhang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu-Ran Zhao
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Si-Ye Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yong-Wen Song
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Jin
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Ping Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Tang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu-Nan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning-Ning Lu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ye-Xiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,*Correspondence: Ye-Xiong Li, ; Shu-Lian Wang,
| | - Shu-Lian Wang
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,*Correspondence: Ye-Xiong Li, ; Shu-Lian Wang,
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Algara M, Rodríguez E, Martínez-Arcelus FJ, Salinas J, Sanz X, Beato I, Manso A, Soler A, Rodríguez JR, Frías A, Calín A, Juan G, Meireles P, Flaquer A. OPTimizing Irradiation through Molecular Assessment of Lymph node (OPTIMAL): a randomized clinical trial. Radiother Oncol 2022; 176:76-82. [PMID: 36210628 DOI: 10.1016/j.radonc.2022.09.006] [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: 03/01/2022] [Revised: 09/06/2022] [Accepted: 09/11/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE In breast cancer (BC) patients, the involvement of four or more lymph nodes (LN) is an indication of regional irradiation. The optimal treatment strategy remains unclear when fewer nodes are involved and lymphadenectomy is not performed. We designed a clinical trial to show the non-inferiority of Incidental (INC) compared to intentional (INT) irradiation of axillary nodes in patients with early-stage BC and low burden LN involvement. MATERIALS AND METHODS BC patients, cN0 (n = 487) undergoing breast conservation surgery and sentinel node biopsy, with total tumor load assessed by OSNA (One-Step Nucleic Acid Amplification) of 250-15,000 copies mRNA CK19/µL in sentinel LN were randomized to receive INC or INT nodal irradiation. The primary endpoint was 5-year disease-free survival (DFS). Secondary endpoints were locoregional recurrence (LRR), distant recurrence (DR), and acute and chronic toxicity (CT). RESULTS Five-years DFS were 93.7% (INC) and 93.8% (INT) (difference 0.1% [one-sided 95% CI < 5.7%]; non-inferiority p = 0.075). Cumulative Incidences of LRR were 3.5% (INC) and 3.4% (INT) (difference of 0.1% [<4.8%]; p = 0.021), and 5% (INC) and 3.5% (INT) (difference 1.4% [<6.0%]; non-inferiority p = 0.101) for DR. CT was more Incident with INT (26.9%) than with INC (19.2%), though the difference was not statistically significant (HR 1.39 [95% CI: 0.92, 2.10]; p = 0.11). CONCLUSION Intentional does not outperform incidental irradiation by more than 5.7% in terms of 5-year DFS, 4.8% for LRR, and 6% for DR. REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT02335957.
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Affiliation(s)
- Manuel Algara
- Radiation Oncology Department, Del Mar Hospital, Passeig Maritim 25, 08003 Barcelona, Spain.
| | - Elvira Rodríguez
- Radiation Oncology Department, Virgen del Rocío University Hospital, Av. Manuel Siurot, S/n, 41013 Sevilla, Spain.
| | - Francisco José Martínez-Arcelus
- Radiation Oncology Department, La Fe Polytechnic University Hospital, Av. Fernando Abril Martorell, 106, 46026 Valencia, Spain.
| | - Juan Salinas
- Radiation Oncology Department, Santa Lucia General University Hospital, C. Minarete, s/n, 30202 Cartagena, Spain.
| | - Xavier Sanz
- Radiation Oncology Department, Del Mar Hospital, Passeig Maritim 25, 08003 Barcelona, Spain.
| | - Inmaculada Beato
- Radiation Oncology Department, Castellón Provincial Hospital, Av. del Dr. Clarà, 19, 12002 Castellón de La Plana, Spain.
| | - Aurea Manso
- Radiation Oncology Department, La Paz University Hospital, P.° de la Castellana, 261, 28046 Madrid, Spain.
| | - Ana Soler
- Radiation Oncology Department, De La Ribera Hospital, km 1, Ctra. Corbera, 46600 Alzira, Spain.
| | - José Reyes Rodríguez
- Radiation Oncology Department, University Hospital of Leon, C. Altos de Nava, s/n, 24071 León, Spain.
| | - Andere Frías
- Radiation Oncology Department, de Cruces University Hospital, Plaza de Cruces, 48903 Barakaldo, Spain.
| | - Ana Calín
- Radiation Oncology Department, Gregorio Marañón University General Hospital, C. Dr. Esquerdo, 46, 28007 Madrid, Spain.
| | - Germán Juan
- Radiation Oncology Department, Cabueñes University Hospital, Los Prados, 395, 33394 Gijón, Spain.
| | - Pedro Meireles
- Radiation Oncology Department, São João Universitary Hospital Center, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal.
| | - Amanda Flaquer
- Radiation Oncology Department, Araba Txagorritxu University Hospital, Jose Atxotegi Kalea, s/n, 01009 Gasteiz, Spain.
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Tumor draining lymph nodes, immune response, and radiotherapy: Towards a revisal of therapeutic principles. Biochim Biophys Acta Rev Cancer 2022; 1877:188704. [DOI: 10.1016/j.bbcan.2022.188704] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/06/2022] [Accepted: 02/21/2022] [Indexed: 12/20/2022]
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Accelerated hypofractionated radiotherapy for chest wall and nodal irradiation using hybrid techniques. JOURNAL OF RADIOTHERAPY IN PRACTICE 2021. [DOI: 10.1017/s1460396921000601] [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
Abstract
Aim:
This study compares three different hybrid plans, for left-sided chest wall (CW) and nodal stations irradiation using a hypofractionated dose regimen.
Materials and methods:
Planning target volumes (PTVs) of 25 breast cancer patients that included CW, supraclavicular (SCL) and internal mammary node (IMN) were planned with 3 different hybrid techniques: 3DCRT+IMRT, 3DCRT+VMAT and IMRT+VMAT. All hybrid plans were generated with a hypofractionated dose prescription of 40·5 Gy in 15 fractions. Seventy per cent of the dose was planned with the base-dose component and remaining 30% of the dose was planned with the hybrid component. All plans were evaluated based on the PTVs and organs at risk (OARs) dosimetric parameters.
Results:
The results for PTVs parameters have shown that the 3DCRT+IMRT and 3DCRT+VMAT plans were superior in uniformity index to the IMRT+VMAT plan. The OARs dose parameters were comparable between hybrid plans. The IMRT+VMAT plan provided a larger low dose volume spread to the heart and ipsilateral lung (p < 0·001). The 3DCRT+VMAT plan required less monitor units and treatment time (p = 0·005) than other plans.
Conclusion:
The 3DCRT+VMAT hybrid plan showed superior results with efficient treatment delivery and provide clinical benefit by reducing both low and high dose levels.
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Figlia V, Simonetto C, Eidemüller M, Naccarato S, Sicignano G, De Simone A, Ruggieri R, Mazzola R, Matuschek C, Bölke E, Pazos M, Niyazi M, Belka C, Alongi F, Corradini S. Mammary Chain Irradiation in Left-Sided Breast Cancer: Can We Reduce the Risk of Secondary Cancer and Ischaemic Heart Disease with Modern Intensity-Modulated Radiotherapy Techniques? Breast Care (Basel) 2021; 16:358-367. [PMID: 34602941 DOI: 10.1159/000509779] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction The aim of the present study was to estimate the impact of the addition of internal mammary chain (IMC) irradiation in node-positive left-sided breast cancer (BC) patients undergoing regional nodal irradiation (RNI) and comparatively evaluate excess relative and absolute risks of radiation-induced lung cancer/BC and ischaemic heart disease for intensity-modulated radiotherapy (IMRT) versus 3D conformal radiotherapy (3D-CRT). Methods Four treatment plans were created (3D-CRT and IMRT -/+ IMC) for each of the 10 evaluated patients, and estimates of excess relative risk (ERR) and 10-year excess absolute risk (EAR) were calculated for radiation-induced lung cancer/BC and coronary events using linear, linear-exponential and plateau models. Results The addition of IMC irradiation to RNI significantly increased the dose exposure of the heart, lung and contralateral breast using both techniques, increasing ERR for secondary lung cancer (58 vs. 44%, p = 0.002), contralateral BC (49 vs. 31%, p = 0.002) and ischaemic heart disease (41 vs. 27%, p = 0.002, IMRT plans). IMRT significantly reduced the mean cardiac dose and mean lung dose as compared to 3D-CRT, decreasing ERR for major coronary events (64% 3D-CRT vs. 41% IMRT, p = 0.002) and ERR for secondary lung cancer (75 vs. 58%, p = 0.004) in IMC irradiation, without a significant impact on secondary contralateral BC risks. Conclusion Although IMC irradiation has been shown to increase survival rates in node-positive BC patients, it increased dose exposure of organs at risk in left-sided BC, resulting in significantly increased risks for secondary lung cancer/contralateral BC and ischaemic heart disease. In this setting, the adoption of IMRT seems advantageous when compared to 3D-CRT.
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Affiliation(s)
- Vanessa Figlia
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | | | - Markus Eidemüller
- Institute of Radiation Medicine, Helmholtz Center Munich, Munich, Germany
| | - Stefania Naccarato
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Gianluisa Sicignano
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Antonio De Simone
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Ruggero Ruggieri
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Rosario Mazzola
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Filippo Alongi
- Advanced Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy.,University of Brescia, Brescia, Italy
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
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Excluding Lung Tissue from the PTV during Internal Mammary Irradiation. A Safe Technique for OAR-Sparing? Cancers (Basel) 2021; 13:cancers13081951. [PMID: 33919587 PMCID: PMC8073233 DOI: 10.3390/cancers13081951] [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: 02/22/2021] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022] Open
Abstract
Simple Summary The planning treatment volume (PTV) during internal mammary irradiation (IMNI) regularly overlaps with lung tissue and is often in close proximity to the heart. Thus, exclusion of lung tissue from the PTV is a potential technique to spare the organs at risk (OARs) during adjuvant breast cancer irradiation. Using an innovative dose recalculation and accumulation algorithm, we evaluated the safety of exclusion of lung tissue from the PTV. According to our data, exclusion of lung tissue from the PTV to spare the OARs leads to significant dose reduction in the target volume and can, therefore, not be recommended. Abstract The current study aims to determine whether exclusion of lung tissue from planning treatment volume (PTV) is a valid organ at risk (OAR)-sparing technique during internal mammary irradiation (IMNI). Twenty patients with left-sided breast cancer undergoing adjuvant radiotherapy including IMNI after mastectomy or lumpectomy with daily ConeBeam CT (CBCT; median n = 28) were enrolled in the current study. The daily dose distribution of the patients was estimated by recalculating treatment plans on CBCT-scans based on a standard PTV (PTV margin: 5mm-STD) and a modified PTV, which excluded overlapping lung tissue (ExLung). Using 3D-deformable dose accumulation, the dose coverage in the target volume was estimated in dependence of the PTV-margins. The estimated delivered dose in the IMN-CTV was significantly lower for the ExLung PTV compared to the STD PTV: ExLung: V95%: 76.6 ± 22.9%; V90%: 89.6 ± 13.2%, STD: V95%: 95.6 ± 7.4%; V90%: 99.1 ± 2.7%. Daily CBCT imaging cannot sufficiently compensate the anatomic changes and intrafraction movement throughout the treatment. Therefore, to ensure adequate delivery of the prescribed dose to the IMN-CTV, exclusion of lung tissue from the PTV to spare the OARs is not recommended.
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Algara López M, Rodríguez García E, Beato Tortajada I, Martínez Arcelus FJ, Salinas Ramos J, Rodríguez garrido JR, Sanz Latiesas X, Soler Rodríguez A, Juan Rijo G, Flaquer García A. OPTimizing Irradiation through Molecular Assessment of Lymph node (OPTIMAL): a randomized open label trial. Radiat Oncol 2020; 15:229. [PMID: 33008422 PMCID: PMC7531133 DOI: 10.1186/s13014-020-01672-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conservative surgery followed by breast and nodal irradiation is the standard loco-regional early breast cancer (BC) treatment for patients with four or more involved lymph nodes. However, the treatment strategy when fewer nodes are involved remains unclear, especially when lymphadenectomy has not been performed. Sensitive nodal status assessment molecular techniques as the One-Step Nucleic Acid Amplification (OSNA) assay can contribute to the definition and standardization of the treatment strategy. Therefore, the OPTIMAL study aims to demonstrate the feasibility of incidental irradiation of axillary nodes in patients with early-stage BC and limited involvement of the SLN. METHODS BC patients who underwent conservative surgery and whose SLN total tumour load assessed with OSNA ranged between 250-15,000 copies/µL will be eligible. Patients will be randomized to receive irradiation on the breast, tumour bed, axillary and supraclavicular lymph node areas (intentional arm) or only on the breast and tumour bed (incidental arm). All areas, including the internal mammary chain, will be contoured. The mean, median, D5% and D95% doses received in all volumes will be calculated. The primary endpoint is the non-inferiority of the incidental irradiation of axillary nodes compared to the intentional irradiation in terms of 5-year disease free survival. Secondary endpoints comprise the comparison of acute and chronic toxicity and loco-regional and distant disease recurrence rates. DISCUSSION Standardizing the treatment and diagnosis of BC patients with few nodes affected is crucial due to the lack of consensus. Hence, the quantitative score for the metastatic burden of SLN provided by OSNA can contribute by improving the discrimination of which BC patients with limited nodal involvement can benefit from incidental radiation as an adjuvant treatment strategy. TRIAL REGISTRATION ClinicalTrial.gov, NCT02335957; https://clinicaltrials.gov/ct2/show/NCT02335957.
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Affiliation(s)
- Manuel Algara López
- Radiation Oncology Department, Del Mar Hospital, Autonomous University of Barcelona, Hospital del Mar Medical Research Institute, Passeig Maritim, 25, 08003 Barcelona, Spain
| | | | | | | | - Juan Salinas Ramos
- Radiation Oncology Department, Santa Lucia General University Hospital, Cartagena, Spain
| | | | - Xavier Sanz Latiesas
- Radiation Oncology Department, Del Mar Hospital, Pompeu Fabra University, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Germán Juan Rijo
- Radiation Oncology Department, Cabueñes University Hospital, Gijón, Spain
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Borm KJ, Simonetto C, Kundrát P, Eidemüller M, Oechsner M, Düsberg M, Combs SE. Toxicity of internal mammary irradiation in breast cancer. Are concerns still justified in times of modern treatment techniques? Acta Oncol 2020; 59:1201-1209. [PMID: 32619381 DOI: 10.1080/0284186x.2020.1787509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The purpose of this study was to estimate the additional risk of side effects attributed to internal mammary node irradiation (IMNI) as part of regional lymph node irradiation (RNI) in breast cancer patients and to compare it with estimated overall survival (OS) benefit from IMNI. MATERIAL AND METHODS Treatment plans (n = 80) with volumetric modulated arc therapy (VMAT) were calculated for 20 patients (4 plans per patient) with left-sided breast cancer from the prospective GATTUM trial in free breathing (FB) and in deep inspiration breath hold (DIBH). We assessed doses to organs at risk ((OARs) lung, contralateral breast and heart) during RNI with and without additional IMNI. Based on the OAR doses, the additional absolute risks of 10-year cardiac mortality, pneumonitis, and secondary lung and breast cancer were estimated using normal tissue complication probability (NTCP) and risk models assuming different age and risk levels. RESULTS IMNI notably increased the mean OAR doses. The mean heart dose increased upon IMNI by 0.2-3.4 Gy (median: 1.9 Gy) in FB and 0.0-1.5 Gy (median 0.4 Gy) in DIBH. However, the estimated absolute additional 10-year cardiac mortality caused by IMNI was <0.5% for all patients studied except 70-year-old high risk patients (0.2-2.4% in FB and 0.0-1.1% in DIBH). In comparison to this, the published oncological benefit of IMNI ranges between 3.3% and 4.7%. The estimated additional 10-year risk of secondary cancer of the lung or contralateral breast ranged from 0-1.5% and 0-2.8%, respectively, depending on age and risk levels. IMNI increased the pneumonitis risk in all groups (0-2.2%). CONCLUSION According to our analyses, the published oncological benefit of IMNI outweighs the estimated risk of cardiac mortality even in case of (e.g., cardiac) risk factors during VMAT. The estimated risk of secondary cancer or pneumonitis attributed to IMNI is low. DIBH reduces the estimated additional risk of IMNI even further and should be strongly considered especially in patients with a high baseline risk.
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Affiliation(s)
- Kai Joachim Borm
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | | | - Pavel Kundrát
- Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany
- Department of Radiation Dosimetry, Nuclear Physics Institute of the Czech Academy of Sciences, Prague, Czech Republic
| | - Markus Eidemüller
- Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | - Mathias Düsberg
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
| | - Stephanie Elisabeth Combs
- Department of Radiation Oncology, Technical University of Munich (TUM), München, Germany
- Institute of Radiation Medicine, Helmholtz Zentrum München, Neuherberg, Germany
- Deutsches Konsortium für Translationale Krebsforschung, (DKTK)-Partner Site Munich, München, Germany
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Utilization patterns and temporal trends of internal mammary nodal irradiation at a tertiary cancer center. Breast Cancer Res Treat 2020; 182:367-379. [PMID: 32474745 DOI: 10.1007/s10549-020-05708-0] [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: 03/21/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The role and uptake of internal mammary nodal irradiation (IMNI) is variable. This study was designed to quantify the rates and determinants of IMNI at a tertiary cancer center. METHODS Consecutively treated breast cancer patients receiving adjuvant locoregional radiation therapy (RT) from January 1, 2012 to December 31, 2017 were sorted by IMNI receipt, disease risk and time period of RT delivery (2012-2015 vs 2016-2017). Differences between risk categories and groups were evaluated using χ2/Fisher's and Mann-Whitney test for categorical and continuous variables, respectively. Univariable and multivariable logistic regression analysis was done to determine factors associated with IMNI receipt. RESULTS A total of 1566 patients were eligible, with 376 in Group 1 (IMNI), and 1190 in Group 2 (no IMNI). The proportion of patients receiving IMNI increased significantly each year (p < 0.0001), and 83% of patients receiving IMNI had pT1-2/pN1 disease. On univariable analysis, younger age, lymphovascular invasion, medial/central quadrant, higher stage, PR negative, mastectomy, axillary dissection, receipt of chemotherapy and nodal positivity had higher odds of IMNI. On multivariable analysis, younger age (p = < 0.001), medial/central quadrant (p = 0.0026), PR negative (p = 0.0011), mastectomy (p = 0.0055), increasing nodal positivity (p < 0.0001) and late cohort (p = 0.001) had increased likelihood of IMNI. The use of deep-inspiration breath hold was significantly higher in those receiving IMNI (45% vs 26%, p < 0.0001), and permitted achievement of acceptable mean heart and lung doses. CONCLUSIONS There was a significant increase in IMNI utilization after 2015. Younger age, medial/central quadrant, PR-negative and node-positive disease predicted for receipt of IMNI. Modern RT techniques permit the safe delivery of IMNI.
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Haussmann J, Corradini S, Nestle-Kraemling C, Bölke E, Njanang FJD, Tamaskovics B, Orth K, Ruckhaeberle E, Fehm T, Mohrmann S, Simiantonakis I, Budach W, Matuschek C. Recent advances in radiotherapy of breast cancer. Radiat Oncol 2020; 15:71. [PMID: 32228654 PMCID: PMC7106718 DOI: 10.1186/s13014-020-01501-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/18/2020] [Indexed: 01/08/2023] Open
Abstract
Radiation therapy is an integral part of the multidisciplinary management of breast cancer. Regional lymph node irradiation in younger trials seems to provide superior target coverage as well as a reduction in long-term toxicity resulting in a small benefit in the overall survival rate. For partial breast irradiation there are now two large trials available which support the role of partial breast irradiation in low risk breast cancer patients. Multiple randomized trials have established that a sequentially applied dose to the tumor bed improves local control with the cost of worse cosmetic results.
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Affiliation(s)
- Jan Haussmann
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Carolin Nestle-Kraemling
- Department of Gynecologic and Obstetrics, Evanglisches Krankenhaus Dusseldorf, Dusseldorf, Germany
| | - Edwin Bölke
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany.
| | | | - Bálint Tamaskovics
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Klaus Orth
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Eugen Ruckhaeberle
- Department of Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Tanja Fehm
- Department of Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Svjetlana Mohrmann
- Department of Gynecology, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Ioannis Simiantonakis
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Wilfried Budach
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
| | - Christiane Matuschek
- Medical Faculty, Department of Radiation Oncology, Heinrich Heine University, Dusseldorf, Germany
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