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Gregucci F, Ciabattoni A. Challenges for breast radiotherapy with SIB: the IMPORT HIGH trial. Lancet 2024; 403:1751-1752. [PMID: 38704170 DOI: 10.1016/s0140-6736(24)00357-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 02/20/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Fabiana Gregucci
- Department of Radiation Oncology, Weill Cornell Medicine, New York, NY 10065, USA.
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2
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Gnerucci A, Esposito M, Ghirelli A, Pini S, Paoletti L, Barca R, Fondelli S, Alpi P, Grilli B, Rossi F, Scoccianti S, Russo S. Robustness analysis of surface-guided DIBH left breast radiotherapy: personalized dosimetric effect of real intrafractional motion within the beam gating thresholds. Strahlenther Onkol 2024; 200:71-82. [PMID: 37380796 DOI: 10.1007/s00066-023-02102-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/16/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE The robustness of surface-guided (SG) deep-inspiration breath-hold (DIBH) radiotherapy (RT) for left breast cancer was evaluated by investigating any potential dosimetric effects due to the residual intrafractional motion allowed by the selected beam gating thresholds. The potential reduction of DIBH benefits in terms of organs at risk (OARs) sparing and target coverage was evaluated for conformational (3DCRT) and intensity-modulated radiation therapy (IMRT) techniques. METHODS A total of 192 fractions of SGRT DIBH left breast 3DCRT treatment for 12 patients were analyzed. For each fraction, the average of the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift") during beam-on was evaluated and applied to the original plan isocenter. The dose distribution for the treatment beams with the new isocenter point was then calculated and the total plan dose distribution was obtained by summing the estimated perturbed dose for each fraction. Then, for each patient, the original plan and the perturbed one were compared by means of Wilcoxon test for target coverage and OAR dose-volume histogram (DVH) metrics. A global plan quality score was calculated to assess the overall plan robustness against intrafractional motion of both 3DCRT and IMRT techniques. RESULTS Target coverage and OAR DVH metrics did not show significant variations between the original and the perturbed plan for the IMRT techniques. 3DCRT plans showed significant variations for the left descending coronary artery (LAD) and the humerus only. However, none of the dose metrics exceeded the mandatory dose constraints for any of the analyzed plans. The global plan quality analysis indicated that both 3DCRT and IMRT techniques were affected by the isocenter shifts in the same way and, generally, the residual isocenter shifts more likely tend to worsen the plan in all cases. CONCLUSION The DIBH technique proved to be robust against residual intrafractional isocenter shifts allowed by the selected SGRT beam-hold thresholds. Small-volume OARs located near high dose gradients showed significant marginal deteriorations in the perturbed plans with the 3DCRT technique only. Global plan quality was mainly influenced by patient anatomy and treatment beam geometry rather than the technique adopted.
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Affiliation(s)
- A Gnerucci
- Department of Physics and Astronomy, University of Florence, Florence, Italy.
| | - M Esposito
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - A Ghirelli
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Pini
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - L Paoletti
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - R Barca
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Fondelli
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - P Alpi
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - B Grilli
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - F Rossi
- Radiotherapy Unit, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - S Scoccianti
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Russo
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
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3
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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.
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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
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4
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Montero A, Ciérvide R, Cañadillas C, Álvarez B, García-Aranda M, Alonso R, López M, Chen-Zhao X, Alonso L, Valero J, Sánchez E, Hernando O, García de Acilu P, Fernandez-Letón P, Rubio C. Acute skin toxicity of ultra-hypofractionated whole breast radiotherapy with simultaneous integrated boost for early breast cancer. Clin Transl Radiat Oncol 2023; 41:100651. [PMID: 37388711 PMCID: PMC10300060 DOI: 10.1016/j.ctro.2023.100651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/18/2023] [Accepted: 06/04/2023] [Indexed: 07/01/2023] Open
Abstract
Background Whole-breast irradiation (WBI) after breast conserving surgery (BCS) is indicated to improve loco-regional control and survival. Former studies showed that addition of tumor bed boost in all age groups significantly improved local control although no apparent impact on overall survival but with an increased risk of worse cosmetic outcome. Even though shortened regimens in 3 weeks are considered the standard, recent studies have shown the non-inferiority of a treatment regimen of 5 fractions in one-week in both locoregional control and toxicity profile, although simultaneous integrated boost (SIB) in this setting has been scarcely studied. Materials and Methods From March-2020 to March-2022, 383 patients with early breast cancer diagnosis and a median age of 56 years-old (range 30-99)were included in a prospective registry of ultra-hypofractionated WBI up to a total dose of 26 Gy in 5.2 Gy/fraction with a SIB of 29 Gy in 5.8 Gy/fraction in 272 patients (71%), 30-31 Gy in 6-6.2 Gy/fraction in 111 patients (29%) with close/focally affected margins. Radiation treatment was delivered by conformal 3-D technique in 366 patients (95%), VMAT in 16patients (4%) and conformal 3-D with deep inspiration breath hold (DIBH) in 4patients (1%). Ninety-three per cent of patients received endocrine therapy and 43% systemic or targeted chemotherapy. Development of acute skin complications was retrospectively reviewed. Results With a median follow-up of 18 months (range 7-31), all patients are alive without evidence of local, regional or distant relapse. Acute tolerance was acceptable, with null o mild toxicity: 182 (48%) and 15 (4%) patients developed skin toxicity grade 1 and 2 respectively; 9 (2%) and 2 (0.5%) patients breast edema grade 1and 2 respectively. No other acute toxicities were observed. We also evaluated development of early delayed complications and observed grade 1 breast edema in 6 patients (2%); grade 1 hyperpigmentation in 20 patients (5%); and grade 1 and 2 breast induration underneath boost region in 10(3%) and 2 patients (0.5%) respectively. We found a statistically significant correlation between the median PTVWBI and presence of skin toxicity (p = 0.028) as well as a significant correlation between late hyperpigmentation with the median PTVBOOST (p = 0.007) and the ratio PTVBOOST/PTVWBI (p = 0.042). Conclusion Ultra-hypofractionated WBI + SIB in 5 fractions over one-week is feasible and well tolerated, although longer follow-up is necessary to confirm these results.
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Affiliation(s)
- Angel Montero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Camilo José Cela, Madrid, Spain
| | - Raquel Ciérvide
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Beatriz Álvarez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | - Rosa Alonso
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Mercedes López
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Xin Chen-Zhao
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Leyre Alonso
- Department of Medical Physics, HM Hospitales, Madrid, Spain
| | - Jeannete Valero
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Emilio Sánchez
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | - Ovidio Hernando
- Department of Radiation Oncology, HM Hospitales, Madrid, Spain
| | | | | | - Carmen Rubio
- Department of Medical Physics, HM Hospitales, Madrid, Spain
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5
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Gnerucci A, Esposito M, Ghirelli A, Pini S, Paoletti L, Barca R, Fondelli S, Alpi P, Grilli B, Rossi F, Scoccianti S, Russo S. Surface-guided DIBH radiotherapy for left breast cancer: impact of different thresholds on intrafractional motion monitoring and DIBH stability. Strahlenther Onkol 2023; 199:55-66. [PMID: 36229656 DOI: 10.1007/s00066-022-02008-y] [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: 06/04/2022] [Accepted: 09/15/2022] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare two left breast cancer patient cohorts (tangential vs. locoregional deep-inspiration breath-hold - DIBH treatment) with different predefined beam gating thresholds and to evaluate their impact on motion management and DIBH stability. METHODS An SGRT-based clinical workflow was adopted for the DIBH treatment. Intrafractional monitoring was performed by tracking both the respiratory signal and the real-time displacement between the isocenter on the daily reference surface and on the live surface ("SGRT shift"). Beam gating tolerances were 5 mm/4 mm for the SGRT shifts and 5 mm/3 mm for the gating window amplitude for breast tangential and breast + lymph nodes locoregional treatments, respectively. A total of 24 patients, 12 treated with a tangential technique and 12 with a locoregional technique, were evaluated for a total number of 684 fractions. Statistical distributions of SGRT shift and respiratory signal for each treatment fraction, for each patient treatment, and for the two population samples were generated. RESULTS Lateral cumulative distributions of SGRT shifts for both locoregional and tangential samples were consistent with a null shift, whereas longitudinal and vertical ones were slightly negative (mean values < 1 mm). The distribution of the percentage of beam on time with SGRT shift > 3 mm, > 4 mm, or > 5 mm was extended toward higher values for the tangential sample than for the locoregional sample. The variability in the DIBH respiration signal was significantly greater for the tangential sample. CONCLUSION Different beam gating thresholds for surface-guided DIBH treatment of left breast cancer can impact motion management and DIBH stability by reducing the frequency of the maximum SGRT shift and increasing respiration signal stability when tighter thresholds are adopted.
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Affiliation(s)
- A Gnerucci
- Department of Physics and Astronomy, University of Florence, Florence, Italy.
| | - M Esposito
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - A Ghirelli
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Pini
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
| | - L Paoletti
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - R Barca
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Fondelli
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - P Alpi
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - B Grilli
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - F Rossi
- Radiotherapy Unit, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - S Scoccianti
- Radiotherapy Unit, Azienda USL Toscana Centro, Florence, Italy
| | - S Russo
- Medical Physics Unit, Azienda USL Toscana Centro, Florence, Italy
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6
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Kim N, Kim YB. Journey to hypofractionation in radiotherapy for breast cancer: critical reviews for recent updates. Radiat Oncol J 2022; 40:216-224. [PMID: 36606299 PMCID: PMC9830038 DOI: 10.3857/roj.2022.00577] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/11/2022] [Indexed: 12/27/2022] Open
Abstract
Historical conventional fractionated radiation therapy (RT) for breast cancer consisted of 1.8-2.0 Gy per fraction with a total dose of 45-60 Gy over 5-7 weeks. Based on radiobiological characteristics, a low α/β is suspected of breast cancer resulting in sensitivity to higher dose per fraction (2.5-3.0 Gy). Over the past 10 years, multiple clinical trials support the application of shorter treatment regimen with hypofractionated RT (HypoRT). Recently, ultra-HypoRT with 5 fractions showed favorable outcomes. Although the safety and efficacy of HypoRT has been supported by high-quality randomized trials, there are still some worries and doubts around HypoRT from radiation oncologists. However, the radiation oncology community have now reached an important timepoint for adopting HypoRT during the COVID-19 pandemic. The aim of this review is to provide an overview of HypoRT in breast cancer based on prospective randomized trials and discuss the special consideration regarding HypoRT.
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Affiliation(s)
- Nalee Kim
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea,Correspondence: Yong Bae Kim Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. Tel: +82-2-2228-8095 Fax: +82-2-2227-7823, E-mail:
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7
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Adam R, Duong TQ, Hodges L, Lu J, Maldjian T. Internal mammary lymph nodal response to neoadjuvant chemotherapy on imaging and breast cancer prognosis. Ann Med Surg (Lond) 2022; 84:104900. [PMID: 36536730 PMCID: PMC9758323 DOI: 10.1016/j.amsu.2022.104900] [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: 08/17/2022] [Revised: 10/06/2022] [Accepted: 11/06/2022] [Indexed: 11/16/2022] Open
Abstract
Background Pathologic complete response (pCR) to neoadjuvant chemotherapy (NAC) is an important prognostic indicator in breast cancer. Internal mammary lymph node involvement is not currently included in pCR determination, as sampling at the time of surgery is not routinely performed. Methods Pre and post neoadjuvant chemotherapy MRI or PET/CT imaging response of the internal mammary lymph node chain was utilized as a surrogate to pCR and imaging data was correlated with patient outcomes. Results Internal mammary lymph node response to NAC was associated with disease free survival over the course of this study, regardless of whether axillary nodal pCR was achieved. Conclusion Internal mammary lymph nodal response to NAC is an important prognostic indicator. Potential use of internal mammary lymph node resolution as an imaging data input for AI models that predict pCR post-NAC may improve accuracy and other metrics in pCR prediction.
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Affiliation(s)
- Richard Adam
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Tim Q Duong
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Laura Hodges
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Jinyu Lu
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
| | - Takouhie Maldjian
- Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
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Yadav BS, Gupta S, Dahiya D, Gupta A, Oinam AS. Accelerated hypofractionated breast radiotherapy with simultaneous integrated boost: a feasibility study. Radiat Oncol J 2022; 40:127-140. [PMID: 35796116 PMCID: PMC9262700 DOI: 10.3857/roj.2021.01053] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/14/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose To assess the feasibility of accelerated hypofractionated radiotherapy with simultaneous integrated boost (SIB) in patients with breast cancer. Materials and Methods A total of 27 patients after breast-conserving surgery were included in this study. Patients were planned on a four-dimensional computerized tomogram, and contouring was done using RTOG guidelines. The dose was 34 Gy/10#/2 week to the breast and 40 Gy/10#/2 week to the tumor bed as SIB with volumetric modulated arc technique. The primary endpoint was grade 2 acute skin toxicity. Doses to the organs-at-risk were calculated. Toxicities and cosmesis were assessed using RTOG/LENT/SOMA and HARVARD/NSABP/RTOG grading scales, respectively. Disease-free survival (DFS) and overall survival (OS) were calculated with Kaplan-Meier curves. Results The mean age of the patients was 42 years. Left and right breast cancers were seen in 17 (63%) and 10 (37%) patients, respectively. The mean values of ipsilateral lung V16 and contralateral lung V5 were 16.01% and 3.74%, respectively. The mean heart doses from the left and right breast were 7.25 Gy and 4.37 Gy, respectively. The mean doses to the contralateral breast, oesophagus, and Dmax to brachial plexus were 2.64 Gy, 3.69 Gy, and 26.95 Gy, respectively. The mean value of thyroid V25 was 19.69%. Grade 1 and 2 acute skin toxicities were observed in 9 (33%) and 5 (18.5%) patients, respectively. Grade 2 hyperpigmentation, edema, and induration were observed in 1 (3.7%), 2 (7.4%), and 4 (14.8%) patients, respectively. Mild breast pain and arm/shoulder discomfort were reported by 1 (3.4%) patient. The median follow-up was 51 months (range, 12 to 61 months). At four years, breast induration, edema, and fibrosis were observed in 1 (3.7%) patient. Cosmesis was excellent and good in 21 (78%) and 6 (22%) patients, respectively. Local recurrence and distant metastases occurred in 1 (3.7%) and 2 (7.4%) patients, respectively. DFS and OS at four years were 88% and 92%, respectively. Conclusion With this radiotherapy schedule, acute and late toxicity rates were acceptable with no adverse cosmesis. Local control, DFS, and OS were good.
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Affiliation(s)
- Budhi Singh Yadav
- Department of Radiation Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Shipra Gupta
- Department of Radiation Oncology, National Cancer Institute, Jhajjar, India
| | - Divya Dahiya
- Department of General Surgery, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Ankita Gupta
- Department of Radiation Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Arun Singh Oinam
- Department of Radiation Oncology, Regional Cancer Centre, Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Duzenli C, Chan EK, Bergman AM, Grahame S, Singer J, Burns L, Olson RA. A novel carbon-fibre adjustable reusable accessory (CARA) for supine breast positioning to reduce toxicity in breast adjuvant radiotherapy: a study protocol for a multicentre phase III randomized controlled trial. BMC Cancer 2022; 22:673. [PMID: 35725457 PMCID: PMC9208179 DOI: 10.1186/s12885-022-09759-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/10/2022] [Indexed: 11/19/2022] Open
Abstract
Background A novel device for supine positioning in breast radiotherapy for patients with large or pendulous breasts has been developed and tested in phase II studies. This trial is designed to assess the efficacy of the device to reduce skin toxicity and unwanted normal tissue dose in comparison to the current clinical standard for supine breast support during breast radiotherapy. Methods Patients at high risk for moist desquamation, having infra-mammary fold or lateral ptosis, will be randomized into two arms. Patients in the control arm will receive breast radiotherapy with supine positioning using current standard of care. Patients in the experimental arm will be positioned supine with the novel device. The primary endpoint is the incidence of moist desquamation in the infra-mammary fold. We hypothesize a 20% reduction (from 50 to 30%) in the rate of moist desquamation in the study arm versus the control arm. For 80% power, two-tailed α = 0.05 and 10% loss to follow up, 110 patients will be assigned to each arm. The proportion of patients experiencing moist desquamation in the two arms will be compared using logistic regression adjusting for brassiere cup size, skin fold size, body mass index, smoking status, and dose fractionation schedule. An unadjusted comparison will also be made using the chi-square test, or Fisher’s exact test, if appropriate. Secondary endpoints include dose-volume statistics for the lung and heart, skin dose and clinical parameters including setup time, reproducibility, and staff experience with setup procedures. Patient-reported pain, skin condition interference with sleep and daily activities, and comfort during treatment are also secondary endpoints. Discussion Based on results from earlier phase II studies, it is expected that the device-enabled elimination of infra-mammary fold should reduce toxicity and improve quality of life for this patient population. Earlier studies showed reduction in dose to organs at risk including lung and heart, indicating potential for other long-term benefits for patients using the device. This study is limited to acute skin toxicity, patient-reported outcomes, and clinical factors to inform integration of the device into standard breast radiotherapy procedures. Trial registration Clinicaltrials.gov identifier: NCT04257396. Registered February 6 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09759-y.
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Affiliation(s)
- Cheryl Duzenli
- Department of Medical Physics, BC Cancer, Vancouver, BC, Canada. .,Department of Surgery, Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, BC, Canada. .,Department of Physics and Astronomy, University of British Columbia, Vancouver, BC, Canada.
| | - Elisa K Chan
- Department of Surgery, Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer, Vancouver, BC, Canada
| | - Alanah M Bergman
- Department of Medical Physics, BC Cancer, Vancouver, BC, Canada.,Department of Surgery, Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Physics and Astronomy, University of British Columbia, Vancouver, BC, Canada
| | - Sheri Grahame
- Department of Radiation Therapy, BC Cancer, Vancouver, BC, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, BC, Canada
| | - Levi Burns
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Robert A Olson
- Department of Surgery, Division of Radiation Oncology and Developmental Radiotherapeutics, University of British Columbia, Vancouver, BC, Canada.,Department of Radiation Oncology, BC Cancer - Centre for the North, Prince George, BC, Canada
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10
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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.
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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:
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11
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Long-term results of hypofractionation with concomitant boost in patients with early breast cancer: A prospective study. PLoS One 2021; 16:e0258186. [PMID: 34618862 PMCID: PMC8496829 DOI: 10.1371/journal.pone.0258186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 09/21/2021] [Indexed: 12/23/2022] Open
Abstract
Aim To report the long-term local control and survival of patients with early breast cancer who had hypofractionated whole breast irradiation with concomitant boost (Hypo-CB). Methods and materials Between October 2009 and June 2010, 73 patients with early breast cancer (T1-3N0-1M0) who underwent breast conserving surgery were enrolled into the study. Thirty-six of these participants received 50 Gy of conventional irradiation in 25 fractions over 5 weeks to the whole breast with a sequential boost to the tumor bed with 10–16 Gy in 5–8 fractions (Conv-SEQ). The other 37 participants received a hypofractionated dose of 43.2 Gy in 16 fractions with an additional daily concomitant boost (CB) of 0.6 Gy over 3 weeks (Hypo-CB). Results At a median follow-up time of 123 months, ipsilateral local recurrence (ILR) was found in 3 participants, 1 of whom was in the hypofractionated group. All 3 ILR were true local recurrence (TR). There were no significant differences in the 10-year disease free survival (DFS) and 10-year overall survival rates (OS) between the conventional and hypofractionated groups (93.9% vs. 94.4%, p = 0.96 and 91.9% vs. 91.6%, p = 0.792, respectively). Conclusion This study showed that the effectiveness, DFS and OS were comparable between hypofractionated whole breast irradiation with a CB and the conventional irradiation with a sequential boost.
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12
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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.
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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
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13
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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.
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14
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Colciago RR, Cavallo A, Magri MC, Vitullo A, La Rocca E, Giandini C, Bonfantini F, Di Cosimo S, Baili P, Sant M, Pignoli E, Valdagni R, Lozza L, De Santis MC. Hypofractionated whole-breast radiotherapy in large breast size patients: is it really a resolved issue? MEDICAL ONCOLOGY (NORTHWOOD, LONDON, ENGLAND) 2021; 38:107. [PMID: 34342725 DOI: 10.1007/s12032-021-01550-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to evaluate the impact of breast size on acute and late side effects in breast cancer (BC) patients treated with hypofractionated radiotherapy (Hypo-RT). In this study we analyzed patients over 50 years with a diagnosis of early BC, candidate for Hypo-RT after conservative surgery. Acute and late skin toxicities were evaluated in accordance with the RTOG scale. Multivariable logistic analysis was performed using dosimetric/anatomical factors resulted associated with toxicity outcome in univariable analysis. Among patients treated between 2009 and 2015, 425 had at least 5 years of follow-up. At RT end, acute skin toxicity ≥ G2 and edema ≥ G2 occurred in 88 (20.7%) and 4 (0.9%) patients, respectively. The multivariable analysis showed association of skin toxicity with boost administration (p < 0.01), treated skin area (TSA) receiving more than 20 Gy (p = 0.027) and breast volume receiving 105% of the prescription dose (V105%) (p = 0.016), but not breast size. At 5 years after RT, fibrosis ≥ G1 occurred in 89 (20.9%) patients and edema ≥ G1 in 36 (8.5%) patients. Fibrosis resulted associated with breast volume ≥ 1000 cm3 (p = 0.04) and hypertension (p = 0.04). As for edema, multivariable logistic analysis showed a correlation with hypertension and logarithm of age, but not with boost administration. Breast volume had an unclear impact (p = 0.055). A recurrent association was found between acute and late toxicities and breast V105%, which is correlated with breast size. This may suggest that a more homogenous RT technique may be preferred for patients with larger breast size.
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Affiliation(s)
- Riccardo Ray Colciago
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Radiotherapy, Università Degli Studi di Milano Bicocca, Milan, Italy
| | - Anna Cavallo
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Maria Chiara Magri
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Angelo Vitullo
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy
| | - Eliana La Rocca
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy. .,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy.
| | - Carlotta Giandini
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy
| | - Francesca Bonfantini
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Serena Di Cosimo
- Department of Applied Research and Technological Development (DRAST), Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Paolo Baili
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Emanuele Pignoli
- Medical Physics Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Riccardo Valdagni
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy.,Department of Oncology and Hemato-Oncology, Università Degli Studi di Milano, Milan, Italy.,Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laura Lozza
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy
| | - Maria Carmen De Santis
- Radiation Oncology 1, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Via Giacomo Venezian, 1, 23100, Milano, Italy
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15
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Vakaet V, Van Hulle H, Vergotte M, Schoepen M, Deseyne P, Van Greveling A, Post G, Speleers B, Paelinck L, Monten C, De Neve W, Veldeman L. 5-Year Outcomes of a Randomized Trial Comparing Prone and Supine Whole Breast Irradiation in Large-Breasted Women. Int J Radiat Oncol Biol Phys 2021; 110:766-771. [PMID: 33508375 DOI: 10.1016/j.ijrobp.2021.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Prone position for whole breast irradiation (WBI) results in lower rates of toxicity and reduced ipsilateral mean lung and heart doses. No randomized trials comparing toxicity and cosmesis at 5 years with prone and supine positioning are available. METHODS AND MATERIALS In this phase 2 open-label trial, 100 patients with large breast size requiring WBI were randomized between prone and supine positioning. Physician-assessed toxicity (retraction, fibrosis, edema, telangiectasia, pigmentation changes) was scored yearly for a total of 5 years, and photographs were taken at 5 years to assess cosmesis. The data were analyzed longitudinally and cross-sectionally. RESULTS Longitudinal analysis shows lower grade 2 late toxicity with prone positioning. The results for at least grade 1 physician-assessed toxicity at 5 years are similar between supine and prone position, respectively, for retraction (56% vs 54%), fibrosis outside the tumor bed (33% vs 24%), tumor bed fibrosis (49% vs 46%), edema (11% vs 8%), telangiectasia (8% vs 3%), and breast pain (6% vs 8%) using cross-sectional analysis. However, the risk of pigmentation changes in prone position (0% vs 19%) 5 years after radiation therapy was significantly lower. Cosmesis was good or excellent in 92% and 75% of patients who used prone and supine positioning, respectively. The 5-year overall survival is 96% in both groups. CONCLUSION Prone positioning results in reduced rates of late toxicity.
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Affiliation(s)
- Vincent Vakaet
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium.
| | - Hans Van Hulle
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Marie Vergotte
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Max Schoepen
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Industrial Systems Engineering and Product Design, Kortrijk, Belgium
| | - Pieter Deseyne
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | | | - Giselle Post
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Bruno Speleers
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Leen Paelinck
- Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Chris Monten
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Wilfried De Neve
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium; Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
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16
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Meduri B, De Rose F, Cabula C, Castellano I, Da Ros L, Grassi MM, Orrù S, Puglisi F, Trimboli RM, Ciabattoni A. Hypofractionated breast irradiation: a multidisciplinary review of the Senonetwork study group. Med Oncol 2021; 38:67. [PMID: 33970358 DOI: 10.1007/s12032-021-01514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/23/2021] [Indexed: 11/30/2022]
Abstract
The multidisciplinary management represents a crucial part of the care for cancer patients, resulting in better clinical and process outcomes, with evidence of improved survival among different cancer primary sites, including breast. According with international recommendations established by the European Society of Breast Cancer Specialists (EUSOMA), all breast-cancer patients have to be evaluated by a multidisciplinary team including radiologist, pathologist, surgeon, medical oncologist and radiation oncologist. Thus, variations in clinical practice of each specialty should be discussed and shared with all team members to guarantee a fruitful cooperation among the involved specialists. During the last decades, radiation treatment was deeply changed by the evidence-based adoption of hypofractionated radiotherapy (HFRT) as standard of treatment in patients with early-stage breast cancer undergoing conservative surgery. Moreover, mature randomized data have showed that partial breast irradiation (PBI) is an effective and safe alternative to whole breast irradiation in selected patients with low-risk early-stage breast cancer. Based on this background, we reviewed indications and critical issues of HFRT and PBI analyzing impact of their adoption from a multidisciplinary perspective.
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Affiliation(s)
- Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Fiorenza De Rose
- Radiation Oncology Unit, Santa Chiara Hospital, Largo Medaglie d'oro 9, 38123, Trento, Italy.
| | - Carlo Cabula
- Oncologic Surgery, A. Businco Oncologic Hospital, Cagliari, Italy
| | - Isabella Castellano
- Pathology Unit, Department of Medical Sciences, "City of Health and Science University Hospital", University of Turin, Turin, Italy
| | - Lucia Da Ros
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | | | - Sandra Orrù
- Pathology Unit, P.O. Businco, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Fabio Puglisi
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy.,Department of Medicine, University of Udine, Udine, Italy
| | - Rubina Manuela Trimboli
- Unit of Radiology, IRCCS Policlinico San Donato, Via Morandi 30 San Donato Milanese, 20097, Milan, Italy
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17
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Eldredge-Hindy H, Pan J, Rai SN, Reshko LB, Dragun A, Riley EC, McMasters KM, Ajkay N. A Phase II Trial of Once Weekly Hypofractionated Breast Irradiation for Early Stage Breast Cancer. Ann Surg Oncol 2021; 28:5880-5892. [PMID: 33738712 DOI: 10.1245/s10434-021-09777-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 02/07/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To report an interim analysis of a phase II trial of once weekly, hypofractionated breast irradiation (WH-WBI) following breast conserving surgery (BCS). METHODS Patients had stage 0-II breast cancer treated with breast BCS with negative margins. WH-WBI was 28.5 or 30Gy delivered to the whole breast using tangential beams with no elective coverage of lymph nodes. The primary endpoint was ipsilateral breast tumor recurrence (IBTR). Secondary endpoints were distant disease-free survival (DDFS), recurrence free survival (RFS), overall survival (OS), adverse events and cosmesis. RESULTS From 2011 to 2015, 158 patients received WH-WBI. Median follow up was 4.4 years (range 0.2-8.1). Stage distribution was DCIS 22%; invasive pN0 68%; invasive pN1 10%. 80 patients received 30 Gy and 78 received 28.5 Gy with median follow up times of 5.6 and 3.7 years, respectively. There were 5 IBTR events, all in the 30 Gy group. The 5- and 7- year risks of IBRT for all patients were 2.2% (95% CI 0.6-5.8) and 6.0% (95% CI 1.1-17.2), respectively. The 7-year rates of DDFS, RFS, and OS were 96.3%, 91.5% and 89.8%, respectively. Improvement in IBTR-free time was seen in DCIS, lobular histology, low grade tumors, Her2 negative tumors and 28.5 Gy dose (all p < 0.0001). CONCLUSIONS Disease-specific outcomes after WH-WBI are favorable and parallel those seen with conventional radiation techniques for stage 0-II breast cancer.
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Affiliation(s)
- Harriet Eldredge-Hindy
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA.
| | - Jianmin Pan
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA
| | - Shesh N Rai
- Biostatistics and Bioinformatics Facility, James Graham Brown Cancer Center, University of Louisville, Louisville, KY, USA.,Department of Bioinformatics and Biostatistics, School of Public Health and Information Sciences, University of Louisville, Louisville, KY, USA
| | - Leonid B Reshko
- Department of Radiation Oncology, Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY, USA
| | - Anthony Dragun
- Department of Radiation Oncology, MD Anderson Cancer Center at Cooper, Cooper University Health Care, Camden, NJ, USA
| | - Elizabeth C Riley
- Department of Medicine, Division of Medical Oncology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Kelly M McMasters
- Department of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, USA
| | - Nicolas Ajkay
- Department of Surgical Oncology, University of Louisville School of Medicine, Louisville, KY, USA
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18
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Dong J, Yang Y, Han D, Zhao Q, Liu C, Sun H, Wang Z, Lin H, Huang W. Hypofractionated Simultaneous Integrated Boost Radiotherapy Versus Conventional Fractionation Radiotherapy of Early Breast Cancer After Breast-Conserving Surgery: Clinical Observation and Analysis. Technol Cancer Res Treat 2021; 20:15330338211064719. [PMID: 34898315 PMCID: PMC8671664 DOI: 10.1177/15330338211064719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/28/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: The objective of this retrospective study is to evaluate the efficacy and safety of hypofractionated simultaneous integrated boost radiotherapy for early breast cancer patients undergoing breast-conserving surgery. Methods: A total of 185 women with early breast cancer undergoing breast-conserving surgery were retrospectively divided into hypofractionated simultaneous integrated boost group and conventional fractionation group. Hypofractionated simultaneous integrated boost included 104 patients and the dose of whole-breast radiation reached 42.56 Gy in 16 fractions and simultaneously tumor bed boost to 48 Gy in 16 fractions, which course of radiotherapy was 22 days. The 81 patients of the conventional fractionation group received whole breast radiation to 50 Gy in 25 fractions and followed by tumor bed boost to 10 Gy in 5 fractions, which course of radiotherapy was 40 days. Clinical information including patients' characteristics, skin toxicity, myelosuppression, radiation pneumonia, and cosmetic effects was recorded to analyze the influence of age, chemotherapy, position, and breast volume on the results of radiotherapy. Results: Hypofractionated simultaneous integrated boost group had no case of recurrence after a median follow-up of 25.6 months (9-47 months)) as compared with 2 after a median follow-up of 33.4 months (25-45 months) in the conventional fractionation group. The 2 groups had similar results in skin toxicity, cosmetic outcomes, and radiation pneumonia. In terms of myelosuppression, grade 1, grade 2, and grade 3 of myelosuppression in the hypofractionated simultaneous integrated boost group accounted for 16.7%, 12.3%, and 3.5% as compared with 30.0%, 21.1%, and 12.3% of the conventional fractionation group, respectively (P = .000). Conclusions: HF-SIB RT is a considerable option in patients after breast-conserving surgery with a lower degree of myelosuppression and shorter treatment time.
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Affiliation(s)
- Jinling Dong
- Department of Clinical Medicine, Weifang Medical University, Weifang, Shandong, China
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Ya Yang
- Department of Health Management Center, Affiliated Hospital of Jining Medical University, Jining, Shandong, China
| | - Dan Han
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Qian Zhao
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Chengxin Liu
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Hongfu Sun
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zhongtang Wang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Haiqun Lin
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Wei Huang
- Department of Radiation Oncology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong, China
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19
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Macchia G, Cilla S, Buwenge M, Zamagni A, Ammendolia I, Zamagni C, Frezza GP, Valentini V, Deodato F, Morganti AG. Intensity-Modulated Radiotherapy with Concomitant Boost After Breast Conserving Surgery: A Phase I-II Trial. BREAST CANCER-TARGETS AND THERAPY 2020; 12:243-249. [PMID: 33209058 PMCID: PMC7670173 DOI: 10.2147/bctt.s261587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 07/10/2020] [Indexed: 12/25/2022]
Abstract
Purpose A concomitant boost (CB) in patients treated with postoperative radiotherapy after conservative surgery of invasive breast cancer (BC) has been suggested for treatment time reduction and therapy intensification. The aim of this analysis was to assess long-term tolerability of a CB in patients treated with postoperative intensity Modulated Accelerated RAdiotherapy (MARA). Patients and Methods In this phase I–II trial, 321 patients with intermediate-high risk BC (pT1-4 with at least one of the following characteristics: pre or perimenopausal status, pN2-3, positive or close margins) were enrolled. Patients were treated with forward-planned intensity modulated radiotherapy (IMRT) and CB. A total dose of 50 Gy (2 Gy/fraction) and 60 Gy (2.4 Gy/fraction) was prescribed to the whole breast and the tumor bed, respectively. The potential impact of hypertension, diabetes, smoking habit, alcohol consumption, chemotherapy, and hormone therapy on both skin and subcutaneous late toxicity-free survival (LTFS) was evaluated. Survival curves were calculated using the Kaplan–Meier method. Results Median follow-up was 52 months (range: 3–115). Regional node irradiation, adjuvant chemotherapy and hormonal therapy were prescribed to 29.3%, 65.4% and 81.0% of patients, respectively. Five-year G2 and G3 skin LTFS were 95.6% and 100.0%, respectively. Five-year G2 and G3 subcutaneous LTFS were 80.0% and 98.6%, respectively. Only diabetes showed a significant correlation with worse G3 subcutaneous LTFS (p: 0.024). Five-year loco-regional control, metastasis-free survival, disease-free survival, and overall survival were 98.0%, 91.8%, 89.7% and 96.3%, respectively. Conclusion IMRT combined with CB was associated with a low risk of > G2 late toxicities (0.0% and 1.4% for skin and subcutaneous tissue, respectively). The cumulative actuarial incidence of local recurrences was 2.0% despite the exclusion of low-risk patients. Our results suggest that CB is safe and effective in patients with intermediate-high risk BC. Trial Registration ClinicalTrials.gov: NCT03471741.
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Affiliation(s)
- Gabriella Macchia
- Radiotherapy Unit, Gemelli Molise Hospital, Università Cattolica Del Sacro Cuore, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Università Cattolica Del Sacro Cuore, Campobasso, Italy
| | - Milly Buwenge
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine ‑ DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Alice Zamagni
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine ‑ DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Ilario Ammendolia
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine ‑ DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Claudio Zamagni
- Addarii Medical Oncology Unit, S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Vincenzo Valentini
- Dipartimento di Scienze Radiologiche, Radioterapiche ed Ematologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, UOC di Radioterapia, Rome, Italy.,Istituto di Radiologia, Università Cattolica Del Sacro Cuore, Rome, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Gemelli Molise Hospital, Università Cattolica Del Sacro Cuore, Campobasso, Italy
| | - Alessio G Morganti
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine ‑ DIMES, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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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]
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21
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Factors Affecting Mean Heart Dose in Patients Receiving Breast Radiotherapy from 2011 to 2018 in a Single Institution. J Med Imaging Radiat Sci 2020; 51:379-393. [DOI: 10.1016/j.jmir.2020.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/17/2020] [Accepted: 03/27/2020] [Indexed: 12/25/2022]
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22
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Lertbutsayanukul C, Pitak M, Ajchariyasongkram N, Rakkiet N, Seuree F, Prayongrat A. Long-term patient-rated cosmetic and satisfactory outcomes of early breast cancer treated with conventional versus hypofractionated breast irradiation with simultaneous integrated boost technique. Breast J 2020; 26:1946-1952. [PMID: 32648331 DOI: 10.1111/tbj.13960] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/12/2020] [Accepted: 06/12/2020] [Indexed: 12/20/2022]
Abstract
To compare patient-rated cosmetic and satisfactory outcomes between conventional fractionation with simultaneously integrated boost (C-SIB) vs hypofractionation with SIB (H-SIB) in early breast cancer. Patients with stage I and II breast cancer who received breast-conserving surgery followed by radiation with SIB to tumor bed and completed questionnaire were included in this study. Radiotherapy was as follows: C-SIB arm = 50 Gy and 65 Gy in 25 fractions and H-SIB arm = 43.2 Gy and 52.8 Gy in 16 fractions to the whole breast and tumor bed, respectively. Single cross-sectional assessment of the breast cosmesis was done by patients and radiation oncologist at a follow-up visit. Breast cosmetic and satisfaction scores were collected using a four-point Harvard/NSABP/RTOG cosmesis criteria scale and a four-point Likert-type scale, respectively. Of a total of 114 patients (C-SIB = 57) and (H-SIB = 57) arms, a median time from radiotherapy completion to questionnaire response was 7.2 years. Patient-rated cosmetic outcome in C-SIB vs H-SIB was "excellent" in 40.3% vs 45.6%, "good" in 33.3% vs 42.1%, "fair" in 21.1% vs 10.5%, and "poor" in 5.3% vs 1.8% (P = .288). Corresponding satisfaction was "very satisfied" in 52.6% vs 57.9%, "satisfied" in 40.4% vs 35.1%, "neutral" in 7.0% vs 5.2%, and "unsatisfied" in 0% vs 1.8% (P = .683). Stage I and older age at radiotherapy were predictors for favorable (good or excellent) cosmesis and satisfaction, respectively. In early-stage breast cancer, H-SIB provided a trend for better cosmesis than C-SIB while maintaining satisfaction. The reduction in treatment duration and cost as well as favorable cosmesis outcomes encourages the use of H-SIB.
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Affiliation(s)
- Chawalit Lertbutsayanukul
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Manida Pitak
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Nichakon Rakkiet
- Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Farinda Seuree
- Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Anussara Prayongrat
- 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, Bangkok, Thailand
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Hypofractionated Whole Breast Irradiation and Simultaneous Integrated Boost in Large-breasted Patients: Long-term Toxicity and Cosmesis. Clin Breast Cancer 2020; 20:527-533. [PMID: 32665192 DOI: 10.1016/j.clbc.2020.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 06/03/2020] [Accepted: 06/12/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the impact of breast size on long-term toxicity and cosmesis in patients with breast cancer treated with hypofractionated simultaneous integrated boost (SIB) using volumetric modulated arc therapy (VMAT). PATIENTS AND METHODS Patients with early stage breast cancer were treated with 3-week hypofractionated SIB-VMAT to the whole breast (40.5 Gy) and tumor bed (48 Gy). Two cohorts were identified: small/medium- (< 1000 cm3) and large- (> 1000 cm3) breasted patients. Acute and late (at 2 and 5 years) skin toxicity and cosmetic data were analyzed. Univariate and multivariate analysis evaluated associations between toxicity and dosimetric/anatomical variables. RESULTS From August 2010 to March 2017, a total of 1160 patients were treated; 831 had at least 2 years of follow-up and were analyzed. Treated skin area (TSA) receiving at least 20 Gy > 400 cm2 and V105% of Boost > 5 cm3 were significant predictors for acute skin toxicity. Multivariate analysis at 2 years was significant for boost volume > 70 cm3, TSA > 400 cm2, and breast size > 1500 cm3. At 5 year analysis (352 patients), none of the analyzed variables was significant. For cosmetic outcome, only the breast size (> 1000 cm3) and the boost size > 70 cm3 at 2 and 5 years, respectively, confirmed significance. CONCLUSIONS The TSA > 400 cm2 resulted as a significant predictor of both acute and late skin toxicity at 2 years; however, at 5 years, no breast size or dosimetric parameter suggested indications for increased toxicity. A worse cosmetic outcome was recorded at the 2-year follow up for large breasts, but was not confirmed at the 5-year follow-up. These long-term data suggest that hypofractionated SIB-VMAT is a viable modality also in large-breasted patients.
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Schmeel LC, Koch D, Schmeel FC, Röhner F, Schoroth F, Bücheler BM, Mahlmann B, Leitzen C, Schüller H, Tschirner S, Fuhrmann A, Heimann M, Brüser D, Abramian AV, Müdder T, Garbe S, Vornholt S, Schild HH, Baumert BG, Wilhelm-Buchstab TM. Acute radiation-induced skin toxicity in hypofractionated vs. conventional whole-breast irradiation: An objective, randomized multicenter assessment using spectrophotometry. Radiother Oncol 2020; 146:172-179. [PMID: 32171945 DOI: 10.1016/j.radonc.2020.02.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/11/2020] [Accepted: 02/23/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Radiation dermatitis represents one of the most frequent side effects in breast cancer patients undergoing adjuvant whole-breast irradiation (WBI). Whether hypofractionated WBI induces comparable or less acute radiation-induced skin reactions than conventional WBI is still not fully clarified, as randomized evidence and objective assessments are limited. The aim of this study was to objectively determine frequency and severity of acute radiation-induced skin reactions during hypofractionated vs. conventionally fractionated adjuvant WBI. METHODS In this randomized multicenter study, a total of 140 breast cancer patients underwent either hypofractionated or conventional WBI following breast-preserving surgery. Maximum radiation dermatitis severity was assessed at completion and during follow-up by physician-assessed CTCAE v4.03 and the patient-reported RISRAS scale. Additionally, photospectrometric skin readings were performed to objectify skin color differences between both treatment arms. RESULTS Radiation dermatitis severity was significantly lower in patients receiving hypofractionation compared with conventional fractionation (mean 1.05 vs. 1.43, p = .024). Grade 0 radiation dermatitis occurred in 21.43% vs. 4.28%, grade ≥2 in 27.14% vs. 42.91% and grade ≥3 in 0% vs. 4.34% of patients following hypofractionated and conventional WBI, respectively. Objective photospectrometric measurements (n = 4200) showed both decreased erythema severity (p = .008) and hyperpigmentation (p = .002) in the hypofractionation arm. Patients allocated to hypofractionated WBI also reported less pain (p = .006), less hyperpigmentation (p = <0.001) and less limitations of day-to-day activities (p = <0.001). CONCLUSION Physician and patient-assessed toxicity scorings as well as objective photospectrometric skin measurements revealed that hypofractionated WBI yielded lower rates and severity of acute radiation-induced skin toxicity.
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Affiliation(s)
| | - David Koch
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | | | - Fred Röhner
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Felix Schoroth
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Bettina Maja Bücheler
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Birgit Mahlmann
- Radiotherapy Bonn-Rhein-Sieg, Practice at Academic St. Marien Hospital, Bonn, Germany
| | - Christina Leitzen
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Heinrich Schüller
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Sabine Tschirner
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Arne Fuhrmann
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Martina Heimann
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Dilini Brüser
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Alina-Valik Abramian
- Department of Gynecology and Obstetrics, Division of Senology, University Hospital Bonn, University of Bonn, Germany
| | - Thomas Müdder
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Stephan Garbe
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany
| | - Susanne Vornholt
- Department of Radiation Oncology, Agaplesion General Hospital, Academic Hospital of the University of Bochum, Hagen, Germany
| | - Hans Heinz Schild
- Department of Radiation Oncology, University Hospital Bonn, University of Bonn, Germany; Department of Radiology, University Hospital Bonn, University of Bonn, Germany
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25
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Gerber NK, Yan SX, Levinson BA, Perez CA, Das IJ, Maisonet OG, Huppert N, No DK, Kelley J, Mistry N, Hitchen CJ, Goldberg JD. A Prospective Trial to Compare Deep Inspiratory Breath Hold With Prone Breast Irradiation. Pract Radiat Oncol 2020; 10:330-338. [PMID: 32014615 DOI: 10.1016/j.prro.2020.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 12/19/2019] [Accepted: 01/11/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE To compare heart and lung doses for adjuvant whole breast irradiation (WBI) between radiation plans generated supine with deep inspiratory breath hold (S-DIBH) and prone with free-breathing (P-FB) and examine the effect of breast volume (BV) on dosimetric parameters. METHODS AND MATERIALS Patients with left breast ductal carcinoma in situ or invasive cancer receiving adjuvant WBI were enrolled on a single-institutional prospective protocol. Patients were simulated S-DIBH and P-FB; plans were generated using both scans. Wilcoxon signed-rank and rank-sum tests were used to compare intrapatient differences between plans for the entire cohort and within BV groups defined by tertiles. RESULTS Forty patients were enrolled. Thirty-four patients are included in the analysis owing to patient withdrawal or inability to hold breath. With WBI dose of 4005 to 4256 cGy, mean heart dose (MHD) was 80 cGy in S-DIBH and 77 cGy in P-FB (P = .08). Mean ipsilateral lung dose (MLD) was 453 cGy in S-DIBH and 45 cGy in P-FB (P < .0001). Mean and max left anterior descending artery doses were 251 cGy and 551 cGy in S-DIBH, respectively (P = .1), and 324 cGy and 993 cGy in P-FB, respectively (P = .3). Hot spot and separation were 109% and 22 cm in S-DIBH, respectively, and 107% and 16 cm in P-FB, respectively (P < .0001). For patients with smallest BV, S-DIBH improved MHD and left anterior descending artery doses; for those with largest BV, P-FB improved cardiac dosimetry. With increasing BV, there was an increasing advantage of P-FB for MHD (P = .05), and max (P = .03) and mean (P = .02) left anterior descending artery doses, and the reduction in MLD, hot spot, and separation with P-FB increased (P < .05). CONCLUSIONS MHD did not differ between P-FB and S-DIBH, whereas MLD was significantly lower with P-FB. Analysis according to breast volume revealed improved cardiac dosimetry with S-DIBH for women with smallest BV and improved cardiac dosimetry with P-FB for women with larger BV, thereby providing a dosimetric rationale for using breast size to help determine the optimal positioning for WBI.
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Affiliation(s)
- Naamit K Gerber
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York.
| | - Sherry X Yan
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Benjamin A Levinson
- Division of Biostatistics Department of Population Health, New York University School of Medicine, New York, New York
| | - Carmen A Perez
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Indra J Das
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Olivier G Maisonet
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Nelly Huppert
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Diana K No
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Jessica Kelley
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Neha Mistry
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Christine J Hitchen
- Department of Radiation Oncology, New York University Langone Perlmutter Cancer Center, New York, New York
| | - Judith D Goldberg
- Division of Biostatistics Department of Population Health, New York University School of Medicine, New York, New York
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26
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Ohri N, Haffty BG. The evolution of adjuvant radiation therapy for early-stage and locally advanced breast cancer. Breast J 2019; 26:59-64. [PMID: 31854499 DOI: 10.1111/tbj.13715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 11/27/2022]
Abstract
Adjuvant radiation therapy is often delivered after breast cancer surgery, both in the post-lumpectomy and post-mastectomy settings. Standard fractionation whole breast irradiation (SF-WBI), which is typically delivered over 5-7 weeks, was previously considered the standard of care. More recent data has helped to establish hypofractionated whole breast irradiation (HF-WBI), which consists of a 3-4 week regimen, as a new standard of care. This article provides an overview of the major randomized trials that support the routine use of HF-WBI for the majority of patients undergoing breast-conserving surgery for early-stage breast cancer. Newer data on the use of a hypofractionated approach in the post-mastectomy setting, as well as ongoing randomized trials addressing this topic, are also discussed.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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A New Technique Using 4DCT Scans to Create Custom Cardiac Blocks for Left-Sided Breast Cancer Treatments. Pract Radiat Oncol 2019; 9:e572-e578. [DOI: 10.1016/j.prro.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 11/15/2022]
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Rárosi F, Boda K, Kahán Z, Varga Z. Decision curve analysis apropos of choice of preferable treatment positioning during breast irradiation. BMC Med Inform Decis Mak 2019; 19:204. [PMID: 31664991 PMCID: PMC6819418 DOI: 10.1186/s12911-019-0927-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 10/14/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Radiotherapy is a standard treatment option for breast cancer, but it may lead to significant late morbidity, including radiation heart damage. Breast irradiation performed individually in the supine or prone position may aid in minimizing the irradiation dose to the heart and LAD coronary artery. A series of CT scans and therapy plans are needed in both positions for the 'gold standard' decision on the preferable treatment position. This method is expensive with respect to technology and physician workload. Our ultimate goal is to develop a predictive tool to identify the preferable treatment position using easily measurable patient characteristics. In this article, we describe the details of how model building and consequently validation of the best model are done. METHODS Different models were used: both logistic regression and multiple linear regressions were used to estimate the LAD mean dose difference (the difference between the mean dose to the LAD in the supine position versus prone position); predicted dose differences were analysed compared to the 'gold standard' values, and the best model was selected accordingly. The final model was checked by random cross-validation. In addition to generally used measures (ROC and Brier score), decision curves were employed to evaluate the performance of the models. RESULTS ROC analysis demonstrated that none of the predictors alone was satisfactory. Multiple logistic regression models and the linear regression model lead to high values of net benefit for a wide range of threshold probabilities. Multiple linear regression seemed to be the most useful model. We also present the results of the random cross-validation for this model (i.e. sensitivity of 80.7% and specificity of 87.5%). CONCLUSIONS Decision curves proved to be useful to evaluate our models. Our results indicate that any of the models could be implemented in clinical practice, but the linear regression model is the most useful model to facilitate the radiation treatment decision. In addition, it is in use in everyday practice in the Department of Oncotherapy, University of Szeged, Hungary.
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Affiliation(s)
- Ferenc Rárosi
- Department of Medical Physics and Informatics, University of Szeged, Korányi fasor 9, Szeged, 6720, Hungary.
| | - Krisztina Boda
- Department of Medical Physics and Informatics, University of Szeged, Korányi fasor 9, Szeged, 6720, Hungary
| | - Zsuzsanna Kahán
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, 6720, Hungary
| | - Zoltán Varga
- Department of Oncotherapy, University of Szeged, Korányi fasor 12, Szeged, 6720, Hungary
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Cao N, Kalet AM, Young LA, Fang LC, Kim JN, Mayr NA, Meyer J. Predictors of cardiac and lung dose sparing in DIBH for left breast treatment. Phys Med 2019; 67:27-33. [PMID: 31629280 DOI: 10.1016/j.ejmp.2019.09.240] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 09/10/2019] [Accepted: 09/25/2019] [Indexed: 01/23/2023] Open
Abstract
This retrospective study of left breast radiation therapy (RT) investigates the correlation between anatomical parameters and dose to heart or/and left lung in deep inspiration breath-hold (DIBH) compared to free-breathing (FB) technique. Anatomical parameters of sixty-seven patients, treated with a step-and-shoot technique to 50 Gy or 50.4 Gy were included. They consisted of the cardiac contact distances in axial (CCDax) and parasagittal (CCDps) planes, and the lateral heart-to-chest distance (HCD). Correlation analysis was performed to identify predictors for heart and lung dose sparing. Paired t-test and linear regression were used for data analysis with significance level of p = 0.05. All dose metrics for heart and lung were significantly reduced with DIBH, however 21% of patients analyzed had less than 1.0 Gy mean heart dose reduction. Both FB-CCDpsdistance and FB-HCD correlated with FB mean heart dose and mean DIBH heart dose reduction. The strongest correlation was observed for the ratio of FB-CCDpsand FB-HCD with heart dose sparing. A FB-CCDps and FB-HCD model was developed to predict DIBH induced mean heart dose reduction, with 1.04 Gy per unit of FB-CCDps/FB-HCD. Variation between predicted and actual mean heart dose reduction ranged from -0.6 Gy to 0.6 Gy. In this study, FB-CCDps and FB-HCD distance served as predictors for heart dose reduction with DIBH equally, with FB-CCDps/FB-HCD as a stronger predictor. These parameters and the prediction model could be further investigated for use as a tool to better select patients who will benefit from DIBH.
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Affiliation(s)
- Ning Cao
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA.
| | - Alan M Kalet
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Lori A Young
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - L Christine Fang
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Janice N Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Nina A Mayr
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Juergen Meyer
- Department of Radiation Oncology, University of Washington, Seattle, WA, USA; Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, WA, USA
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Duma MN, Baumann R, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Hehr T, Krug D, Piroth MD, Sedlmayer F, Souchon R, Sauer R. Heart-sparing radiotherapy techniques in breast cancer patients: a recommendation of the breast cancer expert panel of the German society of radiation oncology (DEGRO). Strahlenther Onkol 2019; 195:861-871. [PMID: 31321461 DOI: 10.1007/s00066-019-01495-w] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/27/2019] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this review was to analyze the respective efficacy of various heart-sparing radiotherapy techniques. MATERIAL AND METHODS Heart-sparing can be performed in three different ways in breast cancer radiotherapy: by seeking to keep the heart out of treated volumes (i.e. by prone position or specific breathing techniques such as deep inspiration breath-hold [DIBH] and/or gating), by solely irradiating a small volume around the lumpectomy cavity (partial breast irradiation, PBI), or by using modern radiation techniques like intensity-modulated radiation therapy (IMRT), volumetric modulated arc therapy (VMAT) or protons. This overview presents the available data on these three approaches. RESULTS Studies on prone position are heterogeneous and most trials only refer to patients with large breasts; therefore, no definitive conclusion can be drawn for clinical routine. Nonetheless, there seems to be a trend toward better sparing of the left anterior descending artery in supine position even for these selected patients. The data on the use of DIBH for heart-sparing in breast cancer patients is consistent and the benefit compared to free-breathing is supported by several studies. In comparison with whole breast irradiation (WBI), PBI has an advantage in reducing the heart dose. Of note, DIBH and PBI with multicatheter brachytherapy are similar with regard to the dose reduction to heart structures. WBI by IMRT/VMAT techniques without DIBH is not an effective strategy for heart-sparing in breast cancer patients with "standard" anatomy. A combination of DIBH and IMRT may be used for internal mammary radiotherapy. CONCLUSION Based on the available findings, the DEGRO breast cancer expert panel recommends the use of DIBH as the best heart-sparing technique. Nonetheless, depending on the treatment volume and localization, other techniques may be employed or combined with DIBH when appropriate.
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Affiliation(s)
- Marciana-Nona Duma
- Department of Radiotherapy and Radiation Oncology, University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07745, Jena, Germany.
| | | | - Wilfried Budach
- Heinrich-Heine-University Hospital Düsseldorf, Düsseldorf, Germany
| | - Jürgen Dunst
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Petra Feyer
- Vivantes Hospital Neukoelln, Berlin, Germany
| | | | - Wulf Haase
- St.-Vincentius-Hospital Karlsruhe, Karlsruhe, Germany
| | | | - Thomas Hehr
- Marienhospital Stuttgart, Stuttgart, Germany
| | - David Krug
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marc D Piroth
- Helios University Hospital Wuppertal, Witten/Herdecke University, Wuppertal, Germany
| | - Felix Sedlmayer
- Paracelsus Medical University Hospital Salzburg, Salzburg, Austria
| | | | - Rolf Sauer
- University Hospital Erlangen, Erlangen, Germany
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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.
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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.
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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
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Kim J, Forouzannia A, Saini A, Hwang C. Hypofractionated whole-breast radiotherapy using a three-dimensional conformal technique: Toxicity comparison in different breast sizes. PRECISION RADIATION ONCOLOGY 2018. [DOI: 10.1002/pro6.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jae Kim
- University of Central Florida College of Medicine; Orlando Florida USA
| | | | - Amitpal Saini
- Florida Hospital, Department of Radiation Oncology; Orlando Florida USA
| | - Catherine Hwang
- Florida Hospital, Department of Radiation Oncology; Orlando Florida USA
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Chan TY, Tang JI, Tan PW, Roberts N. Dosimetric evaluation and systematic review of radiation therapy techniques for early stage node-negative breast cancer treatment. Cancer Manag Res 2018; 10:4853-4870. [PMID: 30425577 PMCID: PMC6205528 DOI: 10.2147/cmar.s172818] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Radiation therapy (RT) is essential in treating women with early stage breast cancer. Early stage node-negative breast cancer (ESNNBC) offers a good prognosis; hence, late effects of breast RT becomes increasingly important. Recent literature suggests a potential for an increase in cardiac and pulmonary events after RT. However, these studies have not taken into account the impact of newer and current RT techniques that are now available. Hence, this review aimed to evaluate the clinical evidence for each technique and determine the optimal radiation technique for ESNNBC treatment. Currently, six RT techniques are consistently used and studied: 1) prone positioning, 2) proton beam RT, 3) intensity-modulated RT, 4) breath-hold, 5) partial breast irradiation, and 6) intraoperative RT. These techniques show dosimetric promise. However, limited data on late cardiac and pulmonary events exist due to challenges in long-term follow-up. Moving forward, future studies are needed to validate the efficacy and clinical outcomes of these current techniques.
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Affiliation(s)
- Tabitha Y Chan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Johann I Tang
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Poh Wee Tan
- Department of Radiation Oncology, National University Cancer Institute, Singapore, Singapore,
| | - Neill Roberts
- Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK
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Matuszak MM, Fuller CD, Yock TI, Hess CB, McNutt T, Jolly S, Gabriel P, Mayo CS, Thor M, Caissie A, Rao A, Owen D, Smith W, Palta J, Kapoor R, Hayman J, Waddle M, Rosenstein B, Miller R, Choi S, Moreno A, Herman J, Feng M. Performance/outcomes data and physician process challenges for practical big data efforts in radiation oncology. Med Phys 2018; 45:e811-e819. [PMID: 30229946 DOI: 10.1002/mp.13136] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/20/2018] [Accepted: 08/08/2018] [Indexed: 11/11/2022] Open
Abstract
It is an exciting time for big data efforts in radiation oncology. The use of big data to help aid both outcomes and decision-making research is becoming a reality. However, there are true challenges that exist in the space of gathering and utilizing performance and outcomes data. Here, we summarize the current state of big data in radiation oncology with respect to outcomes and discuss some of the efforts and challenges in radiation oncology big data.
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Affiliation(s)
| | | | | | | | - Todd McNutt
- Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Maria Thor
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Arvind Rao
- University of Michigan, Ann Arbor, MI, USA
| | - Dawn Owen
- University of Michigan, Ann Arbor, MI, USA
| | - Wade Smith
- University of Washington, Seattle, WA, USA
| | | | | | | | | | | | | | | | - Amy Moreno
- MD Anderson Cancer Center, Houston, TX, USA
| | | | - Mary Feng
- University of California at San Francisco, San Francisco, CA, USA
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Duma MN, Oechsner M, Ertl C, Mozes P, Reitz S, Borm KJ, Combs SE. A prospective study on the need of gated (GAT) radiotherapy in left sided breast cancer patients treated at the Technical University Munich (TUM)
The GATTUM Trial: Study Protocol (Preprint). JMIR Res Protoc 2018. [DOI: 10.2196/11894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ohri N, Haffty BG. Alternatives to Standard Fractionation Radiation Therapy After Lumpectomy: Hypofractionated Whole-Breast Irradiation and Accelerated Partial-Breast Irradiation. Surg Oncol Clin N Am 2018; 27:181-194. [PMID: 29132560 DOI: 10.1016/j.soc.2017.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Adjuvant whole-breast irradiation (WBI) after lumpectomy has been an established standard of care for decades. Standard-fractionation WBI delivered over 5 to 7 weeks can achieve durable tumor control with low toxicity but can be inconvenient for patients and cost ineffective. Hypofractionated WBI can be completed in 3 to 4 weeks and, based on long-term randomized data, is the preferred standard of care in select patients. Accelerated partial-breast irradiation can be delivered using even shorter treatment regimens. Although the available data on accelerated partial-breast irradiation is more limited, early results suggest it is an effective alternative to WBI in select patients.
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Affiliation(s)
- Nisha Ohri
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, USA.
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Kang J, Rancati T, Lee S, Oh JH, Kerns SL, Scott JG, Schwartz R, Kim S, Rosenstein BS. Machine Learning and Radiogenomics: Lessons Learned and Future Directions. Front Oncol 2018; 8:228. [PMID: 29977864 PMCID: PMC6021505 DOI: 10.3389/fonc.2018.00228] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 06/04/2018] [Indexed: 12/25/2022] Open
Abstract
Due to the rapid increase in the availability of patient data, there is significant interest in precision medicine that could facilitate the development of a personalized treatment plan for each patient on an individual basis. Radiation oncology is particularly suited for predictive machine learning (ML) models due to the enormous amount of diagnostic data used as input and therapeutic data generated as output. An emerging field in precision radiation oncology that can take advantage of ML approaches is radiogenomics, which is the study of the impact of genomic variations on the sensitivity of normal and tumor tissue to radiation. Currently, patients undergoing radiotherapy are treated using uniform dose constraints specific to the tumor and surrounding normal tissues. This is suboptimal in many ways. First, the dose that can be delivered to the target volume may be insufficient for control but is constrained by the surrounding normal tissue, as dose escalation can lead to significant morbidity and rare. Second, two patients with nearly identical dose distributions can have substantially different acute and late toxicities, resulting in lengthy treatment breaks and suboptimal control, or chronic morbidities leading to poor quality of life. Despite significant advances in radiogenomics, the magnitude of the genetic contribution to radiation response far exceeds our current understanding of individual risk variants. In the field of genomics, ML methods are being used to extract harder-to-detect knowledge, but these methods have yet to fully penetrate radiogenomics. Hence, the goal of this publication is to provide an overview of ML as it applies to radiogenomics. We begin with a brief history of radiogenomics and its relationship to precision medicine. We then introduce ML and compare it to statistical hypothesis testing to reflect on shared lessons and to avoid common pitfalls. Current ML approaches to genome-wide association studies are examined. The application of ML specifically to radiogenomics is next presented. We end with important lessons for the proper integration of ML into radiogenomics.
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Affiliation(s)
- John Kang
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, United States
| | - Tiziana Rancati
- Prostate Cancer Program, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sangkyu Lee
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jung Hun Oh
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sarah L. Kerns
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, United States
| | - Jacob G. Scott
- Department of Translational Hematology and Oncology Research, Cleveland Clinic, Cleveland, OH, United States
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH, United States
| | - Russell Schwartz
- Computational Biology Department, Carnegie Mellon School of Computer Science, Pittsburgh, PA, United States
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Seyoung Kim
- Computational Biology Department, Carnegie Mellon School of Computer Science, Pittsburgh, PA, United States
| | - Barry S. Rosenstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Hypofractionated Whole-Breast Irradiation in Women Less Than 50 Years Old Treated on 4 Prospective Protocols. Int J Radiat Oncol Biol Phys 2018; 101:1159-1167. [PMID: 29859789 DOI: 10.1016/j.ijrobp.2018.04.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/19/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE Hypofractionated whole-breast radiation therapy (RT) has proved to be equivalent to conventionally fractionated RT in multiple randomized trials. There is controversy regarding its use in younger women because of their underrepresentation in trials and the concern for late toxicity. We evaluated disease control and cosmetic outcomes in patients aged <50 years treated with hypofractionated RT in 4 prospective single-institutional trials. METHODS AND MATERIALS From 2003 to 2015, 1313 patients were enrolled in 4 prospective protocols investigating the use of adjuvant hypofractionated RT after breast-conserving surgery with a daily or weekly concomitant boost. We identified the records of 348 patients aged <50 years at consultation for this analysis. Overall survival, disease-free survival, and local recurrence-free survival were estimated using the Kaplan-Meier method by study and across studies using meta-analytic methods. The late effects of RT, clinician-rated cosmesis, and patient-rated cosmesis were also evaluated. RESULTS With a median follow-up period of 66.9 months, the overall survival rate was 99.6%, the disease-free survival rate was 96.3%, and the local recurrence-free survival rate was 97.7% at 3 years. Clinician-rated cosmesis (n = 242) was excellent or good in 93.4% of cases and fair or poor in 6.6%. Patient-rated cosmesis (n = 259) was excellent or good in 86.1% and fair or poor in 13.9%. When patients rated themselves differently than their physicians, patients more often rated themselves poorly compared with their physicians (P = .0044, Cochran-Mantel-Haenszel test). CONCLUSIONS At a median follow-up of 5 years, an analysis of patients aged <50 years demonstrated that hypofractionated RT was safe and effective, with good to excellent cosmesis as assessed by both clinicians and patients.
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Kahán Z, Rárosi F, Gaál S, Cserháti A, Boda K, Darázs B, Kószó R, Lakosi F, Gulybán Á, Coucke PA, Varga Z. A simple clinical method for predicting the benefit of prone vs. supine positioning in reducing heart exposure during left breast radiotherapy. Radiother Oncol 2018; 126:487-492. [DOI: 10.1016/j.radonc.2017.12.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 12/20/2017] [Accepted: 12/22/2017] [Indexed: 12/25/2022]
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Yu E, Huang D, Leonard K, Dipetrillo T, Wazer D, Hepel J. Analysis of Outcomes Using Hypofractionated Tumor Bed Boost Combined With Hypofractionated Whole Breast Irradiation for Early-stage Breast Cancer. Clin Breast Cancer 2017. [DOI: 10.1016/j.clbc.2017.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
The overall goal of radiogenomics is the identification of genomic markers that are predictive for the development of adverse effects resulting from cancer treatment with radiation. The principal rationale for a focus on toxicity in radiogenomics is that for many patients treated with radiation, especially individuals diagnosed with early-stage cancers, the survival rates are high, and therefore a substantial number of people will live for a significant period of time beyond treatment. However, many of these patients could suffer from debilitating complications resulting from radiotherapy. Work in radiogenomics has greatly benefited from creation of the Radiogenomics Consortium (RGC) that includes investigators at multiple institutions located in a variety of countries. The common goal of the RGC membership is to share biospecimens and data so as to achieve large-scale studies with increased statistical power to enable identification of relevant genomic markers. A major aim of research in radiogenomics is the development of a predictive instrument to enable identification of people who are at greatest risk for adverse effects resulting from cancer treatment using radiation. It is anticipated that creation of a predictive assay characterized by a high level of sensitivity and specificity will improve precision radiotherapy and assist patients and their physicians to select the optimal treatment for each individual.
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Affiliation(s)
- Barry S Rosenstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY.
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The feasibility of a heart block with an electron compensation as an alternative whole breast radiotherapy technique in patients with underlying cardiac or pulmonary disease. PLoS One 2017; 12:e0184137. [PMID: 28863179 PMCID: PMC5580979 DOI: 10.1371/journal.pone.0184137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 08/18/2017] [Indexed: 11/19/2022] Open
Abstract
PURPOSE We aimed to evaluate the feasibility of the heart block with electron compensation (HBE) technique, based on three-dimensional conformal radiotherapy (3D-CRT) in left-sided breast cancer patients with underlying cardiac or pulmonary disease. METHODS Twenty patients with left-sided breast cancer who were treated with whole breast radiotherapy (WBRT) were included in this study. Intensity-modulated radiotherapy (IMRT), 3D-CRT, and HBE treatment plans were generated for each patient. Based on the 3D-CRT plan, the HBE plan included a heart block from the medial tangential field to shield the heart and added an electron beam to compensate for the loss in target volume coverage. The dosimetric parameters for the heart and lung and the target volume between the three treatment types were compared. RESULTS Of the three plans, the HBE plan yielded the most significant reduction in the doses received by the heart and lung (heart Dmean: 5.1 Gy vs. 12.9 Gy vs. 4.0 Gy and lung Dmean: 11.4 Gy vs. 13.2 Gy vs. 10.5 Gy, for 3D-CRT, IMRT, and HBE, respectively). Target coverage with all three techniques was within the acceptable range (Dmean 51.0 Gy vs. 51.2 Gy vs. 50.6 Gy, for 3D-CRT, IMRT, and HBE, respectively). CONCLUSIONS The HBE plan effectively reduced the amount of radiation exposure to the heart and lung. It could be beneficial for patients who are vulnerable to radiation-related cardiac or pulmonary toxicities.
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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.
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Internal mammary lymph nodes radiotherapy of breast cancer in the era of individualized medicine. Oncotarget 2017; 8:81583-81590. [PMID: 29113416 PMCID: PMC5655311 DOI: 10.18632/oncotarget.20186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 07/25/2017] [Indexed: 12/26/2022] Open
Abstract
Inclusion internal mammary lymph nodes as a part of regional nodal irradiation have a potential to reduce local recurrence, distant recurrence, and improve survival in breast cancer. However, the increased risk of cardiac toxicity and lungs injure associated with internal mammary lymph nodes irradiation has drew more and more attention. Estimating risk of metastasis in internal mammary lymph nodes based on axillary lymph nodes metastasis status is not always reliable: low-risk do not always mean negative in internal mammary lymph nodes and high-risk do not always indicate positive in internal mammary lymph nodes. Inaccurate prediction of in internal mammary lymph nodes metastasis might lead to over- or under-treatment of in internal mammary lymph node. Internal mammary sentinel lymph node biopsy is a minimally invasive technique which has a high potential to accurately evaluate the metastasis status in in internal mammary lymph nodes and improve accuracy of nodal staging. This technique might be a useful tool to guide individualized internal mammary lymph nodes irradiation.
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Duma MN, Münch S, Oechsner M, Combs SE. Heart-sparing radiotherapy in patients with breast cancer: What are the techniques used in the clinical routine?: A pattern of practice survey in the German-speaking countries. Med Dosim 2017; 42:197-202. [PMID: 28502653 DOI: 10.1016/j.meddos.2017.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/20/2017] [Accepted: 03/21/2017] [Indexed: 12/09/2022]
Abstract
The aim of this study was to understand the practice of care in German-speaking countries with regard to heart-sparing radiotherapy techniques. Between August 2015 and September 2015, an e-mail/fax-based survey was sent to radiation oncology departments in Germany, Austria, and the German-speaking Switzerland. The questionnaire was divided into 3 chapters: a general chapter on the department, a chapter specific for heart-sparing techniques in patients with breast cancer, and a third chapter on personal beliefs on the topic of heart sparing in patients with breast cancer. A total of 82 radiation oncology departments answered the questionnaire: 16 university clinics and 66 other departments. In general, heart-sparing techniques are being offered by 90.2% of departments for radiation oncology in the German-speaking countries. However, in the clinical routine, 87.7% of institutions use heart-sparing techniques in less than 50% of patients with breast cancer. Heart-sparing techniques are especially provided for patients with left-sided breast cancer (80%), patients after mastectomy (52.5%), and when the mammaria interna lymph drainage vessels are irradiated (41.3%). In 46.3% of departments, there are written internal guidelines for heart sparing in patients with breast cancer. Breathing-adapted radiotherapy is used as the most frequent heart-sparing technique in 64.7% of the institutions, followed by intensity-modulated radiation therapy, which is most frequently used by 22.1%. The only significant difference between university hospitals and other departments was seen for the offering of partial breast irradiation. The most commonly used heart-sparing technique is breathing-adapted radiotherapy, but there is no coherent approach for heart sparing in patients with breast cancer in the German-speaking countries. Overall, all options for cardiac protection/cardiac avoidance have their advantages and disadvantages, with deep inspiration breath-hold radiotherapyhaving the most clear data, which should be the preferred choice when using heart-sparing techniques.
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Affiliation(s)
- Marciana-Nona Duma
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany; Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764 Oberschleißheim, Germany; Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), München, Germany.
| | - Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany
| | - Markus Oechsner
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany; Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), München, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, TU München, Ismaninger Str. 22, 81675 München, Germany; Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764 Oberschleißheim, Germany; Zentrum für Stereotaxie und personalisierte Hochpräzisionsstrahlentherapie (StereotakTUM), Technische Universität München (TUM), München, Germany
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Whole-Breast Irradiation Following Breast-Conserving Surgery for Invasive Breast Cancer. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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48
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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.
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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
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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.
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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
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Linares I, Tovar MI, Zurita M, Guerrero R, Expósito M, del Moral R. Hypofractionated Breast Radiation: Shorter Scheme, Lower Toxicity. Clin Breast Cancer 2016; 16:262-8. [DOI: 10.1016/j.clbc.2015.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 08/28/2015] [Accepted: 09/11/2015] [Indexed: 12/01/2022]
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