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Nichols EM, Bentzen SM, Milburn M, Kesmodel SB, Bellavance E, Becker SJ, Mutaf Y, Tkaczuk K, Rosenblatt P, Feigenberg SJ. A Prospective Trial of Single-Fraction Radiation to the Tumor Bed with a Novel Breast-Specific Stereotactic Radiation Therapy Device: The GammaPod. Adv Radiat Oncol 2024; 9:101398. [PMID: 38778822 PMCID: PMC11110030 DOI: 10.1016/j.adro.2023.101398] [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: 01/27/2023] [Accepted: 09/24/2023] [Indexed: 05/25/2024] Open
Abstract
Purpose Radiation therapy for early-stage breast cancer is typically delivered in a hypofractionated regimen to the whole breast followed by a tumor bed boost. This results in a treatment course of approximately 4 weeks. In this study, the tumor bed boost was delivered in a single fraction as part of a safety and feasibility study for FDA clearance of the device. Methods and Materials Eligible women with early-stage breast cancer underwent lumpectomy followed by radiation therapy. Patients underwent breast immobilization using a system specific to the GammaPod followed by CT simulation, boost treatment planning, and boost treatment delivery all in a single treatment day. Patients then started whole-breast radiation therapy within 1 week of the boost treatment. Patients and treatments were assessed for safety and feasibility. Acute toxicities were recorded. Results A single-fraction boost of 8 Gy was delivered to the tumor bed before a course of whole-breast radiation. The GammaPod treatment was successfully delivered to 14 of 17 enrolled patients. Acute toxicities from all radiation therapy, inclusive of the boost and whole-breast radiation, were limited to grade 1 events. Conclusions The GammaPod device successfully delivered a single-fraction boost treatment to the tumor bed with no change in expected acute toxicities. The results of this study led to FDA clearance of the device through the Investigational Device Exemption process at the FDA. The GammaPod is in clinical use at 4e institutions nationally and internationally, with additional sites pending in 2023.
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Affiliation(s)
- Elizabeth M. Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Søren M. Bentzen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | - Steven J. Feigenberg
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Grendarova P, Roumeliotis M, Quirk S, Phan T, Liu HW, Craighead P, Lesiuk M, Pinilla J, Long K, Olivotto IA. Accelerated Partial Breast Irradiation Using 5 Daily Fractions: A Prospective, Phase 2, Multicenter Trial of Cosmetic Outcomes and Toxicity-ACCEL Final Results. Int J Radiat Oncol Biol Phys 2024; 118:1041-1048. [PMID: 37871884 DOI: 10.1016/j.ijrobp.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE This study investigated the cosmetic degradation and toxicity for an accelerated partial breast irradiation (APBI) prescription delivered in 5 fractions over 1 week and compared the outcomes with those of whole breast irradiation (WBI). METHODS AND MATERIALS The trial was a multicenter, single-arm, phase 2 prospective cohort study. Eligible women 50 years of age or older with estrogen receptor-positive and human epidermal growth factor receptor 2-negative invasive ductal carcinoma or ductal carcinoma in situ after breast-conserving surgery received 27 Gy in 5 daily fractions of APBI. The primary endpoint was noninferiority of 2-year cosmesis using the RAPID trial's WBI arm as the control arm. A global consensus cosmetic score using a European Organisation for Research and Treatment of Cancer rating scale score of excellent, good, fair, or poor for each patient at baseline and 2 years was generated by a panel of 5 radiation oncologists using photographs of treated and untreated breasts. RESULTS From 2016 to 2019, 298 eligible women were enrolled. By the 2-year follow-up, 76 patients had been lost or withdrawn and 3 had died, resulting in 219 patients available for complete, 2-year photographic cosmetic evaluation. The median follow-up for all participants was 4.7 years (IQR, 3.8-5.5 years). No patient had a fair or poor cosmetic score at the 2-year evaluation. Cosmesis was better or unchanged for 97% of patients and worse for 3% (excellent to good), and no cosmetic failures occurred. The confidence intervals were 0.88 (0.86-0.90) and 1.00 (0.99-1.00) for the RAPID and ACCEL trials, respectively. CONCLUSIONS Cosmetic degradation with 5 daily treatments of the ACCEL trial's APBI intervention is noninferior to the WBI arm of the RAPID trial.
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Affiliation(s)
- Petra Grendarova
- Department of Radiation Oncology, British Columbia Cancer Agency, Victoria, British Columbia, Canada.
| | - Michael Roumeliotis
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Sarah Quirk
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.
| | - Tien Phan
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Hong-Wei Liu
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Central Alberta Cancer Centre, Red Deer, Alberta, Canada
| | - Peter Craighead
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Mark Lesiuk
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | | | - Karen Long
- Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Ivo A Olivotto
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada; Tom Baker Cancer Centre, Calgary, Alberta, Canada
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3
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Burkon P, Selingerova I, Slavik M, Holanek M, Vrzal M, Coufal O, Polachova K, Muller P, Slampa P, Kazda T. Toxicity of external beam accelerated partial-breast irradiation (APBI) in adjuvant therapy of early-stage breast cancer: prospective randomized study. Radiat Oncol 2024; 19:17. [PMID: 38310249 PMCID: PMC10837889 DOI: 10.1186/s13014-024-02412-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/29/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) is an alternative breast-conserving therapy approach where radiation is delivered in less time compared to whole breast irradiation (WBI), resulting in improved patient convenience, less toxicity, and cost savings. This prospective randomized study compares the external beam APBI with commonly used moderate hypofractionated WBI in terms of feasibility, safety, tolerance, and cosmetic effects. METHODS Early breast cancer patients after partial mastectomy were equally randomized into two arms- external APBI and moderate hypofractionated WBI. External beam technique using available technical innovations commonly used in targeted hypofractionated radiotherapy to minimize irradiated volumes was used (cone beam computed tomography navigation to clips in the tumor bed, deep inspiration breath hold technique, volumetric modulated arc therapy dose application, using flattening filter free beams and the six degrees of freedom robotic treatment couch). Cosmetics results and toxicity were evaluated using questionnaires, CTCAE criteria, and photo documentation. RESULTS The analysis of 84 patients with a median age of 64 years showed significantly fewer acute adverse events in the APBI arm regarding skin reactions, local and general symptoms during a median follow-up of 37 months (range 21-45 months). A significant difference in favor of the APBI arm in grade ≥ 2 late skin toxicity was observed (p = 0.026). Late toxicity in the breast area (deformation, edema, fibrosis, and pain), affecting the quality of life and cosmetic effect, occurred in 61% and 17% of patients in WBI and APBI arms, respectively. The cosmetic effect was more favorable in the APBI arm, especially 6 to 12 months after the radiotherapy. CONCLUSION External APBI demonstrated better feasibility and less toxicity than the standard regimen in the adjuvant setting for treating early breast cancer patients. The presented study confirmed the level of evidence for establishing the external APBI in daily clinical practice. TRIAL REGISTRATION NCT06007118.
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Affiliation(s)
- Petr Burkon
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Iveta Selingerova
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic.
- Department of Mathematics and Statistics, Faculty of Science, Masaryk University, Brno, Czech Republic.
| | - Marek Slavik
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milos Holanek
- Department of Comprehensive Cancer Care, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Comprehensive Cancer Care, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslav Vrzal
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Oldrich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Katerina Polachova
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Muller
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic
| | - Pavel Slampa
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Tomas Kazda
- Department of Radiation Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Research Centre for Applied Molecular Oncology (RECAMO), Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53, Brno, Czech Republic
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Zerella MA, Zaffaroni M, Ronci G, Dicuonzo S, Rojas DP, Morra A, Gerardi MA, Fodor C, Rondi E, Vigorito S, Penco S, Sargenti M, Baratella P, Vicini E, Morigi C, Kahler-Ribeiro-Fontana S, Galimberti VE, Gandini S, De Camilli E, Renne G, Cattani F, Veronesi P, Orecchia R, Jereczek-Fossa BA, Leonardi MC. A narrative review for radiation oncologists to implement preoperative partial breast irradiation. LA RADIOLOGIA MEDICA 2023; 128:1553-1570. [PMID: 37650981 DOI: 10.1007/s11547-023-01706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
The strategy to anticipate radiotherapy (RT) before surgery, for breast cancer (BC) treatment, has recently generated a renewed interest. Historically, preoperative RT has remained confined either to highly selected patients, in the context of personalized therapy, or to clinical research protocols. Nevertheless, in the recent years, thanks to technological advances and increased tumor biology understanding, RT has undergone great changes that have also impacted the preoperative settings, embracing the modern approach to breast cancer. In particular, the reappraisal of preoperative RT can be viewed within the broader view of personalized and tailored medicine. In fact, preoperative accelerated partial breast irradiation (APBI) allows a more precise target delineation, with less variability in contouring among radiation oncologists, and a smaller treatment volume, possibly leading to lower toxicity and to dose escalation programs. The aim of the present review, which represents a benchmark study for the AIRC IG-23118, is to report available data on different technical aspects of preoperative RT including dosimetric studies, patient's selection and set-up, constraints, target delineation and clinical results. These data, along with the ones that will become available from ongoing studies, may inform the design of the future trials and representing a step toward a tailored APBI approach with the potential to challenge the current treatment paradigm in early-stage BC.Trial registration: The study is registered at clinicaltrials.gov (NCT04679454).
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Affiliation(s)
- Maria Alessia Zerella
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Mattia Zaffaroni
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Giuseppe Ronci
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Damaris Patricia Rojas
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Anna Morra
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | | | - Cristiana Fodor
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
| | - Elena Rondi
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Sabrina Vigorito
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Silvia Penco
- Division of Breast Radiology, IRCSS, IEO European Institute of Oncology, Milan, Italy
| | - Manuela Sargenti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paola Baratella
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Elisa Vicini
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Consuelo Morigi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | | | - Sara Gandini
- Department of Experimental Oncology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Elisa De Camilli
- Department of Pathology and Laboratory Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Renne
- Department of Pathology and Laboratory Medicine, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Maria Cristina Leonardi
- Department of Radiation Oncology, European Institute of Oncology IRCCS, 20141, Milan, Italy.
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5
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Haussmann J, Budach W, Corradini S, Krug D, Jazmati D, Tamaskovics B, Bölke E, Pedotoa A, Kammers K, Matuschek C. Comparison of adverse events in partial- or whole breast radiotherapy: investigation of cosmesis, toxicities and quality of life in a meta-analysis of randomized trials. Radiat Oncol 2023; 18:181. [PMID: 37919752 PMCID: PMC10623828 DOI: 10.1186/s13014-023-02365-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
PURPOSE/OBJECTIVE Adjuvant whole breast radiotherapy and systemic therapy are part of the current evidence-based treatment protocols for early breast cancer, after breast-conserving surgery. Numerous randomized trials have investigated the therapeutic effects of partial breast irradiation (PBI) compared to whole breast irradiation (WBI), limiting the treated breast tissue. These trials were designed to achieve equal control of the disease with possible reduction in adverse events, improvements in cosmesis and quality of life (QoL). In this meta-analysis, we aimed to investigate the differences between PBI and WBI in side effects and QoL. MATERIAL/METHODS We performed a systematic literature review searching for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was performed using the published event rates and the effect-sizes for available acute and late adverse events. Additionally, we evaluated cosmetic outcomes as well as general and breast-specific QoL using the EORTC QLQ-C30 and QLQ-BR23 questionnaires. RESULTS Sixteen studies were identified (n = 19,085 patients). PBI was associated with a lower prevalence in any grade 1 + acute toxicity and grade 2 + skin toxicity (OR = 0.12; 95% CI 0.09-0.18; p < 0.001); (OR = 0.16; 95% CI 0.07-0.41; p < 0.001). There was neither a significant difference in late adverse events between the two treatments, nor in any unfavorable cosmetic outcomes, rated by either medical professionals or patients. PBI-technique using EBRT with twice-daily fractionation schedules resulted in worse cosmesis rated by patients (n = 3215; OR = 2.08; 95% CI 1.22-3.54; p = 0.007) compared to WBI. Maximum once-daily EBRT schedules (n = 2071; OR = 0.60; 95% CI 0.45-0.79; p < 0.001) and IORT (p = 0.042) resulted in better cosmetic results grade by medical professionals. Functional- and symptom-based QoL in the C30-scale was not different between PBI and WBI. Breast-specific QoL was superior after PBI in the subdomains of "systemic therapy side effects" as well as "breast-" and "arm symptoms". CONCLUSION The analysis of multiple randomized trials demonstrate a superiority of PBI in acute toxicity as well breast-specific quality of life, when compared with WBI. Overall, late toxicities and cosmetic results were similar. PBI-technique with a fractionation of twice-daily schedules resulted in worse cosmesis rated by patients.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, Ludwig Maximillian University, Munich, Germany
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bálint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Alessia Pedotoa
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kai Kammers
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Germany
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6
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Lapen K, Fiasconaro M, Zhang Z, Abaya A, McCormick B, Xu AJ, Cuaron J, Powell SN, Kahn AJ, Gillespie EF, Braunstein LZ. Accelerated Partial Breast Irradiation: Association of Dosimetric Parameters With Patient-Reported Outcomes. Adv Radiat Oncol 2023; 8:101263. [PMID: 37305071 PMCID: PMC10248091 DOI: 10.1016/j.adro.2023.101263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/25/2023] [Indexed: 06/13/2023] Open
Abstract
Purpose Accelerated partial breast irradiation (APBI) after breast-conserving surgery offers a well-tolerated adjuvant radiation therapy option for patients with breast cancer. We sought to describe patient-reported acute toxicity as a function of salient dosimetric parameters during and after an APBI regimen of 40 Gy in 10 once-daily fractions. Methods and Materials From June 2019 to July 2020, patients undergoing APBI were assigned a weekly, response-adapted, patient reported outcomes-common terminology criteria for adverse events-based acute toxicity assessment. Patients reported acute toxicity during treatment and for up to 8 weeks after treatment. Dosimetric treatment parameters were collected. Descriptive statistics and univariable analyses were used to summarize patient-reported outcomes and their correlation to corresponding dosimetric measures, respectively. Results Overall, 55 patients who received APBI completed a total of 351 assessments. Median planning target volume was 210 cc (range, 64-580 cc), and median planning target volume:ipsilateral breast volume ratio was 0.17 (range, 0.05-0.44). Overall, 22% of patients reported moderate breast enlargement and 27% reported maximum skin toxicity as severe or very severe. Furthermore, 35% of patients reported fatigue, and 44% of patients reported pain in the radiated area as moderate to very severe. Median time to first report of any moderate to very severe symptom was 10 days (interquartile range, 6-27 days). By 8 weeks after APBI, most patients reported resolution of symptoms, with 16% reporting residual moderate symptoms. Upon univariable analysis, none of the ascertained salient dosimetric parameters were associated with maximum symptoms or with the presence of moderate to very severe toxicity. Conclusions Weekly assessments during and after APBI showed that patients experienced moderate to very severe toxicities, most commonly skin toxicity, but that these typically resolved by 8 weeks after radiation therapy. More comprehensive evaluations among larger cohorts are warranted to define the precise dosimetric parameters that correspond to outcomes of interest.
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Affiliation(s)
- Kaitlyn Lapen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Megan Fiasconaro
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anthony Abaya
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy J. Xu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Simon N. Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Atif J. Kahn
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erin F. Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lior Z. Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
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7
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Shumway DA, Corbin KS, Farah MH, Viola KE, Nayfeh T, Saadi S, Shah V, Hasan B, Shah S, Mohammed K, Riaz IB, Prokop LJ, Murad MH, Wang Z. Partial breast irradiation compared with whole breast irradiation: a systematic review and meta-analysis. J Natl Cancer Inst 2023; 115:1011-1019. [PMID: 37289549 PMCID: PMC10483267 DOI: 10.1093/jnci/djad100] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND Early-stage breast cancer is among the most common cancer diagnoses. Adjuvant radiotherapy is an essential component of breast-conserving therapy, and several options exist for tailoring its extent and duration. This study assesses the comparative effectiveness of partial-breast irradiation (PBI) compared with whole-breast irradiation (WBI). METHODS A systematic review was completed to identify relevant randomized clinical trials and comparative observational studies. Independent reviewers working in pairs selected studies and extracted data. Randomized trial results were pooled using a random effects model. Prespecified main outcomes were ipsilateral breast recurrence (IBR), cosmesis, and adverse events (AEs). RESULTS Fourteen randomized clinical trials and 6 comparative observational studies with 17 234 patients evaluated the comparative effectiveness of PBI. PBI was not statistically significantly different from WBI for IBR at 5 years (RR = 1.34, 95% CI = 0.83 to 2.18; high strength of evidence [SOE]) and 10 years (RR = 1.29, 95% CI = 0.87 to 1.91; high SOE). Evidence for cosmetic outcomes was insufficient. Statistically significantly fewer acute AEs were reported with PBI compared with WBI, with no statistically significant difference in late AEs. Data from subgroups according to patient, tumor, and treatment characteristics were insufficient. Intraoperative radiotherapy was associated with higher IBR at 5, 10, and over than 10 years (high SOE) compared with WBI. CONCLUSIONS Ipsilateral breast recurrence was not statistically significantly different between PBI and WBI. Acute AEs were less frequent with PBI. This evidence supports the effectiveness of PBI among selected patients with early-stage, favorable-risk breast cancer who are similar to those represented in the included studies.
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Affiliation(s)
- Dean A Shumway
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Kimberly S Corbin
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN, USA
| | - Magdoleen H Farah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Kelly E Viola
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Samer Saadi
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Vishal Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Sahrish Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Khaled Mohammed
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Irbaz Bin Riaz
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Larry J Prokop
- Library Public Services, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
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8
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Matar-Ujvary R, Haglich K, Flanagan MR, Fuzesi S, Sevilimedu V, Nelson JA, Gemignani ML. The Impact of Breast-Conserving Surgery Re-excision on Patient-Reported Outcomes Using the BREAST-Q. Ann Surg Oncol 2023; 30:5341-5349. [PMID: 37306849 PMCID: PMC10782578 DOI: 10.1245/s10434-023-13592-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/13/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Approximately 14% of women undergoing breast-conserving surgery (BCS) require re-excision to achieve negative margins following the Society of Surgical Oncology (SSO) and American Society for Radiation Oncology (ASTRO) margin guidelines, which may influence patient-reported outcomes (PROs). Few studies have assessed the impact of re-excision on PROs following BCS. PATIENTS AND METHODS Women with stage 0-III breast cancer undergoing BCS who completed a BREAST-Q PRO measure from 2010 to 2016 were identified from a prospective database. Baseline characteristics were compared between women who underwent one BCS and those who underwent ≥ 1 re-excision surgery for positive margins (R-BCS). Linear mixed models were used to analyze associations between number of excisions and BREAST-Q scores over time. RESULTS Of 2543 eligible women, 1979 (78%) had one BCS and 564 (22%) had R-BCS. Younger age, lower BMI, surgery pre-SSO Invasive Guidelines issuance, ductal carcinoma in situ (DCIS), multifocal disease, radiation therapy receipt, and endocrine therapy omission were more common in the R-BCS group. Breast satisfaction and sexual well-being were lower in the R-BCS group 2 years postoperatively. There were no differences in psychosocial well-being between groups over 5 years. On multivariable analysis, re-excision was associated with lower breast satisfaction and sexual well-being (p= 0.007 and p= 0.049, respectively), but there was no difference in psychosocial well-being (p= 0.250). CONCLUSIONS Women with R-BCS had lower breast satisfaction and sexual well-being 2 years postoperatively, but this difference did not remain long term. Psychosocial well-being in women who underwent one BCS were largely comparable over time to the R-BCS group. These findings may help in counseling women who are concerned about satisfaction and quality-of-life outcomes with BCS if re-excision is necessary.
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Affiliation(s)
- Regina Matar-Ujvary
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kathryn Haglich
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Sarah Fuzesi
- Breast Surgery, New York-Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonas A Nelson
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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9
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Wang Y, Shen J, Gu P, Wang Z. Recent advances progress in radiotherapy for breast cancer after breast-conserving surgery: a review. Front Oncol 2023; 13:1195266. [PMID: 37671064 PMCID: PMC10475720 DOI: 10.3389/fonc.2023.1195266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/07/2023] [Indexed: 09/07/2023] Open
Abstract
Adjuvant radiotherapy after breast-conserving surgery has become an integral part of the treatment of breast cancer. In recent years, the development of radiotherapy technology has made great progress in this field, including the comparison of the curative effects of various radiotherapy techniques and the performance of the segmentation times. The choice of radiotherapy technology needs to be co-determined by clinical evidence practice and evaluated for each individual patient to achieve precision radiotherapy. This article discusses the treatment effects of different radiotherapy, techniques, the risk of second cancers and short-range radiation therapy techniques after breast-conserving surgery such as hypo fractionated whole breast irradiation and accelerated partial breast irradiation. The choice of radiotherapy regimen needs to be based on the individual condition of the patient, and the general principle is to focus on the target area and reduce the irradiation of the normal tissues and organs. Short-range radiotherapy and hypofractionated are superior to conventional radiotherapy and are expected to become the mainstream treatment after breast-conserving surgery.
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Affiliation(s)
- Yun Wang
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Jingjing Shen
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Peihua Gu
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
| | - Zhongming Wang
- Department of Radiation Oncology, Shidong Hospital, Shidong Hospital Affiliated to University of Shanghai for Science and Technology, Shanghai, China
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
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10
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Meattini I, de Oliveira Franco R, Salvestrini V, Hijal T. Special issue. De-escalation of loco-regional treatment in breast cancer: Time to find the balance? Partial breast irradiation. Breast 2023; 69:401-409. [PMID: 37116401 PMCID: PMC10163674 DOI: 10.1016/j.breast.2023.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/15/2023] [Accepted: 04/23/2023] [Indexed: 04/30/2023] Open
Abstract
Breast cancer is the most common cancer in women worldwide. Over the past few decades, remarkable progress has been made in understanding the biology and pathology of breast cancer. A personalized conservative approach has been currently adopted addressing the patient's individual risk of relapse. After postoperative whole breast irradiation for early-stage breast cancer, a rate of recurrences outside the initial tumour bed lower than 4% was observed. Thus, the highest benefits of breast irradiation seem to result from the dose delivered to the tissue neighbouring the tumour bed. Nonetheless, reducing treatment morbidity while maintaining radiation therapy's ability to decrease local recurrences is an important challenge in treating patients with radiation therapy. In this regard, strategies such as partial-breast irradiation have been developed to reduce toxicity without compromising oncologic outcomes. According to the national and international published guidelines, clinical oncologists can refer to specific dose/fractionation schedules and eligible criteria. However, there are still some areas of open questions. Breast cancer represents a multidisciplinary paradigm; it should be considered a heterogeneous disease where a "one-treatment-fits-all" approach cannot be considered an appropriate option. This is a wide overview on the main partial breast irradiation advantages, risks, timings, techniques, and available recommendations. We aim to provide practical findings to support clinical decision-making, exploring future perspectives, towards a balance for optimisation of breast cancer.
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Affiliation(s)
- Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy.
| | - Rejane de Oliveira Franco
- Department of Oncology, McGill University, Montreal, Canada; Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
| | - Viola Salvestrini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence, Florence, Italy; Radiation Oncology Unit, Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Tarek Hijal
- Department of Oncology, McGill University, Montreal, Canada; Division of Radiation Oncology, McGill University Health Centre, Montreal, Canada
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11
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Pogue JA, Cardenas CE, Cao Y, Popple RA, Soike M, Boggs DH, Stanley DN, Harms J. Leveraging intelligent optimization for automated, cardiac-sparing accelerated partial breast treatment planning. Front Oncol 2023; 13:1130119. [PMID: 36845685 PMCID: PMC9950631 DOI: 10.3389/fonc.2023.1130119] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
Background Accelerated partial breast irradiation (APBI) yields similar rates of recurrence and cosmetic outcomes as compared to whole breast radiation therapy (RT) when patients and treatment techniques are appropriately selected. APBI combined with stereotactic body radiation therapy (SBRT) is a promising technique for precisely delivering high levels of radiation while avoiding uninvolved breast tissue. Here we investigate the feasibility of automatically generating high quality APBI plans in the Ethos adaptive workspace with a specific emphasis on sparing the heart. Methods Nine patients (10 target volumes) were utilized to iteratively tune an Ethos APBI planning template for automatic plan generation. Twenty patients previously treated on a TrueBeam Edge accelerator were then automatically replanned using this template without manual intervention or reoptimization. The unbiased validation cohort Ethos plans were benchmarked via adherence to planning objectives, a comparison of DVH and quality indices against the clinical Edge plans, and qualitative reviews by two board-certified radiation oncologists. Results 85% (17/20) of automated validation cohort plans met all planning objectives; three plans did not achieve the contralateral lung V1.5Gy objective, but all other objectives were achieved. Compared to the Eclipse generated plans, the proposed Ethos template generated plans with greater evaluation planning target volume (PTV_Eval) V100% coverage (p = 0.01), significantly decreased heart V1.5Gy (p< 0.001), and increased contralateral breast V5Gy, skin D0.01cc, and RTOG conformity index (p = 0.03, p = 0.03, and p = 0.01, respectively). However, only the reduction in heart dose was significant after correcting for multiple testing. Physicist-selected plans were deemed clinically acceptable without modification for 75% and 90% of plans by physicians A and B, respectively. Physicians A and B scored at least one automatically generated plan as clinically acceptable for 100% and 95% of planning intents, respectively. Conclusions Standard left- and right-sided planning templates automatically generated APBI plans of comparable quality to manually generated plans treated on a stereotactic linear accelerator, with a significant reduction in heart dose compared to Eclipse generated plans. The methods presented in this work elucidate an approach for generating automated, cardiac-sparing APBI treatment plans for daily adaptive RT with high efficiency.
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Affiliation(s)
| | - Carlos E. Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Yanan Cao
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Richard A. Popple
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael Soike
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Drexell Hunter Boggs
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Dennis N. Stanley
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Joseph Harms
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
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12
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Goldberg M, Bridhikitti J, Khan AJ, McGale P, Whelan TJ. A Meta-Analysis of Trials of Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2023; 115:60-72. [PMID: 36155214 DOI: 10.1016/j.ijrobp.2022.09.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 02/09/2023]
Abstract
PURPOSE Partial breast irradiation (PBI) is the delivery of radiation therapy (RT) limited to the tumor bed after breast conserving surgery. The results of recent trials of PBI compared with whole breast irradiation (WBI) have suggested conflicting results with respect to local control and toxicity. The purpose of this meta-analysis was to assess effectiveness of PBI and to compare the different techniques. METHODS AND MATERIALS A meta-analysis of aggregate data from published randomized trials was performed to examine the effectiveness of PBI compared with WBI in patients with invasive breast cancer and ductal carcinoma in situ. Relevant data were extracted. The primary outcome was any ipsilateral breast event (invasive or noninvasive). Secondary outcomes included acute and late toxicity. The results of randomized trials were pooled using a fixed effects model and the inverse variance method. RESULTS Fifteen trials involving 16,474 patients were identified. The majority of enrolled patients were >60 years of age and had T1N0 grade 1 to 2 disease treated with hormone therapy. The percent of ipsilateral breast events was higher in patients treated with PBI compared with WBI (5.0% vs 2.8%; risk ratio [RR], 1.72; 95% confidence interval [CI], 1.47-2.02). Heterogeneity (P = .0002) was observed between the 4 PBI techniques: external beam RT without computed tomography (CT) planning (RR, 2.06; 95% CI, 1.36-3.12); brachytherapy (RR, 1.21; 95% CI, 0.65-2.25); intraoperative RT (RR, 2.79; 95% CI, 2.08-3.73); and external beam RT with CT planning (RR, 1.25; 95% CI, 0.99-1.58). When external beam RT without CT planning and intraoperative RT trials were excluded, the percent of ipsilateral breast events was 3.3% versus 2.6%, respectively (RR, 1.25; 95% CI, 1.00-1.55; P = .05), and no heterogeneity was observed (P = .92). Overall, acute toxicity was less with PBI, and the effect on late toxicity varied by technique. CONCLUSIONS Overall, WBI was more effective than PBI, but the effectiveness of PBI was technique related. PBI was less effective when given by external beam RT without CT planning or intraoperative therapy. Although PBI given by multicatheter brachytherapy or external beam RT with CT planning tended to be statistically less effective than WBI, the absolute difference between groups for ipsilateral breast events was very small (<1%), supporting these approaches for women considering PBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jidapa Bridhikitti
- Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paul McGale
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Timothy J Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Division of Radiation Oncology, Juravinski Cancer Centre at Hamilton Health Sciences, Hamilton, Ontario, Canada.
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13
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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14
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Early Outcome, Cosmetic Result and Tolerability of an IOERT-Boost Prior to Adjuvant Whole-Breast Irradiation. Cancers (Basel) 2022; 14:cancers14153636. [PMID: 35892894 PMCID: PMC9332060 DOI: 10.3390/cancers14153636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/21/2022] [Accepted: 07/22/2022] [Indexed: 02/01/2023] Open
Abstract
Background/Aims: Due to its favorable dose distribution and targeting of the region at highest risk of recurrence due to direct visualization of tumor bed, intraoperative electron radiation therapy (IOERT) is used as part of a breast-conserving treatment approach. The aim of this study was to analyze tumor control and survival, as well as the toxicity profile, and cosmetic outcomes in patients irradiated with an IOERT boost for breast cancer. Materials and Methods: 139 Patients treated at our institution between January 2010 and January 2015 with a single boost dose of 10 Gy to the tumor bed during breast-conserving surgery followed by whole-breast irradiation were retrospectively analyzed. Results: 139 patients were included in this analysis. The median age was 54 years (range 28−83 years). The preferred surgical strategy was segmental resection with sentinel lymphonodectomy (66.5%) or axillary dissection (23.1%). Regarding adjuvant radiotherapy, the vast majority received 5 × 1.8 Gy to 50.4 Gy. At a median follow-up of 33.6 months, recurrence-free and overall survival were 95.5% and 94.9%, respectively. No patient developed an in-field recurrence. Seven patients (5.0%) died during the follow-up period, including two patients due to disease recurrence (non-in-field). High-grade (CTCAE > 2) perioperative adverse events attributable to IOERT included wound healing disorder (N = 1) and hematoma (N = 1). High-grade late adverse events (LENT-SOMA grade III) were reported only in one patient with fat necrosis. Low-grade late adverse events (LENT-SOMA grade I-II) included pain (18.0%), edema (10.5%), fibrosis (21%), telangiectasia (4.5%) and pigmentation change (23.0%). The mean breast retraction assessment score was 1.66 (0−6). Both patients and specialists rated the cosmetic result “excellent/good” in 84.8% and 87.9%, respectively. Conclusion: Our study reports favorable data on the cosmetic outcome as well as the acute and early long-term tolerability for patients treated with an IOERT boost. Our oncologic control rates are comparable to the previous literature. However, prospective investigations on the role of IOERT in comparison to other boost procedures would be desirable.
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15
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Polgár C, Kahán Z, Ivanov O, Chorváth M, Ligačová A, Csejtei A, Gábor G, Landherr L, Mangel L, Mayer Á, Fodor J. Radiotherapy of Breast Cancer—Professional Guideline 1st Central-Eastern European Professional Consensus Statement on Breast Cancer. Pathol Oncol Res 2022; 28:1610378. [PMID: 35832115 PMCID: PMC9272418 DOI: 10.3389/pore.2022.1610378] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/31/2022] [Indexed: 12/12/2022]
Abstract
The international radiotherapy (RT) expert panel has revised and updated the RT guidelines that were accepted in 2020 at the 4th Hungarian Breast Cancer Consensus Conference, based on new scientific evidence. Radiotherapy after breast-conserving surgery (BCS) is indicated in ductal carcinoma in situ (stage 0), as RT decreases the risk of local recurrence (LR) by 50–60%. In early stage (stage I-II) invasive breast cancer RT remains a standard treatment following BCS. However, in elderly (≥70 years) patients with stage I, hormone receptor-positive tumour, hormonal therapy without RT can be considered. Hypofractionated whole breast irradiation (WBI) and for selected cases accelerated partial breast irradiation are validated treatment alternatives to conventional WBI administered for 5 weeks. Following mastectomy, RT significantly decreases the risk of LR and improves overall survival of patients who have 1 to 3 or ≥4 positive axillary lymph nodes. In selected cases of patients with 1 to 2 positive sentinel lymph nodes axillary dissection can be substituted with axillary RT. After neoadjuvant systemic treatment (NST) followed by BCS, WBI is mandatory, while after NST followed by mastectomy, locoregional RT should be given in cases of initial stage III–IV and ypN1 axillary status.
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Affiliation(s)
- Csaba Polgár
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Kahán
- Department of Oncotherapy, University of Szeged, Szeged, Hungary
| | - Olivera Ivanov
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
- Department for Radiation Oncology, Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Martin Chorváth
- Department of Radiation Oncology, St. Elisabeth Cancer Institute, Slovak Medical University, Bratislava, Slovakia
| | - Andrea Ligačová
- Department of Radiation Oncology, St. Elisabeth Cancer Institute, Slovak Medical University, Bratislava, Slovakia
| | - András Csejtei
- Department of Oncoradiology, Markusovszky University Teaching Hospital, Szombathely, Hungary
| | - Gabriella Gábor
- Oncoradiology Centre, Bács-Kiskun County Hospital, Kecskemét, Hungary
| | - László Landherr
- Municipal Oncoradiology Centre, Uzsoki Street Hospital, Budapest, Hungary
| | - László Mangel
- Oncotherapy Institute, University of Pécs, Pécs, Hungary
| | - Árpád Mayer
- Municipal Oncoradiology Centre, Uzsoki Street Hospital, Budapest, Hungary
| | - János Fodor
- Centre of Radiotherapy, National Institute of Oncology, Budapest, Hungary
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16
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Residual image registration error by fiducial markers in accelerated partial breast irradiation using C-arm linac: a phantom study. Phys Eng Sci Med 2022; 45:769-779. [PMID: 35657476 DOI: 10.1007/s13246-022-01142-2] [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: 11/14/2021] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
External beam accelerated partial breast irradiation (APBI) is an alternative treatment for patients with early-stage breast cancer. The efficacy of image-guided radiotherapy (IGRT) using fiducial markers, such as gold markers or surgical clips, has been demonstrated. However, the effects of respiratory motion during a single fraction have not been reported. This study aimed to evaluate the residual image registration error of fiducial marker-based IGRT by respiratory motion and propose a suitable treatment strategy. We developed an acrylic phantom embedded with surgical clips to verify the registration error under moving conditions. The frequency of the phase difference in the respiratory cycle due to sequential acquisition was verified in a preliminary study. Fiducial marker-based IGRT was then performed in ten scenarios. The residual registration error (RRE) was calculated on the basis of the differences in the coordinates of clips between the true position if not moved and the last position. The frequencies of the phase differences in 0.0-0.99, 1.0-1.99, 2.0-2.99, 3.0-3.99, and 4.0-5.0 mm were 23%, 24%, 22%, 20%, and 11%, respectively. When assuming a clinical case, the mean RREs for all directions were within 1.0 mm, even if respiratory motion of 5 mm existed in two axes. For APBI with fiducial marker-based IGRT, the introduction of an image registration strategy that employs stepwise couch correction using at least three orthogonal images should be considered.
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Gradishar WJ, Moran MS, Abraham J, Aft R, Agnese D, Allison KH, Anderson B, Burstein HJ, Chew H, Dang C, Elias AD, Giordano SH, Goetz MP, Goldstein LJ, Hurvitz SA, Isakoff SJ, Jankowitz RC, Javid SH, Krishnamurthy J, Leitch M, Lyons J, Mortimer J, Patel SA, Pierce LJ, Rosenberger LH, Rugo HS, Sitapati A, Smith KL, Smith ML, Soliman H, Stringer-Reasor EM, Telli ML, Ward JH, Wisinski KB, Young JS, Burns J, Kumar R. Breast Cancer, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:691-722. [PMID: 35714673 DOI: 10.6004/jnccn.2022.0030] [Citation(s) in RCA: 363] [Impact Index Per Article: 181.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The therapeutic options for patients with noninvasive or invasive breast cancer are complex and varied. These NCCN Clinical Practice Guidelines for Breast Cancer include recommendations for clinical management of patients with carcinoma in situ, invasive breast cancer, Paget disease, phyllodes tumor, inflammatory breast cancer, and management of breast cancer during pregnancy. The content featured in this issue focuses on the recommendations for overall management of ductal carcinoma in situ and the workup and locoregional management of early stage invasive breast cancer. For the full version of the NCCN Guidelines for Breast Cancer, visit NCCN.org.
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Affiliation(s)
| | | | - Jame Abraham
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Rebecca Aft
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Doreen Agnese
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | - Chau Dang
- Memorial Sloan Kettering Cancer Center
| | | | | | | | | | | | | | | | - Sara H Javid
- Fred Hutchinson Cancer Research Center/University of Washington
| | | | | | - Janice Lyons
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | | | - Hope S Rugo
- UCSF Helen Diller Family Comprehensive Cancer Center
| | | | | | | | | | | | | | - John H Ward
- Huntsman Cancer Institute at the University of Utah
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Chin YS. Extreme hypofractionation in radiation therapy for patients with early breast cancer: what is the optimal technique? J Med Radiat Sci 2022; 69:143-146. [PMID: 35441811 PMCID: PMC9163474 DOI: 10.1002/jmrs.590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/02/2022] [Accepted: 04/07/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Yaw Sinn Chin
- Department of Radiation Oncology, St. George Hospital, Kogarah, New South Wales, Australia.,St George & Sutherland Clinical School, UNSW Medicine, Sydney, New South Wales, Australia.,Clinical Management Committee, Oncology NSW, GenesisCare, Alexandria, New South Wales, Australia.,Faculty of Radiation Oncology, The Royal Australian & New Zealand College of Radiologists, Sydney, New South Wales, Australia
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19
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Baliski C, Bakos B. Patient reported outcomes following breast conserving surgery are improved by minimizing re-excisions and excessive breast tissue removal. Am J Surg 2022; 224:716-721. [DOI: 10.1016/j.amjsurg.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/31/2022] [Accepted: 03/01/2022] [Indexed: 11/01/2022]
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Sarnelli A, Negrini M, Mezzenga E, Feliciani G, D'Arienzo M, Amato A, Paganelli G. Modelling a new approach for radio-ablation after resection of breast ductal carcinoma in-situ based on the BAT-90 medical device. Sci Rep 2022; 12:14. [PMID: 34996956 PMCID: PMC8741759 DOI: 10.1038/s41598-021-03807-6] [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: 12/01/2020] [Accepted: 12/03/2021] [Indexed: 11/28/2022] Open
Abstract
The majority of local recurrences, after conservative surgery of breast cancer, occurs in the same anatomical area where the tumour was originally located. For the treatment of ductal carcinoma in situ (DCIS), a new medical device, named BAT-90, (BetaGlue Technologies SpA) has been proposed. BAT-90 is based on the administration of 90Y β-emitting microspheres, embedded in a bio-compatible matrix. In this work, the Geant4 simulation toolkit is used to simulate BAT-90 as a homogenous cylindrical 90Y layer placed in the middle of a bulk material. The activity needed to deliver a 20 Gy isodose at a given distance z from the BAT-90 layer is calculated for different device thicknesses, tumour bed sizes and for water and adipose bulk materials. A radiobiological analysis has been performed using both the Poisson and logistic Tumour Control Probability (TCP) models. A range of radiobiological parameters (α and β), target sizes, and densities of tumour cells were considered. Increasing α values, TCP increases too, while, for a fixed α value, TCP decreases as a function of clonogenic cell density. The models predict very solid results in case of limited tumour burden while the activity/dose ratio could be further optimized in case of larger tumour beds.
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Affiliation(s)
- Anna Sarnelli
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Via P. Maroncelli 40, 47014, Meldola, FC, Italy.
| | - Matteo Negrini
- Istituto Nazionale di Fisica Nucleare, Sezione di Bologna, 40126, Bologna, Italy
| | - Emilio Mezzenga
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Via P. Maroncelli 40, 47014, Meldola, FC, Italy
| | - Giacomo Feliciani
- Medical Physics Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Via P. Maroncelli 40, 47014, Meldola, FC, Italy
| | - Marco D'Arienzo
- Medical Physics Unit, ASL Roma 6, Via Borgo Garibaldi 12, 00041, Albano Laziale, RM, Italy
| | - Antonino Amato
- BetaGlue Technologies Spa, Lungadige Galtarossa 21, 37133, Verona, Italy
| | - Giovanni Paganelli
- Nuclear Medicine Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST), Dino Amadori", Via P. Maroncelli 40, 47014, Meldola, FC, Italy
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21
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Frederick A, Roumeliotis M, Grendarova P, Quirk S. Performance of a knowledge-based planning model for optimizing intensity-modulated radiotherapy plans for partial breast irradiation. J Appl Clin Med Phys 2021; 23:e13506. [PMID: 34936195 PMCID: PMC8906226 DOI: 10.1002/acm2.13506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 11/09/2021] [Accepted: 12/04/2021] [Indexed: 12/25/2022] Open
Abstract
Purpose To evaluate a knowledge‐based (KB) planning model for RapidPlan, generated using a five‐field intensity‐modulated radiotherapy (IMRT) class solution beam strategy and rigorous dosimetric constraints for accelerated partial breast irradiation (APBI). Materials and methods The RapidPlan model was configured using 64 APBI treatment plans and validated for 120 APBI patients who were not included in the training dataset. KB plan dosimetry was compared to clinical plan dosimetry, the clinical planning constraints, and the constraints used in phase III APBI trials. Dosimetric differences between clinical and KB plans were evaluated using paired two‐tailed Wilcoxon signed‐rank tests. Results KB planning was able to produce IMRT‐based APBI plans in a single optimization without manual intervention that are comparable or better than the conventionally optimized, clinical plans. Comparing KB plans to clinical plans, differences in PTV, heart, contralateral breast, and ipsilateral lung dose–volume metrics were not clinically significant. The ipsilateral breast volume receiving at least 50% of the prescription dose was statistically and clinically significantly lower in the KB plans. Conclusion KB planning for IMRT‐based APBI provides equivalent or better dosimetry compared to conventional inverse planning. This model may be reliably applied in clinical practice and could be used to transfer planning expertise to ensure consistency in APBI plan quality.
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Affiliation(s)
- Amy Frederick
- Department of Physics and AstronomyUniversity of CalgaryCalgaryAlbertaCanada
- Division of Medical PhysicsTom Baker Cancer CentreCalgaryAlbertaCanada
| | - Michael Roumeliotis
- Department of Physics and AstronomyUniversity of CalgaryCalgaryAlbertaCanada
- Division of Medical PhysicsTom Baker Cancer CentreCalgaryAlbertaCanada
- Department of OncologyUniversity of CalgaryCalgaryAlbertaCanada
| | - Petra Grendarova
- Department of OncologyUniversity of CalgaryCalgaryAlbertaCanada
- Division of Radiation OncologyGrande Prairie Cancer CentreGrande PrairieAlbertaCanada
| | - Sarah Quirk
- Department of Physics and AstronomyUniversity of CalgaryCalgaryAlbertaCanada
- Division of Medical PhysicsTom Baker Cancer CentreCalgaryAlbertaCanada
- Department of OncologyUniversity of CalgaryCalgaryAlbertaCanada
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22
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Ladbury C, Liu J, Radany E, Vora N, Amini A, Beriwal S, Yashar C, Shah C, Glaser S. An examination of nationwide trends in accelerated partial breast irradiation - The replacement of breast brachytherapy with intraoperative radiotherapy and external beam radiation. Radiother Oncol 2021; 166:79-87. [PMID: 34838893 DOI: 10.1016/j.radonc.2021.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/03/2021] [Accepted: 11/18/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To examine recent modality utilization trends in accelerated partial breast irradiation (APBI) in the National Cancer Database (NCDB) based on the American Society for Radiation Oncology (ASTRO) guidelines. MATERIALS AND METHODS A total of 58,194 patients treated with APBI were identified. Patients were segregated by APBI modality (brachytherapy, external beam radiotherapy [EBRT], and intraoperative radiotherapy ([IORT]). These patients were then further classified by suitability to receive APBI based on ASTRO guidelines. Temporal trends in utilization were evaluated using linear regression. Logistic regression was applied to study factors contributing to APBI modality choice and treatment within the ASTRO suitability groups. RESULTS Patients treated with brachytherapy, EBRT, and IORT comprised 70.5%, 17.5%, and 12.0% of patients treated with APBI. From 2008 to 2017, total APBI cases remained relatively stable (-54.1 cases/year, p = 0.161) while brachytherapy cases decreased by 258.7 cases/year (p < 0.001). EBRT and IORT increased by 51.5 cases/year (p = 0.019) and 153.1 cases/year (p < 0.001), respectively. 40.0% of patients treated with APBI were classified as "suitable", which increased from 2010 to 2017 from 35.3% to 45.3% (slope = 1.51%/year, r2 = 0.61, p = 0.022). In comparison, 36.0% (36.1% in 2010 to 33.1% in 2017) of patients were classified as "cautionary" (slope = -0.33%/year, r2 = 0.63, p = 0.019) and 23.9% (28.6% in 2010 to 21.6% in 2017) of patients were classified as "unsuitable" (slope = -1.18%/year, r2 = 0.67, p = 0.012). CONCLUSIONS While overall APBI utilization has remained stable since 2008, this has been accompanied by a decline in brachytherapy and a rise in IORT. The causes of these trends should be the topic of future research.
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Affiliation(s)
- Colton Ladbury
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA.
| | - Jason Liu
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Eric Radany
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Nayana Vora
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Arya Amini
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA
| | - Sushil Beriwal
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, USA
| | - Catheryn Yashar
- Department of Radiation Oncology, University of California San Diego, San Diego, USA
| | - Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, USA
| | - Scott Glaser
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, USA.
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23
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Price AT, Kennedy WR, Henke LE, Brown SR, Green OL, Thomas MA, Ginn J, Zoberi I. Implementing stereotactic accelerated partial breast irradiation using magnetic resonance guided radiation therapy. Radiother Oncol 2021; 164:275-281. [PMID: 34624406 DOI: 10.1016/j.radonc.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Accelerated partial breast irradiation (APBI) seeks to reduce irradiated volumes and radiation exposure for patients while maintaining acceptable clinical outcomes. Magnetic resonance image-guided radiotherapy (MRgRT) provides excellent soft-tissue contrast for treatment localization, which can reduce setup uncertainty, thus reducing margins in the external beam setting. Additionally, stereotactic body radiotherapy (SBRT)-style regimens with high gradients can also be executed. This MR-guided stereotactic APBI (MRgS-APBI) approach can be utilized for a lower number of fractions and spare a greater volume of healthy tissues compared to conventional 3D external beam APBI. METHODS Our MRgS-APBI program was developed for two prospective non-randomized phase I/II clinical trials (20Gyx1 and 8.5Gyx3). Both breast SBRT treatment planning and MRgRT delivery techniques were described in this study. Simulation included both CT and MRI with specialized immobilization to accommodate MR-guided setup and cine-MRI treatment gating. Dosimetry data from 48 single-fraction and 19 three-fraction patients were collected and evaluated. This included planning objectives and SBRT-specific indices. During treatment, setup errors were calculated to evaluate setup reproducibility and duty cycle was calculated using cine-MRI data during gated delivery. RESULTS In both the single- and three- fraction trials combined, 88.5% of the possible dosimetric objectives across all patients were met during planning. The majority of the planning objectives were easily achievable indicating the potential for stricter objectives for subsequent S-APBI treatments. The average magnitude of setup uncertainties was 1.0 cm ± 0.6 cm across all treatments. In the three-fraction trial, the average beam-on duty-cycle for the MRI-gated delivery was 83.0 ± 13.0%. There were no technical MRgS-APBI related issues that resulted in discontinuation of treatment across all patients. CONCLUSION SBRT-style dosimetry and delivery for APBI is feasible using MR-guidance. The program development and dosimetric outcomes reported here can serve as a guide for other institutions considering the clinical implementation of MR-guided stereotactic APBI.
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Affiliation(s)
- Alex T Price
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - William R Kennedy
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Lauren E Henke
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Sean R Brown
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Olga L Green
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Maria A Thomas
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - John Ginn
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States
| | - Imran Zoberi
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, United States.
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24
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Berlangieri A, Elliott S, Wasiak J, Chao M, Foroudi F. Use of magnetic resonance image-guided radiotherapy for breast cancer: a scoping review. J Med Radiat Sci 2021; 69:122-133. [PMID: 34523823 PMCID: PMC8892442 DOI: 10.1002/jmrs.545] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 08/09/2021] [Accepted: 08/19/2021] [Indexed: 12/28/2022] Open
Abstract
In recent years, we have seen the integration of magnetic resonance imaging (MRI) simulators into radiotherapy centres and the emergence MR linear accelerators (MR-linac). Currently, there are limited studies to demonstrate the clinical effectiveness of MRI guided radiotherapy (MRIgRT) treatment for breast cancer patients. The objective of this scoping review was to identify and map the existing evidence surrounding the clinical implementation of MRIgRT for breast cancer patients. We also identified the challenges and knowledge gaps in the literature. The scoping review was reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews reporting guidelines. Titles and abstracts were screened by two independent reviewers. Quantitative and qualitative data were extracted and summarised using thematically organised tables. Results identify that accelerated partial breast irradiation (APBI) is the most common form of treatment for MRIgRT. The presence of the magnet does not affect target coverage or violate organ at risk (OAR) constraints compared to standard radiotherapy methods. Consideration is advised for skin and chest wall (CW) due to the electron return effect (ERE) and areas such as armpit and chin due to the electron stream effect (ESE). Clinically, bolus has been used to protect and prevent unwanted dose in these areas. Overall treatment for APBI on the MR-linac is feasible.
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Affiliation(s)
- Alexandra Berlangieri
- Olivia Newton John Cancer Wellness and Research Centre (ONCWRC), Austin Health, Heidelberg, Victoria, Australia
| | - Sarah Elliott
- Olivia Newton John Cancer Wellness and Research Centre (ONCWRC), Austin Health, Heidelberg, Victoria, Australia
| | - Jason Wasiak
- Olivia Newton John Cancer Wellness and Research Centre (ONCWRC), Austin Health, Heidelberg, Victoria, Australia
| | - Michael Chao
- Olivia Newton John Cancer Wellness and Research Centre (ONCWRC), Austin Health, Heidelberg, Victoria, Australia
| | - Farshad Foroudi
- Olivia Newton John Cancer Wellness and Research Centre (ONCWRC), Austin Health, Heidelberg, Victoria, Australia
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25
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Leonard CE, Wang Y, Asmar L, Lei RY, Howell KT, Henkenberns PL, Johnson TK, Hobart TL, Tole SP, Kercher JM, Widner JL, Barke L, Kaske T, Carter DL. A prospective Phase III trial evaluating patient self-reported pain and cosmesis in accelerated partial breast irradiation utilizing 3-D versus intensity-modulated radiotherapy. Cancer Med 2021; 10:7089-7100. [PMID: 34469056 PMCID: PMC8525102 DOI: 10.1002/cam4.4242] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/09/2021] [Accepted: 08/11/2021] [Indexed: 12/24/2022] Open
Abstract
Purpose/Objective The primary objective is to examine patient self‐assessment of breast pain and cosmesis between three‐dimensional (3D‐CRT) versus intensity‐modulated radiotherapy (IMRT). The secondary objective is to evaluate any relationship of treatment planning conformality of both cohorts to patient‐assessed pain. Assessments were performed at interim 12, 24, 36, and 48 months with a final 5‐year assessment. Materials/Methods In total, 656 patients (3D‐CRT n = 328; IMRT n = 328) were randomly assigned to either IMRT or 3D‐CRT accelerated partial breast radiotherapy to 38.5 Gy in 10 BID 3.85 Gy fractions. Results Median follow‐up was 3 years. Multivariate analysis showed that pain severity significantly decreased from baseline to the 12‐month follow‐up visit (<0.001 for both 3D‐CRT and IMRT) in each cohort. There was significantly less pain at 2 (p = 0.002) and 3 years (0.045) in the IMRT arm versus the 3D‐CRT arm when compared to the baseline pain level. There was no difference in patient‐assessed cosmesis at any follow‐up point; however, although MD‐assessed cosmesis showed no difference from years 1 to 4, there was significantly better cosmesis for 3D‐CRT versus IMRT (p = 0.047) at 5 years. There was a significant correlation between a maximum pain score and an increase in the CI100 (indicating less conformity) in the IMRT cohort (p < 0.01) and in the IMRT subgroup when the CI100 was ≤0.37 cohort arm (p = 0.01). Conclusion In the analysis of our primary objective we found that at 2 years, IMRT resulted in more interval improvement in breast pain after baseline when compared to patients treated with 3D‐CRT planning. As seen in our secondary analysis, this may be due to the ability of IMRT to achieve higher conformality (as evidenced by lower CI values) resulting in less fibrosis. There were no differences in patient‐assessed cosmesis or MD‐assessed cosmesis for years 1–4; however, physician‐assessed 5‐year cosmesis was better with 3D‐CRT.
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Affiliation(s)
| | | | - Lina Asmar
- Linasmar Consulting, Houston, Texas, USA
| | - Rachel Y Lei
- Rocky Mountain Cancer Centers, Littleton, Colorado, USA
| | | | | | | | | | | | | | | | - Lora Barke
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
| | - Terese Kaske
- Sally Jobe Diagnostic Breast Center, Greenwood Village, Colorado, USA
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Hickey BE, Lehman M. Partial breast irradiation versus whole breast radiotherapy for early breast cancer. Cochrane Database Syst Rev 2021; 8:CD007077. [PMID: 34459500 PMCID: PMC8406917 DOI: 10.1002/14651858.cd007077.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)). OBJECTIVES To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer. SEARCH METHODS On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible. DATA COLLECTION AND ANALYSIS Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis. MAIN RESULTS We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence). AUTHORS' CONCLUSIONS It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.
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Affiliation(s)
- Brigid E Hickey
- Radiation Oncology Raymond Terrace, Princess Alexandra Hospital, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
| | - Margot Lehman
- School of Medicine, The University of Queensland, Brisbane, Australia
- Division of Cancer Services, Princess Alexandra Hospital, Brisbane, Australia
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Shah BA, Xiao J, Oh C, Taneja S, Barbee D, Maisonet O, Huppert N, Perez C, Gerber NK. Five-Fraction Prone Accelerated Partial Breast Irradiation: Long-Term Oncologic, Dosimetric, and Cosmetic Outcome. Pract Radiat Oncol 2021; 12:106-112. [PMID: 34474168 DOI: 10.1016/j.prro.2021.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
PURPOSE Randomized data support accelerated partial breast irradiation (APBI) for early-stage breast cancer with variable techniques and cosmesis outcomes. We have treated patients with 5-fraction prone external beam APBI for over a decade and herein report acute and late outcomes. METHODS AND MATERIALS Patients receiving APBI 600 cGy × 5 between 2010 and 2019 were included. APBI was primarily delivered prone, with opposed tangents targeting the tumor bed expanded by 1.5 cm (cropped 6 mm from skin). Ipsilateral breast was constrained to V50% < 60% and V100% < 35%. Survival was estimated with Kaplan-Meier. Late toxicities and clinician- and patient-rated cosmesis were evaluated for patients with >6 months follow-up (FU). RESULTS Of 345 patients meeting criteria, 14 were excluded due to APBI given for ipsilateral breast tumor recurrence (IBTR; n = 3), palliation (n = 9), and incomplete radiation therapy course (n = 2). Of the 331 remaining, median age was 70, 7.2% had ductal carcinoma in situ, and 94.3% were treated prone, with 32% treated every other day and 68% on consecutive days. Mean heart dose was 23.8 cGy for left-sided and 12.7 cGy for right-sided cancers. Ipsilateral lung V30% was 0.4%. At 5-year median FU, there were 7 (2.1%) IBTR, 9 (2.7%) contralateral recurrences, and 1 (0.3%) distant metastasis. Five-year local recurrence-free, disease-free, and overall survival was 99.5%, 96.7%, and 98.1%, respectively. When comparing patients with IBTR versus without, a higher proportion did not receive hormone therapy (71.4% vs. 26.2%, P = .018). Rates of acute grade 1 to 2 dermatitis, fatigue, and pain were 35.4%, 21.8%, and 9.4%, respectively, with no grade 3 toxicity. The rate of good-excellent physician- and patient-rated cosmesis (n = 199, median FU 2.8 years) was 92.5% and 89.4%, respectively. Patients experienced low rates of telangiectasia, fibrosis, and retraction/atrophy. CONCLUSIONS We report excellent dosimetric, oncologic, cosmetic, and late toxicity outcomes for patients treated with 5-fraction APBI. To our knowledge this is the largest series of women treated with prone APBI.
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Affiliation(s)
| | | | - Cheongeun Oh
- Biostatistics, Department of Population Health, NYU Langone Health, New York, New York
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28
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Boutrus RR, El Sherif S, Abdelazim Y, Bayomy M, Gaber AS, Farahat A, Hashem T, El Sebaie M. Once Daily Versus Twice Daily External Beam Accelerated Partial Breast Irradiation: A Randomized Prospective Study. Int J Radiat Oncol Biol Phys 2021; 109:1296-1300. [PMID: 33714527 DOI: 10.1016/j.ijrobp.2020.11.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/11/2020] [Accepted: 11/13/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of the current study was to compare toxicity, cosmesis, and local control between the once daily and the twice daily fractionation schemes for external beam accelerated partial breast irradiation. METHODS AND MATERIALS From December 2012 to June 2018, we enrolled 113 patients with ductal carcinoma in situ or invasive breast cancer, node negative disease, and tumors less than 3 cm in size to receive accelerated partial breast irradiation (APBI) to a total dose of 38.5 Gy over 10 fractions given either once (oAPBI) or twice daily (tAPBI). Sixty patients were included in the tAPBI arm and 53 patients were included in the oAPBI arm. RESULTS Median follow-up was 74 months (range, 24-105). The median pain score during treatment was 3 out of 10 in the oAPBI and 5 in the tAPBI (P = .001). No differences were observed in GIII early skin toxicity (P = .4) or GI early pulmonary toxicity (P = 1.0) between the 2 treatment arms. GIII late skin toxicity developed in 3.8% and 11.7% of patients in the oAPBI and tAPBI arms, respectively (P = .001). GIII subcutaneous fibrosis developed in 1.9% and 8.3% of patients in the oAPBI and tAPBI, respectively (P = .001). The rate of patients with adverse cosmesis (poor/fair) was 7.5% at 12 months and at 24 months in the oAPBI arm compared with 21.7% and 26.7% in the tAPBI arm (P = .03 and .008, respectively). CONCLUSIONS oAPBI is a safe, well-tolerated schedule with more favorable outcomes than the tAPBI schedule with regards to late toxicity and cosmesis.
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Affiliation(s)
- Rimoun R Boutrus
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt.
| | - Sara El Sherif
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Yasser Abdelazim
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohammed Bayomy
- Clinical Oncology Department, Zagazig University, Zagazig, Egypt
| | - Ayman S Gaber
- Medical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Farahat
- Surgical Oncology Department, Breast Division, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Tarek Hashem
- Surgical Oncology Department, Breast Division, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Medhat El Sebaie
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
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Health-related quality of life of early-stage breast cancer patients after different radiotherapy regimens. Breast Cancer Res Treat 2021; 189:387-398. [PMID: 34216316 PMCID: PMC8357747 DOI: 10.1007/s10549-021-06314-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/22/2021] [Indexed: 02/08/2023]
Abstract
Purpose To evaluate and compare health-related quality of life (HRQL) of women with early-stage breast cancer (BC) treated with different radiotherapy (RT) regimens. Methods Data were collected from five prospective cohorts of BC patients treated with breast-conserving surgery and different RT regimens: intraoperative RT (IORT, 1 × 23.3 Gy; n = 267), external beam accelerated partial breast irradiation (EB-APBI, 10 × 3.85 Gy; n = 206), hypofractionated whole breast irradiation(hypo-WBI, 16 × 2.67 Gy; n = 375), hypo-WBI + boost(hypo-WBI-B, 21–26 × 2.67 Gy; n = 189), and simultaneous WBI + boost(WBI-B, 28 × 2.3 Gy; n = 475). Women ≥ 60 years with invasive/in situ carcinoma ≤ 30 mm, cN0 and pN0-1a were included. Validated EORTC QLQ-C30/BR23 questionnaires were used to asses HRQL. Multivariable linear regression models adjusted for confounding (age, comorbidity, pT, locoregional treatment, systemic therapy) were used to compare the impact of the RT regimens on HRQL at 12 and 24 months. Differences in HRQL over time (3–24 months) were evaluated using linear mixed models. Results There were no significant differences in HRQL at 12 months between groups except for breast symptoms which were better after IORT and EB-APBI compared to hypo-WBI at 12 months (p < 0.001). Over time, breast symptoms, fatigue, global health status and role functioning were significantly better after IORT and EB-APBI than hypo-WBI. At 24 months, HRQL was comparable in all groups. Conclusion In women with early-stage breast cancer, the radiotherapy regimen did not substantially influence long-term HRQL with the exception of breast symptoms. Breast symptoms are more common after WBI than after IORT or EB-APBI and improve slowly until no significant difference remains at 2 years posttreatment. Supplementary Information The online version contains supplementary material available at 10.1007/s10549-021-06314-4.
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Comparison between Accelerated Partial Breast Irradiation with multicatheter interstitial brachytherapy and Whole Breast Irradiation, in clinical practice. Clin Transl Oncol 2021; 24:24-33. [PMID: 34213744 PMCID: PMC8251685 DOI: 10.1007/s12094-021-02664-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/07/2021] [Indexed: 11/05/2022]
Abstract
Purpose The aim of this study was to compare accelerated partial breast irradiation (APBI) with multicatheter interstitial brachytherapy (BT) and whole breast irradiation (WBI), in terms of toxicity, aesthetic result, quality of life and survival, in clinical practice.
Materials and methods A comparative study of two prospectively recorded cohorts of 76 breast cancer patients who complied with the recommendations of GEC-ESTRO for APBI was conducted. The main objective was toxicity, quality of life measured through validated questionnaires and the aesthetic results. Secondary objectives were overall survival and disease-free survival.
Results Seventy-six stage I/II breast cancer patients, with a mean age of 66 years entered the study. APBI group showed less acute G1-2 dermatitis (51.4 vs 94.9%, p < 0.001) and late hyperpigmentation (0 vs 17.9%, p = 0.04). There were no differences in aesthetic results, both assessed by the patient herself and by the doctor. Statistically significant differences in measures of quality of life were observed in favour of the APBI, both in EORTC QLQ-BR23 and body image scale questionnaires. With a median follow-up of 72 months (6 years), the estimated overall survival at 5 and 10 years was 96.8 and 77.7%, respectively, and disease-free survival at 5 and 10 years was 91.1 and 69.4%, respectively, without statistically significant differences between groups.
Discussion APBI is an attractive alternative in candidate patients with initial breast cancer, with benefits in acute toxicity and quality of life and fewer visits to the hospital, without compromising tumor control or survival.
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Rahimi A, Morgan HE, Kim DW, Zhang Y, Leitch M, Wooldridge R, Goudreau S, Haley B, Rao R, Rivers A, Spangler AE, Jones RT, Stevenson S, Staley J, Albuquerque K, Ahn C, Neufeld S, Alluri PG, Ding C, Garwood D, Seiler S, Zhao B, Gu X, Timmerman R. Cosmetic Outcomes of a Phase 1 Dose Escalation Study of 5-Fraction Stereotactic Partial Breast Irradiation for Early Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2021; 110:772-782. [PMID: 33476737 DOI: 10.1016/j.ijrobp.2021.01.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE Our purpose was to evaluate cosmetic changes after 5-fraction adjuvant stereotactic partial breast irradiation (S-PBI). METHODS AND MATERIALS Seventy-five women with in situ or invasive breast cancer stage 0, I, or II, with tumor size ≤3 cm, were enrolled after lumpectomy in a phase 1 dose escalation trial of S-PBI into cohorts receiving 30, 32.5, 35, 37.5, or 40 Gy in 5 fractions. Before S-PBI, 3 to 4 gold fiducial markers were placed in the lumpectomy cavity for tracking with the Synchrony respiratory tracking system. S-PBI was delivered with a CyberKnife robotic radiosurgery system. Patients and physicians evaluated global cosmesis using the Harvard Breast Cosmesis Scale. Eight independent panelists evaluated digital photography for global cosmesis and 10 subdomains at baseline and follow-up. McNemar tests were used to evaluate change in cosmesis, graded as excellent/good or fair/poor, from baseline to year 3. Wilcoxon signed rank tests were used to evaluate change in subdomains. Cohen's kappa (κ) statistic was used to estimate interobserver agreement (IOA) between raters, and Fleiss' κ was used to estimate IOA between panelists. RESULTS Median cosmetic follow-up was 5, 5, 5, 4, and 3 years for the 30, 32.5, 35, 37.5, and 40 Gy cohorts. Most patients reported excellent/good cosmesis at both baseline (86.3%) and year 3 (89.8%). No dose cohort had significantly worsened cosmesis by year 3 on McNemar analysis. No cosmetic subdomain had significant worsening by year 3. IOA was fair for patient-physician (κ = 0.300, P < .001), patient-panel (κ = 0.295, P < .001), physician-panel (κ = 0.256, P < .001), and individual panelists (Fleiss κ = 0.327, P < .001). CONCLUSIONS Dose escalation of S-PBI from 30 to 40 Gy in 5 fractions for early stage breast cancer was not associated with a detectable change in cosmesis by year 3. S-PBI is a promising modality for treatment of early stage breast cancer.
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Affiliation(s)
- Asal Rahimi
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Howard E Morgan
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dong W Kim
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yuanyuan Zhang
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Marilyn Leitch
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rachel Wooldridge
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sally Goudreau
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Barbara Haley
- Department of Medicine, Division of Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Roshni Rao
- Department of Surgery, Columbia University, New York, New York
| | - Aeisha Rivers
- Department of Surgery, Memorial Health Care System, Pembroke Pines, Florida
| | - Ann E Spangler
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ryan T Jones
- Department of Radiation Oncology, Tennessee Oncology, Nashville, Tennessee
| | - Stella Stevenson
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jason Staley
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kevin Albuquerque
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chul Ahn
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sarah Neufeld
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Prasanna G Alluri
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chuxiong Ding
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dan Garwood
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephen Seiler
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bo Zhao
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, Uniondale, New York
| | - Xuejun Gu
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert Timmerman
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
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Jones BM, Green S. Modern radiation techniques in early stage breast cancer for the breast radiologist. Clin Imaging 2021; 80:19-25. [PMID: 34224950 DOI: 10.1016/j.clinimag.2021.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 01/22/2023]
Abstract
Partial breast irradiation (PBI) and ultra-hypofractionated whole breast irradiation (uWBI) are contemporary alternatives to conventional and standard hypofractionated whole breast irradiation (WBI), which shorten treatment from 3 to 6 weeks to 1-2 weeks for select patients. PBI and accelerated PBI (APBI) can be delivered with external beam radiation (3D conformal radiation therapy (3D-CRT) or intensity modulated radiation therapy (IMRT)), intraoperative radiation (IORT), or brachytherapy. These new radiation techniques offer the advantage of convenience and lower cost, which ultimately improves access to care. Globally, the COVID 19 pandemic has accelerated APBI/PBI and ultra-hypofractionated regimens into routine practice for carefully selected patients. Recent long-term data from randomized controlled trials (RCTs) have demonstrated these techniques are safe and effective in suitable patients demonstrating equivalent or improved local recurrence, acute/late toxicity, and cosmesis. PBI and APBI should be limited to low risk unifocal invasive ductal carcinoma and ductal carcinoma in situ with tumor size < 2 cm, clear margins (≥2 mm), ER+, and negative nodes. Based on the results from UK Fast-Forward and UK FAST ultra-hypofractionated breast radiation can be safely employed for early stage node negative patients, but is not yet considered an international standard of care. In this review, authors will appraise recent data for these shorter course radiation treatment regimens, as well as, considerations for breast radiologists including surveillance imaging and radiographic findings.
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Affiliation(s)
- Brianna M Jones
- Icahn School of Medicine at Mount Sinai, United States of America.
| | - Sheryl Green
- Icahn School of Medicine at Mount Sinai, United States of America.
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Haussmann J, Budach W, Strnad V, Corradini S, Krug D, Schmidt L, Tamaskovics B, Bölke E, Simiantonakis I, Kammers K, Matuschek C. Comparing Local and Systemic Control between Partial- and Whole-Breast Radiotherapy in Low-Risk Breast Cancer-A Meta-Analysis of Randomized Trials. Cancers (Basel) 2021; 13:2967. [PMID: 34199281 PMCID: PMC8231985 DOI: 10.3390/cancers13122967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/09/2021] [Accepted: 06/09/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE/OBJECTIVE The standard treatment for localized low-risk breast cancer is breast-conserving surgery, followed by adjuvant radiotherapy and appropriate systemic therapy. As the majority of local recurrences occur at the site of the primary tumor, numerous trials have investigated partial-breast irradiation (PBI) instead of whole-breast treatment (WBI) using a multitude of irradiation techniques and fractionation regimens. This meta-analysis addresses the impact on disease-specific endpoints, such as local and regional control, as well as disease-free survival of PBI compared to that of WBI in published randomized trials. MATERIAL AND METHODS We conducted a systematic literature review and searched for randomized trials comparing WBI and PBI in early-stage breast cancer with publication dates after 2009. The meta-analysis was based on the published event rates and the effect sizes for available oncological endpoints of at least two trials reporting on them. We evaluated in-breast tumor recurrences (IBTR), local recurrences at the primary site and elsewhere in the ipsilateral breast, regional recurrences (RR), distant metastasis-free interval (DMFI), disease-free survival (DFS), contralateral breast cancer (CBC), and second primary cancer (SPC). Furthermore, we aimed to assess the impact of different PBI techniques and subgroups on IBTR. We performed all statistical analyses using the inverse variance heterogeneity model to pool effect sizes. RESULTS For the intended meta-analysis, we identified 13 trials (overall 15,561 patients) randomizing between PBI and WBI. IBTR was significantly higher after PBI (OR = 1.66; CI-95%: 1.07-2.58; p = 0.024) with an absolute difference of 1.35%. We detected significant heterogeneity in the analysis of the PBI technique with intraoperative radiotherapy resulting in higher local relapse rates (OR = 3.67; CI-95%: 2.28-5.90; p < 0.001). Other PBI techniques did not show differences to WBI in IBTR. Both strategies were equally effective at the primary tumor site, but PBI resulted in statistically more IBTRs elsewhere in the ipsilateral breast. IBTRs after WBI were more likely to be located at the primary tumor bed, whereas they appeared equally distributed within the breast after PBI. RR was also more frequent after PBI (OR = 1.75; CI-95%: 1.07-2.88; p < 0.001), yet we did not detect any differences in DMFI (OR = 1.08; CI-95%: 0.89-1.30; p = 0.475). DFS was significantly longer in patients treated with WBI (OR = 1.14; CI-95%: 1.02-1.27; p = 0.003). CBC and SPC were not different in the test groups (OR = 0.81; CI-95%: 0.65-1.01; p = 0.067 and OR = 1.09; CI-95%: 0.85-1.40; p = 0.481, respectively). CONCLUSION Limiting the target volume to partial-breast radiotherapy appears to be appropriate when selecting patients with a low risk for local and regional recurrences and using a suitable technique.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Vratislav Strnad
- Department of Radiation Oncology, University Erlangen, 91054 Erlangen, Germany;
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital LMU (Ludwig Maximillian), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Livia Schmidt
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Edwin Bölke
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Ioannis Simiantonakis
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
| | - Kai Kammers
- Division of Biostatistics and Bioinformatics, Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Christiane Matuschek
- Department of Radiation Oncology, Heinrich Heine University, 40225 Dusseldorf, Germany; (J.H.); (W.B.); (L.S.); (B.T.); (I.S.); (C.M.)
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Hannoun-Levi JM, Chamorey E, Boulahssass R, Polgar C, Strnad V. Endocrine therapy with accelerated Partial breast irradiati On or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early-stage breast cancer (EPOPE): The rationale for a GEC-ESTRO randomized phase III-controlled trial. Clin Transl Radiat Oncol 2021; 29:1-8. [PMID: 33997321 PMCID: PMC8102143 DOI: 10.1016/j.ctro.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 11/20/2022] Open
Abstract
Epidemiologic data confirm the increase of breast cancer incidence in the elderly. The risk of recurrence of breast cancer is basically low. De-escalation breast cancer adjuvant therapy is justified in selected elderly patients. Ultra-accelerated breast irradiation with endocrine therapy omission is under debate. Prospective randomized trial is warranted.
Purpose Breast cancer in the elderly has become a public health concern; there is a need to re-design its treatment with a view to de-escalation. Our paper sets out the rationale for a phase 3 randomized trial to evaluate less burdensome adjuvant procedures that remain effective and efficient. Materials and methods For low-risk breast cancer in the elderly, adjuvant treatment has been adjusted in order to make it more suitable and efficient. Hypofractionated radiation therapy based on accelerated or non-accelerated regimens as well as accelerated and ultra-accelerated partial breast irradiation (APBI) protocols were reviewed. Withdrawal of radiation (RT) or endocrine therapies (ET) from the adjuvant procedure were also investigated. Based on molecular and APBI classifications, inclusion criteria were discussed. Results Phase 3 randomized trials which compared standard vs. accelerated/non-accelerated hypofractionated regimens confirmed that the latter were non-inferior in terms of local control. Similarly, except for intraoperative-based techniques, APBI achieved non-inferior local control rates compared to whole breast irradiation for low-risk breast cancer. In phase 2 prospective trials using ultra APBI, encouraging results were observed regarding oncological outcome and toxicity profile. In phase 3 trials, adjuvant ET without RT significantly increased the rate of local relapse with no impact on overall survival while RT alone proved effective. Elderly patients aged 60 or more with low-risk, luminal A breast cancer were chosen as the target population in a phase 3 randomized trial comparing APBI + 5-year ET vs. uAPBI (16 Gy 1f) alone. Conclusion To investigate de-escalation adjuvant treatment for elderly breast cancer patients, we have defined a road map for testing more convenient strategies. This EPOPE phase 3 randomized trial is supported by the GEC-ESTRO breast cancer working group.
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Key Words
- ABS, American Brachytherapy Society
- APBI, Accelerated and partial breast irradiation
- ASTRO, American Society of Radiation Oncology
- BCS, Breast cancer surgery
- BCWG, Breast Cancer Working Group
- Brachytherapy
- Breast cancer in the elderly
- DCIS, Ductal carcinoma in situ
- DFS, Disease-free survival
- EPOPE, Endocrine therapy with accelerated Partial breast irradiatiOn or exclusive ultra-accelerated Partial breast irradiation for women aged ≥ 60 years with Early stage breast cancer
- EQD2, Equivalent Dose in 2Gy fractions
- ET, Endocrine therapy
- Endocrine therapy
- GEC-ESTRO, Groupe Européen de Curiethérapie/European Society for Therapeutic Radiation and Oncology
- HDB, High-dose rate Brachytherapy
- LCIS, Lobular carcinoma in situ
- MAPBI, Molecular and APBI GEC-ESTRO
- MIB, Multicatheter Interstitial Brachytherapy
- Oncogeriatric assessment
- QoL, Quality of Life
- RT, Radiotherapy
- Radiation therapy
- WBI, Whole breast irradiation
- uAPBI, ultra-Accelerated Partial Breast Irradiation
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Affiliation(s)
- Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Centre, University of Côte d'Azur, Nice, France
| | - Emmanuel Chamorey
- Department of Epidemiology and Biostatistics, Antoine Lacassagne Cancer Centre, University of Cote d'Azur, Nice, France
| | - Rabia Boulahssass
- Geriatric Unit. CHU de NICE, FHU ONCOAGE, University of Cote d'Azur, Nice, France
| | - Csaba Polgar
- Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Vratislav Strnad
- Department of Radiation Oncology, Erlangen University Hospital, Erlangen, Germany
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Li X, Sanz J, Foro P, Martínez A, Zhao M, Reig A, Liu F, Huang Y, Membrive I, Algara M, Rodríguez N. Long-term results of a randomized partial irradiation trial compared to whole breast irradiation in the early stage and low-risk breast cancer patients after conservative surgery. Clin Transl Oncol 2021; 23:2127-2132. [PMID: 33880724 DOI: 10.1007/s12094-021-02618-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To report long-term results of a randomized trial comparing accelerated partial breast irradiation (APBI) to whole-breast irradiation (WBI) in terms of efficacy, toxicity, and cosmesis. METHODS AND MATERIALS WBI group was treated with 3D conformal external irradiation, 2 Gy daily/fraction, 5 fractions/week, to a total dose of 50 Gy. APBI group was treated with 3D conformal external irradiation 3.75 Gy/fraction, twice a day, 5 fractions/week, to a total dose of 37.5 Gy in the APBI group. Patients were followed up every 6 months up to 5 years and yearly thereafter. During follow-up visits, the clinician evaluated chronic toxicity and scored cosmetic results with a four-scale system. RESULTS After a median follow-up of 10.3 years, 43 patients in each group (84%) are alive without disease. One patient died after disease progression in the APBI arm, and there was no death in the WBI arm. The rest of the patients died from another disease different than breast cancer, similarly between groups. There was greater fibrosis in the APBI group (9 patients grade 1 and one grade 2) compared to WBI (3 patients grade 1 and one grade 2); p = 0.18. Regarding cosmesis, in APBI group, 19 and 21 (43.2 and 47%) patients had excellent or good results, similar to the WBI group with 18 patients (40.9%) in each cosmesis outcome. The WBI group did not have any patient with poor cosmesis but the APBI had 3 (6.8%; p = 0.24). CONCLUSION After a follow-up of 10 years, there were no differences in efficacy between the 2 treatment arms. Despite slight greater toxicity in the APBI group, the cosmesis was similar and satisfactory in both groups.
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Affiliation(s)
- X Li
- Universidad Autónoma de Barcelona, Barcelona, Spain
| | - J Sanz
- Universitat Pompeu Fabra, Barcelona, Spain. .,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain. .,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain.
| | - P Foro
- Universitat Pompeu Fabra, Barcelona, Spain.,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - A Martínez
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain
| | - M Zhao
- Universidad Autónoma de Barcelona, Barcelona, Spain
| | - A Reig
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - F Liu
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain
| | - Y Huang
- Universidad Autónoma de Barcelona, Barcelona, Spain
| | - I Membrive
- Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - M Algara
- Universidad Autónoma de Barcelona, Barcelona, Spain.,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
| | - N Rodríguez
- Universitat Pompeu Fabra, Barcelona, Spain.,Radiation Oncology Department, Hospital del Mar, Parc de Salut Mar, C/. Del Gas s/n Edificio B, sótano -2, 08003, Barcelona, Spain.,Radiation Oncology Research Group, Institut Municipal d'InvestigacióMédica IMIM, Barcelona, Spain
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Snider JW, Nichols EM, Mutaf YD, Chen S, Molitoris J, Diwanji T, Becker SJ, Feigenberg SJ. Reproducibility of a novel, vacuum-assisted immobilization for breast stereotactic radiotherapy. J Appl Clin Med Phys 2021; 22:8-15. [PMID: 33656237 PMCID: PMC7984473 DOI: 10.1002/acm2.13127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 11/13/2022] Open
Abstract
A novel, breast‐specific stereotactic radiotherapy device has been developed for delivery of highly conformal, accelerated partial breast irradiation. This device employs a unique, vacuum‐assisted, breast cup immobilization system that applies a gentle, negative pressure to the target breast with the patient in the prone position. A device‐specific patient loader is utilized for simulation scanning and device docking. Prior to clinical activation, a prospective protocol enrolled 25 patients who had been or were to be treated with breast conservation surgery and adjuvant radiotherapy for localized breast cancer. The patients underwent breast cup placement and two separate CT simulation scans. Surgical clips within the breast were mapped and positions measured against the device’s integrated stereotactic fiducial/coordinate system to confirm reproducible and durable immobilization during the simulation, treatment planning, and delivery process for the device. Of the enrolled 25 patients, 16 were deemed eligible for analysis. Seventy‐three clips (median, 4; mean, 4.6; range, 1–8 per patient) were mapped in these selected patients on both the first and second CT scans. X, Y, and Z coordinates were determined for the center point of each clip. Length of vector change in position was determined for each clip between the two scans. The mean displacement of implanted clips was 1.90 mm (median, 1.47 mm; range, 0.44–6.52 mm) (95% CI, 1.6–2.20 mm). Additional analyses stratified clips by position within the breast and depth into the immobilization cup. Overall, this effort validated the clinically utilized 3‐mm planning target volume margin for accurate, reliable, and precise employment of the device.
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Affiliation(s)
- James W Snider
- Department of Radiation Oncology, University of Alabama at Birmingham Alabama, Birmingham, AL, USA
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yildirim D Mutaf
- Department of Radiation Oncology, Kaiser Permanente, Dublin, CA, USA
| | - Shifeng Chen
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jason Molitoris
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tejan Diwanji
- Department of Radiation Oncology, University of Miami, Coral Gables, FL, USA
| | - Stewart J Becker
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, USA
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Multi-institutional registry study evaluating the feasibility and toxicity of accelerated partial breast irradiation using noninvasive image-guided breast brachytherapy. Brachytherapy 2021; 20:631-637. [PMID: 33642174 DOI: 10.1016/j.brachy.2021.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 12/04/2020] [Accepted: 01/15/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE The noninvasive image-guided breast brachytherapy (NIBB) technique is a novel noninvasive yet targeted method for accelerated partial breast irradiation. We established a multi-institutional registry to evaluate the toxicity and efficacy of this technique across various practice settings. METHODS AND MATERIALS Institutions using the NIBB technique were invited to participate. Data for acute/late toxicity, cosmetic outcome, and tumor recurrence were collected. Toxicity and cosmetic outcome were graded based on the Common Terminology Criteria for Adverse Events version 3.0 and NRG/Radiation Therapy Oncology Group scale, respectively. Treatment variables were analyzed for association with outcomes. RESULTS A total of 252 patients from eight institutions were analyzed. The median age was 69 years. The mean tumor size was 1.1 cm (0.1-4.0 cm). Treatment was delivered 10 fractions (34-36 Gy) in 75% and five fractions (28.5 Gy) in 22%. B.i.d. fractionation was used in 9%. Acute radiation dermatitis was Grade 0-1, 2, and 3 in 77%, 19%, and 4%, respectively. One hundred ninety-one patients with a median followup of 18 months (4-72 months) were evaluable for late outcomes. Late toxicity Grades 2 and 3 were observed in 8.8% and 1%, respectively. Cosmetic outcome was excellent, good, and fair/poor in 62%, 36%, and 2%, respectively. B.i.d. fractionation was associated with higher acute and late toxicity. Second-generation applicators were associated with lower late toxicity and better cosmetic outcome. Actuarial freedom from ipsilateral breast tumor recurrence and true recurrence were 98.3% and 98.3% at 2 years and 90.9% and 95.4% at 5 years, respectively. CONCLUSIONS Accelerated partial breast irradiation using NIBB was well tolerated with a low rate of acute and late toxicity across various practice settings. Ipsilateral breast tumor recurrence and cosmetic outcomes were favorable. b.i.d. fractionation was associated with higher toxicity. Longer followup is needed to confirm late endpoints.
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Moderate hypofractionation remains the standard of care for whole-breast radiotherapy in breast cancer: Considerations regarding FAST and FAST-Forward. Strahlenther Onkol 2021; 197:269-280. [PMID: 33507331 PMCID: PMC7841378 DOI: 10.1007/s00066-020-01744-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/31/2020] [Indexed: 12/27/2022]
Abstract
Moderate hypofractionation is the standard of care for adjuvant whole-breast radiotherapy after breast-conserving surgery for breast cancer. Recently, 10-year results from the FAST and 5‑year results from the FAST-Forward trial evaluating adjuvant whole-breast radiotherapy in 5 fractions over 5 weeks or 1 week have been published. This article summarizes recent data for moderate hypofractionation and results from the FAST and FAST-Forward trial on ultra-hypofractionation. While the FAST trial was not powered for comparison of local recurrence rates, FAST-Forward demonstrated non-inferiority for two ultra-hypofractionated regimens in terms of local control. In both trials, the higher-dose experimental arms resulted in elevated rates of late toxicity. For the lower dose experimental arms of 28.5 Gy over 5 weeks and 26 Gy over 1 week, moderate or marked late effects were similar in the majority of documented items compared to the respective standard arms, but significantly worse in some subdomains. The difference between the standard arm and the 26 Gy of the FAST-Forward trial concerning moderate or marked late effects increased with longer follow-up in disadvantage of the experimental arm for most items. For now, moderate hypofractionation with 40–42.5 Gy over 15–16 fractions remains the standard of care for the majority of patients with breast cancer who undergo whole-breast radiotherapy without regional nodal irradiation after breast-conserving surgery.
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Musunuru HB, Yadav P, Olson SJ, Anderson BM. Improved Ipsilateral Breast and Chest Wall Sparing With MR-Guided 3-fraction Accelerated Partial Breast Irradiation: A Dosimetric Study Comparing MR-Linac and CT-Linac Plans. Adv Radiat Oncol 2021; 6:100654. [PMID: 34195491 PMCID: PMC8233460 DOI: 10.1016/j.adro.2021.100654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 11/11/2020] [Accepted: 12/15/2020] [Indexed: 01/21/2023] Open
Abstract
Purpose External beam accelerated partial breast irradiation (APBI) is subject to treatment uncertainties that must be accounted for through planning target volume (PTV) margin. We hypothesize that magnetic resonance–guided radiation therapy with reduced PTV margins enabled by real-time cine magnetic resonance image (MRI) target monitoring results in better normal tissue sparing compared with computed tomography (CT)-guided radiation therapy with commonly used clinical PTV margins. In this study, we compare the plan quality of ViewRay MRIdian Linac forward planned intensity modulated radiation therapy and TrueBeam volumetric modulated arc therapy for a novel 3-fraction APBI schedule. Methods and Materials Targets and organs at risk (OARs) were segmented for 10 patients with breast cancer according to NSABP B39/RTOG 0413 protocol. A 3 mm margin was used to generate MR PTV3mm and CT PTV3mm plans, and a 10 mm margin was used for CT PTV10mm. An APBI schedule delivering 24.6 Gy to the clinical target volume and 23.4 Gy to the PTV in 3 fractions was used. OAR dose constraints were scaled down from existing 5-fraction APBI protocols. Target and OAR dose-volume metrics for the following data sets were analyzed using Wilcoxon matched-pairs signed-rank test: (1) MR PTV3mm versus CT PTV3mm plans and (2) MR PTV3mm versus CT PTV10mm. Results Average PTVs were 84.3 ± 51.9 cm3 and 82.6 ± 55 cm3 (P = .5) for MR PTV3mm and CT PTV3mm plans, respectively. PTV V23.4Gy, dose homogeneity index, conformity index (CI), and R50 were similar. There was no meaningful difference in OAR metrics, despite MR PTV3mm being larger than the CT PTV3mm in 70% of the patients. Average PTVs for MR PTV3mm and CT PTV10mm plans were 84.3 ± 51.9 cm3 and 131.7 ± 74.4 cm3, respectively (P = .002). PTV V23.4Gy was 99% ± 0.9% versus 97.6% ± 1.4% (P = .03) for MR PTV3mm and CT PTV10mm, respectively. Dose homogeneity index, CI, and R50 were similar. MR PTV3mm plans had better ipsilateral breast (V12.3Gy, 34.8% ± 12.7% vs 44.4% ± 10.9%, P = .002) and chest wall sparing (V24Gy, 8.5 ± 5.5 cm3 vs 21.8 ± 14.9 cm3, P = .004). Conclusions MR- and CT-based planning systems produced comparable plans when a 3 mm PTV margin was used for both plans. As expected, MR PTV3mm plans produced better ipsilateral breast and chest wall sparing compared with CT PTV10mm. The clinical relevance of these differences in dosimetric parameters is not known.
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Affiliation(s)
- Hima Bindu Musunuru
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- Department of Radiation Oncology, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
- Corresponding author: Hima Bindu Musunuru, MD
| | - Poonam Yadav
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stephanie J. Olson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Bethany M. Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Guebert A, Roumeliotis M, Watt E, Meyer T, Quirk S. Dosimetric consequences of seed placement accuracy in permanent breast seed implant brachytherapy. Brachytherapy 2021; 20:664-672. [PMID: 33358141 DOI: 10.1016/j.brachy.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This study quantifies the dosimetric impact of implant accuracy and derives a quantitative relationship relating implant accuracy to target dosimetry. METHODS AND MATERIALS A framework was developed to simulate multiple implants for error combinations. Spherical clinical target volumes (CTVs) were modeled with volumes 1.4 cm3, 9.2 cm3, and 20.6 cm3, representing the range seen clinically. Each CTV was expanded 10 mm isotropically to create a planning target volume (PTV).. Random and systematic seed placement errors were simulated by shifting needles from their planned positions. Implant errors were simulated over the range of clinically practical errors in permanent breast seed implant. The relative effect on target coverage was evaluated. Regression analysis was performed to derive relationships between CTV dosimetry and the magnitude of implant accuracy. The validity of the clinically used 10 mm PTV margin for each of the CTVs was assessed. RESULTS Introducing practical implant errors resulted in CTV V90% median (10th and 90th percentile) of 97.7% (85.9% and 100%), 96.2% (86.8% and 99.7%), and 100% (77.8% and 100%) for the typical, large, and small CTV, respectively. All CTVs show similar trends in target coverage. Polynomials were derived relating seed placement accuracy to median (R2 = 0.82) and 10th percentile (R2 = 0.78) CTV V90%.. CONCLUSIONS: This work quantitatively describes the relationship between implant accuracy and CTV coverage. Based on simulations, the 10 mm PTV margin is adequate to maintain target coverage. These equations can be used with institutional seed placement accuracy to estimate coverage.
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Affiliation(s)
- Alexandra Guebert
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Division of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada.
| | - Michael Roumeliotis
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Division of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada; Okolo Health, Calgary, AB, Canada
| | - Elizabeth Watt
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Division of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada; Okolo Health, Calgary, AB, Canada
| | - Tyler Meyer
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Division of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada; Okolo Health, Calgary, AB, Canada
| | - Sarah Quirk
- Department of Physics and Astronomy, University of Calgary, Calgary, AB, Canada; Division of Medical Physics, Tom Baker Cancer Centre, Calgary, AB, Canada; Department of Oncology, University of Calgary, Calgary, AB, Canada
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Advances in Breast Cancer Radiation Therapy. CURRENT BREAST CANCER REPORTS 2021. [DOI: 10.1007/s12609-020-00401-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Shah C, Jia X, Hobbs BP, Tendulkar RD, Sittenfeld SMC, Al-Hilli Z, Arthur DW, Keisch ME, Khan AJ, Shaitelman SF, Boyages J, Wazer D, Kundu N, Vicini FA. Outcomes with Partial Breast Irradiation vs. Whole Breast Irradiation: a Meta-Analysis. Ann Surg Oncol 2021; 28:4985-4994. [PMID: 33393051 DOI: 10.1245/s10434-020-09447-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/03/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Several randomized trials have been performed comparing partial breast irradiation (PBI) and whole breast irradiation (WBI) though controversy remains, including regarding differences by PBI technique. We performed a meta-analysis to compare results between WBI versus PBI and between PBI techniques. METHODS A systematic review was performed to identify modern randomized studies listed in MEDLINE from 2005 to 2020. PBI trials were divided into external beam radiation and brachytherapy techniques, with intraoperative radiation excluded. A Bayesian logistic regression model evaluated the risk of ipsilateral breast tumor recurrence (IBTR) and acute and chronic toxicities. The primary outcome was IBTR at 5 years with WBI compared with PBI. RESULTS A total of 9758 patients from 7 studies were included (4840-WBI, 4918-PBI). At 5 years, no statistically significant difference in the rate of IBTR was noted between PBI (1.8%, 95% HPD 0.68-3.2%) and WBI (1.7%, 95% HPD 0.92-2.4%). By PBI technique, the 5-year rate of IBTR rate for external beam was 1.7% and 2.2% for brachytherapy. Rates of grade 2 + acute toxicity were 7.1% with PBI versus 47.5% with WBI. For late toxicities, grade 2/3 rates were 0%/0% with PBI compared with 1.0%/0% with WBI. CONCLUSIONS IBTR rates were similar between PBI and WBI with no significant differences noted by PBI technique; PBI had reduced acute toxicities compared to WBI. Because studies did not provide toxicity data in a consistent fashion, definitive conclusions cannot be made with additional data from randomized trials needed to compare toxicity profiles between PBI techniques.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xuefei Jia
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Brian P Hobbs
- Quantitative Health Sciences, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sarah M C Sittenfeld
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of Breast Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Atif J Khan
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Simona F Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, MA, USA.,Department of Radiation Oncology, Brown University, Providence, RI, USA
| | - Neilendu Kundu
- Department of Plastic Surgery, Mercy Health, Cincinnati, OH, USA
| | - Frank A Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA.
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Accelerated Partial Breast Radiation: Information on Dose, Volume, Fractionation, and Efficacy from Randomized Trials. Int J Radiat Oncol Biol Phys 2020; 108:1123-1128. [PMID: 33220220 DOI: 10.1016/j.ijrobp.2020.06.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/10/2023]
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Campos Magalhães Garcia LS, Garcia Trigo ML. Results of accelerated partial breast irradiation in patients not suitable for external beam irradiation stratified by GEC-ESTRO, ASTRO, and ABS guidelines. Brachytherapy 2020; 20:315-325. [PMID: 33199176 DOI: 10.1016/j.brachy.2020.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE This study aims to review the outcome of an institution in multicatheter/interstitial accelerated partial breast irradiation (MC-APBI) for treatment of patients with breast cancer, either with strong criteria for APBI or unable to be treated with whole-breast irradiation. The outcomes were also stratified by the American Society for Radiation Oncology, American Brachytherapy Society, and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology patient selection criteria. METHODS The study includes 118 patients and 120 MC-APBI treatments, treated in a single tertiary center, between November 2003 and August 2016. The analysis is focused on the clinical baseline characteristics, local control, relapse-free survival, disease-specific survival (DSS), and overall survival. RESULTS In accordance to the American Society for Radiation Oncology, American Brachytherapy Society, and Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology, 17.1% were "unsuitable," 19.2% were "unacceptable," and 19.5% were "high risk," respectively. The main reasons why high-risk patients were submitted to MC-APBI were as follows: cardiopathy (n = 7), social difficulties (n = 4), and mobility limitations (n = 4). At the median followup period of 86.5 months, ipsilateral breast tumor recurrence was observed in one (0.8%) patient. The 3-year and 5-year relapse-free survival were 100% and 99.1%, respectively. DSS was 100%. CONCLUSIONS This study demonstrated excellent control rates, DFS, and DSS of MC-APBI, rendering APBI as an excellent treatment for patients with breast cancer, even those who are not necessarily eligible for this treatment approach. The selection criteria for ABPI diverge according to different guidelines and are based on studies with discrepancies, making extremely possible that these recommendations could be changed.
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Affiliation(s)
| | - Maria Lurdes Garcia Trigo
- Department of Brachytherapy, Instituto Português de Oncologia do Porto Francisco Gentil E.P.E., Porto, Portugal
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Polgár C, Major T, Takácsi-Nagy Z, Fodor J. Breast-Conserving Surgery Followed by Partial or Whole Breast Irradiation: Twenty-Year Results of a Phase 3 Clinical Study. Int J Radiat Oncol Biol Phys 2020; 109:998-1006. [PMID: 33186620 DOI: 10.1016/j.ijrobp.2020.11.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/22/2020] [Accepted: 11/02/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To report the 20-year results of a phase 3 clinical trial comparing the survival and cosmetic results of breast-conserving surgery followed by partial breast irradiation (PBI) or whole breast irradiation (WBI). METHODS AND MATERIALS Between 1998 and 2004, 258 selected patients with low-risk invasive breast carcinoma (pT1 pN0-1mi, grade 1-2, nonlobular breast cancer) resected with negative margins were randomized after breast-conserving surgery to receive PBI (n = 128) or 50 Gy WBI (n = 130). Partial breast irradiation was given either by multicatheter high-dose-rate (HDR) brachytherapy (BT; n = 88) with 7 × 5.2 Gy twice daily or 50 Gy external beam irradiation with electron beams (n = 40). RESULTS Median follow-up time was 17 years. The 20-year actuarial rates of ipsilateral breast tumor recurrences were 9.6% versus 7.9% (P = .59) in the PBI and WBI arms, respectively. There was no significant difference in the 20-year probability of disease-free (79.7% vs 78.3%), cancer-specific (92.6% vs 88.1%), and overall survival (59.5% vs 59.7%). Significantly more patients had excellent or good cosmetic result in the PBI and WBI groups (79.2% vs 59.5%; P = .0007). CONCLUSIONS The 20-year updated results of our phase 3 clinical trial add further scientific evidence that PBI either with multicatheter HDR BT or electron beams for low-risk invasive breast carcinomas yield long-term local tumor control and survival comparable to those achieved with standard WBI. Interstitial HDR BT improved cosmetic results compared with WBI.
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Affiliation(s)
- Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Budapest, Hungary
| | - János Fodor
- Department of Oncology, Semmelweis University, Budapest, Hungary
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Mészáros N, Major T, Stelczer G, Jánváry L, Zaka Z, Pukancsik D, Takácsi-Nagy Z, Md JF, Polgár C. Accelerated partial breast irradiation with 3-dimensional conformal and image-guided intensity-modulated radiotherapy following breast conserving surgery - 7-Year results of a phase II trial. Breast 2020; 54:222-228. [PMID: 33161336 PMCID: PMC7648201 DOI: 10.1016/j.breast.2020.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose To present the 7-year results of accelerated partial breast irradiation (APBI) using three-dimensional conformal (3D-CRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) following breast-conserving surgery (BCS). Patients and methods Between 2006 and 2014, 104 patients were treated with APBI given by means of 3D-CRT using 3–5 non-coplanar, isocentric wedged fields, or IG-IMRT using kV-CBCT. The total dose of APBI was 36.9 Gy (9 × 4.1 Gy) using twice-a-day fractionation. Survival results, side effects and cosmetic results were assessed. Results At a median follow-up of 90 months three (2.9%) local recurrences, one (0.9%) regional recurrence and two (1.9%) distant metastases were observed. The 7-year local (LRFS), recurrence free survival was 98.9%. The 7-year disease-free (DFS), metastases free (MFS) and overall survival (OS) was 94.8%, 97.9% and 94.8%, respectively. Late side effects included G1 skin toxicity in 15 (14.4%), G1, G2, and G3 fibrosis in 26 (25%), 3 (2.9%) and 1 (0.9%) patients respectively. Asymptomatic (G1) fat necrosis occurred in 10 (9.6%) patients. No ≥ G2 or higher late side effects occurred with IMRT. The rate of excellent/good and fair/poor cosmetic results was 93.2% and 6.8%, respectively. Conclusion 7-year results of APBI with 3D-CRT and IG-IMRT are encouraging. Toxicity profile and local tumor control are comparable to other series using multicatheter interstitial brachytherapy. Therefore, these external beam APBI techniques are valid alternatives to whole breast irradiation and brachytherapy based APBI. Phase II APBI trial using 3D-CRT or IG-IMRT. Twice-a-day fractionation, with a total dose of 36.9 Gy (9 × 4.1Gy). No Grade 2 or worst late side effects with IG-IMRT at median follow up of 90 months. These APBI techniques are valid alternatives to WBI or brachytherapy based APBI.
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Affiliation(s)
- Norbert Mészáros
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary.
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - Gábor Stelczer
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary.
| | - Levente Jánváry
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Zaka
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Dávid Pukancsik
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Takácsi-Nagy
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
| | - János Fodor Md
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary
| | - Csaba Polgár
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary; Department of Oncology, Semmelweis University, Faculty of Medicine, Budapest, Hungary
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Sumodhee S, Pujalte M, Gal J, Cham Kee DL, Gautier M, Schiappa R, Chand ME, Hannoun-Levi JM. Accelerated partial breast irradiation in the elderly: 8-year oncological outcomes and prognostic factors. Brachytherapy 2020; 20:146-154. [PMID: 33132071 DOI: 10.1016/j.brachy.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The purpose of the study is to evaluate long-term clinical outcomes and prognostic factors after accelerated partial breast irradiation (APBI) in the elderly using high-dose-rate interstitial multicatheter brachytherapy (HIBT). METHODS AND MATERIALS Between 2005 and 2018, 109 patients underwent APBI using HIBT (34 Gy/10f/5d or 32 Gy/8f/4d). Based on a prospective database, outcomes were retrospectively analyzed (local relapse-free survival, metastatic-free survival, specific survival (SS), and overall survival (OS)). Prognostic factors were investigated. Late toxicity and cosmetic evaluation were reported. RESULTS With a median followup of 97 months [7-159], median age was 81.7 years [58-89]. In accordance with the GEC-ESTRO APBI classification, 72.5%, 11.9%, and 15.6% were classified as low, intermediate, and high risk, respectively. The histological type was mainly invasive ductal carcinoma (87.1%). The median tumor size was 10 mm [range 1-35]. Eight-year local relapse-free survival, SS, and OS were 96.7% [95% confidence interval (CI) [0.923; 1]), 96.7% [95% CI [0.924; 1], and 72% [95% CI [0.616; 0.837], respectively. In univariate analysis, APBI classification was not considered as prognostic factor, whereas molecular classification was prognostic factor for OS (p < 0.0001), SS (p = 0.007), and metastatic-free survival (p = 0.009) but not for local recurrence (p = 0.586). No Grade ≥3 late toxicity was observed, whereas 61 patients (88.4%) and 8 patients (11.6%) presented Grade 1 and 2 toxicities, respectively. The cosmetic outcome was excellent/good for 96.4%. CONCLUSIONS Long-term followup confirms that HIBT is safe and effective for elderly early breast cancer. Our results suggest that selected elderly women presenting with high-risk breast cancer could be also considered for APBI.
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Affiliation(s)
- Shakeel Sumodhee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Marc Pujalte
- Department of Medical Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Jocelyn Gal
- Biostatistics Unit, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Daniel Lam Cham Kee
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Mathieu Gautier
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Renaud Schiappa
- Department of Medical Oncology, Antoine Lacassagne Cancer Center, University of Cote d'Azur, Nice, France
| | - Marie-Eve Chand
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France
| | - Jean-Michel Hannoun-Levi
- Department of Radiation Oncology, Antoine Lacassagne Cancer Center & University of Cote d'Azur, Nice, France.
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Yamauchi R, Mizuno N, Itazawa T, Kawamori J. The influence of respiratory motion on dose distribution in accelerated partial breast irradiation using volumetric modulated arc therapy. Phys Med 2020; 80:23-33. [PMID: 33075732 DOI: 10.1016/j.ejmp.2020.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) is alternative treatment option for patients with early stage breast cancer. The interplay effect on volumetric modulated arc therapy APBI (VMAT-APBI) has not been clarified. This study aimed to evaluate the feasibility of VMAT-APBI for patients with small breasts and investigate the amplitude of respiratory motion during VMAT-APBI delivery that significantly affects dose distribution. METHODS The VMAT-APBI plans were generated with 28.5 Gy in five fractions. We performed patient-specific quality assurance using Delta4 phantom under static conditions. We also measured point dose and dose distribution using the ionization chamber and radiochromic film under static and moving conditions of 2, 3 and 5 mm. We compared the measured and calculated point doses and dose distributions by dose difference and gamma passing rates. RESULTS A total of 20 plans were generated; the dose distributions were consistent with those of previous reports. For all measurements under static conditions, the measured and calculated point doses and dose distributions showed good agreement. The dose differences for chamber measurement were within 3%, regardless of moving conditions. The mean gamma passing rates with 3%/2 mm criteria in the film measurement under static conditions and with 2 mm, 3 mm, and 5 mm of amplitude were 95.0 ± 2.0%, 93.3 ± 3.3%, 92.1 ± 6.2% and 84.8 ± 7.8%, respectively. The difference between 5 mm amplitude and other conditions was statistically significant. CONCLUSIONS Respiratory management should be considered for the risk of unintended dose distribution if the respiratory amplitude is >5 mm.
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Affiliation(s)
- Ryohei Yamauchi
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan.
| | - Norifumi Mizuno
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Tomoko Itazawa
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
| | - Jiro Kawamori
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan
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Joo JH, Ki Y, Jeon H, Kim DW, Jung J, Kim SS. Who are the optimal candidates for partial breast irradiation? Asia Pac J Clin Oncol 2020; 17:305-311. [PMID: 33078898 DOI: 10.1111/ajco.13462] [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: 10/23/2019] [Accepted: 09/05/2020] [Indexed: 11/28/2022]
Abstract
At the 2017 St. Gallen International Expert Consensus Conference on the Primary Therapy for Early Breast Cancer, the consensus panel recognized "partial breast irradiation as an option for women meeting the low-risk criteria put forward by the American Society for Radiation Oncology/European Society for Radiotherapy and Oncology (ASTRO/ESTRO) guideline," although acknowledging that there was less evidence for this approach. Partial breast irradiation is defined as irradiation localized to the surgical resection cavity only as opposed to the entire breast. Accelerated partial breast irradiation (APBI) involves intensive treatment in a short time period. The methods vary, and three available APBI options are brachytherapy, external beam and intra-operative irradiation. The long-term follow-up results from two large-scale, well-designed phase III randomized clinical trials have been released. However, further discussion of the optimal treatment candidates and delivery method is needed before the clinical application of APBI as a mainstream breast conservation treatment.
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Affiliation(s)
- Ji Hyeon Joo
- Department of Radiation Oncology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Yongkan Ki
- Department of Radiation Oncology, Pusan National University School of Medicine, Yangsan, South Korea
| | - Hosang Jeon
- Department of Radiation Oncology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Dong Woon Kim
- Department of Radiation Oncology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Goldberg M, Whelan TJ. Accelerated Partial Breast Irradiation (APBI): Where Are We Now? CURRENT BREAST CANCER REPORTS 2020; 12:275-284. [PMID: 33101597 PMCID: PMC7568840 DOI: 10.1007/s12609-020-00384-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2020] [Indexed: 01/26/2023]
Abstract
Purpose of Review Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings. APBI can be delivered using brachytherapy, intraoperative RT, or conformal external beam radiation therapy (EBRT) techniques. In this review, the authors appraise the latest modern randomized controlled trials (RCTs) of APBI and discuss the application of the data to clinical practice. Recent Findings The OCOG-RAPID and NSABP B-39/RTOG 0413 trials recently reported long-term outcomes of APBI. The OCOG-RAPID trial delivered 38.5 Gy/10 fractions twice daily (at least 6 h apart using EBRT) or WBI and demonstrated non-inferiority of APBI compared with WBI (8-year cumulative rate of ipsilateral breast tumor recurrence (IBTR) was 3% after APBI or 2.8% after WBI, HR 1.27, 90%CI: 0.84–1.91). While acute toxicity was reduced, late toxicity and breast cosmesis were worse with APBI. The NSABP B-39 trial included higher risk patients and was unable to demonstrate equivalence between APBI (38.5 Gy/10 fractions delivered twice daily using EBRT or brachytherapy techniques) and WBI. However, 10-year IBTR rates were low: 4.6% vs. 3.9%, respectively, HR 1.22, 90%CI: 0.94–1.58. The University of Florence demonstrated low rates of local recurrence at 10 years and overall excellent breast cosmetic outcomes when APBI was delivered using EBRT to a dose of 30 Gy/5 fractions delivered on non-consecutive days. Summary Recent RCTs of APBI have shed light on important factors for the integration of APBI into clinical practice, including patient selection and treatment delivery. APBI should be limited to patients with low-risk ductal carcinoma in situ or early stage (T1) invasive ductal cancer with clear margins of excision, estrogen receptor positivity, and node negative disease. Ongoing research should focus on the optimal dose/fractionation for delivery of EBRT-based APBI.
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Affiliation(s)
- Mira Goldberg
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
| | - Timothy J. Whelan
- Department of Oncology, McMaster University and Juravinski Cancer Centre, 699 Concession Street, Hamilton, ON L8V 5C2 Canada
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