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Thomsen MS, Alsner J, Lutz CM, Berg M, Jensen I, Lorenzen EL, Nielsen HM, Jakobsen EH, Stenbygaard L, Nielsen MH, Jensen MB, Overgaard J, Offersen BV. Breast induration and irradiated volume in the DBCG HYPO trial: The impact of age, smoking, and boost. Radiother Oncol 2024; 201:110574. [PMID: 39395667 DOI: 10.1016/j.radonc.2024.110574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 09/28/2024] [Accepted: 10/02/2024] [Indexed: 10/14/2024]
Abstract
PURPOSE To investigate the association between irradiated breast volume and grade 2-3 breast induration three years after radiotherapy in the phase III Danish Breast Cancer Group HYPO trial randomizing patients ≥ 41 years to whole breast irradiation (WBI) with 40 Gy/15fr versus 50 Gy/25fr. METHODS Treatment plans were available for all Danish patients. Associations between frequency of induration and irradiated volume, age, smoking status, and boost were assessed by logistic regression. A sequential boost was given to patients < 50 years or in case of a narrow (<2 mm) resection margin. RESULTS RT plans from 1,333 patients were analyzed with 178 (13 %) having grade 2-3 induration. 1135 patients had only WBI. For this group, induration was correlated with irradiated breast volume for patients ≥ 65 years (n = 343, 10 %/22 % for small/large irradiated volumes, p = 0.005) but not for patients aged 50-64 years (n = 792, 11 % for both small and large volumes, p = 0.82). Smoking doubled the frequency irrespective of irradiated volume and age. All patients < 50 years (n = 156) had a boost. A volume effect was found for this group (5 %/21 % induration for small/large volume, p = 0.002). 42 patients ≥ 50 years had a boost and 14 (33 %) had grade 2-3 induration, however, with a p-value > 0.05 due to the few numbers of patients. CONCLUSION A relationship between irradiated breast volume and 3-year frequency of breast induration was found for patients ≥ 65 years, whilst not for patients aged 50-64 years. Smoking doubled the risk of induration irrespective of volume and age. A dose-induration relationship was seen for boost patients < 50 years.
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Affiliation(s)
- Mette S Thomsen
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark.
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christina M Lutz
- Department of Medical Physics, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Berg
- Department of Medical Physics, University Hospital of Southern Denmark, Vejle, Denmark
| | - Ingelise Jensen
- Department of Medical Physics, Aalborg University Hospital, Aalborg, Denmark
| | - Ebbe L Lorenzen
- Laboratory of Radiation Physics, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Hanne M Nielsen
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik H Jakobsen
- Department of Oncology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Lars Stenbygaard
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette H Nielsen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Maj-Britt Jensen
- Danish Breast Cancer Group, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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2
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Kaidar-Person O, Ratosa I, Franco P, Masiello V, Marazzi F, Pedretti S, Ciabattoni A, Leonardi MC, Tramm T, Coles EC, Meattini I, Arenas M, Offersen BV, Boersma LJ, Valentini V, Dodwell D, Poortmans P, Aristei C. The Assisi think tank focus review on postoperative radiation for lobular breast cancer. Radiother Oncol 2024:110573. [PMID: 39395669 DOI: 10.1016/j.radonc.2024.110573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2024] [Revised: 10/04/2024] [Accepted: 10/06/2024] [Indexed: 10/14/2024]
Abstract
The "Assisi Think Tank Meeting" (ATTM) on Breast Cancer, endorsed by the European Society for Radiotherapy & Oncology (ESTRO) and the Italian Association of Radiotherapy and Clinical Oncology (AIRO), and conducted under the auspices of the European Society of Breast Cancer Specialists (EUSOMA), is a bi-annual meeting aiming to identify major clinical challenges in breast cancer radiation therapy (RT) and proposing clinical trials to address them. The topics discussed at the meeting are pre-selected by the steering committee. At the meeting, these topics are discussed in different working groups (WG), after preparation of the meeting by performing a systematic review of existing data and of ongoing trials. Prior to the meeting, each WG designs a survey on the topic to be discussed to reflect current clinical practice and to identify areas requiring further research. Herein, we present the work done by the Assisi WG focusing on lobular carcinoma and the RT perspectives in its treatment, including providing recommendations for locoregional therapy, mainly RT for patients with non-metastatic lobular breast cancer.
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Affiliation(s)
- O Kaidar-Person
- Breast Radiation Unit, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medical & Health Sciences, Tel-Aviv University, Tel-Aviv, Israel; GROW- Research Institute for Oncology and Reproduction, Maastricht University, Maastricht, Netherlands.
| | - I Ratosa
- Division of Radiation Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Franco
- Department of Translational Medicine (DIMET), University of Eastern Piedmont, Novara, Italy; Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | - V Masiello
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - F Marazzi
- Fondazione Policlinico Universitario "A. Gemelli" IRCCS, UOC di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Rome, Italy
| | - S Pedretti
- Radiation Oncology, ASST Spedali Civili, Brescia, Italy
| | - A Ciabattoni
- Radiotherapy Unit, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - M C Leonardi
- Radiotherapy Division, European Institute of Oncology, IEO IRCCS, Milan, Italy
| | - T Tramm
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - E C Coles
- CRUK Cambridge Centre (Regno Unito), UK
| | - I Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence. Radiation Oncology Unit, Breast Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - M Arenas
- University Rovira and Virgili. Depaertment of Radiation Oncology, Hospital Universitari Sant Joan de Reus, Tarragona, Spain
| | - B V Offersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - L J Boersma
- Department of Radiation Oncology (Maastro), GROW Research Institute for Oncology and Reproduction, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - V Valentini
- Centro Eccellenza Oncologia e Diagnostica per Immagini, Ospedale Isola Tiberina - Gemelli Isola, Roma, Italy
| | - D Dodwell
- Oxford Population Health, The University of Oxford, Oxford, UK
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - C Aristei
- Radiation Oncology Section, University of Perugia and Perugia General Hospital, Italy
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3
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de Jonge C, Schipper RJ, Walstra CJEF, Van Riet YE, Verrijssen ASE, Voogd AC, van der Sangen MJC, Theuws J, Degreef E, Gielens MPM, Bloemen JG, van den Berg HA, Nieuwenhuijzen GAP. Breast conserving surgery with intraoperative electron beam radiation therapy for low-risk breast cancer: Five-year follow-up of 306 patients. Int J Cancer 2024; 155:1237-1247. [PMID: 38752603 DOI: 10.1002/ijc.35033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/09/2024] [Accepted: 04/26/2024] [Indexed: 08/03/2024]
Abstract
Recent studies have reported a higher than expected risk of ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery (BCS) and a single dose of electron beam intra-operative radiotherapy (IORT). This finding was the rationale to perform a retrospective single center cohort study evaluating the oncologic results of consecutive patients treated with BCS and IORT. Women were eligible if they had clinical low-risk (N0, ≤2 cm unifocal, Bloom and Richardson grade 1-2), estrogen receptor-positive and human-epidermal-growth-factor-receptor-2-negative breast cancer. Prior to BCS, pN0 status was determined by sentinel lymph node biopsy. Data on oncologic follow-up were analyzed. Between 2012 and 2019, 306 consecutive patients were treated and analyzed, with a median age of 67 (50-86) years at diagnosis. Median follow-up was 60 (8-120) months. Five-year cumulative risk of IBTR was 13.4% (95% confidence interval [CI] 9.4-17.4). True in field recurrence was present in 3.9% of the patients. In 4.6% of the patients, the IBRT was classified as a local recurrence due to seeding of tumor cells in the cutis or subcutis most likely related to percutaneous biopsy. In 2.9% of the patients, the IBRT was a new outfield primary tumor. Three patients had a regional lymph node recurrence and two had distant metastases as first event. One breast cancer-related death was observed. Estimated 5-year overall survival was 89.8% (95% CI 86.0-93.6). In conclusion, although some of IBTR cases could have been prevented by adaptations in biopsy techniques and patient selection, BCS followed by IORT was associated with a substantial risk of IBTR.
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Affiliation(s)
- Charlotte de Jonge
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Robert-Jan Schipper
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Coco J E F Walstra
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Yvonne E Van Riet
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - An-Sofie E Verrijssen
- Department of Radiotherapy, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Adri C Voogd
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
- Department of Epidemiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | | | - Jacqueline Theuws
- Department of Radiotherapy, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Ellen Degreef
- Department of Pathology, Eurofins PAMM, Veldhoven, The Netherlands
| | - Maaike P M Gielens
- Department of Radiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Hetty A van den Berg
- Department of Radiotherapy, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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4
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López-Fernández T, Marco I, Aznar MC, Barac A, Bergler-Klein J, Meattini I, Scott JM, Cardinale D, Dent S. Breast cancer and cardiovascular health. Eur Heart J 2024:ehae637. [PMID: 39320463 DOI: 10.1093/eurheartj/ehae637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/08/2024] [Accepted: 09/06/2024] [Indexed: 09/26/2024] Open
Abstract
Modern cancer therapies greatly improve clinical outcomes for both early and advanced breast cancer patients. However, these advances have raised concerns about potential short- and long-term toxicities, including cardiovascular toxicities. Therefore, understanding the common risk factors and underlying pathophysiological mechanisms contributing to cardiovascular toxicity is essential to ensure best breast cancer outcomes. While cardio-oncology has emerged as a sub-speciality to address these challenges, it is essential that all cardiologists recognize and understand the cardiovascular consequences of cancer therapy. This review aims to provide a comprehensive overview of the potential adverse cardiovascular effects associated with modern breast cancer therapies. A preventive, diagnostic, and therapeutic workflow to minimize the impact of cardiovascular toxicity on patient outcomes is presented. Key aspects of this workflow include regular monitoring of cardiovascular function, early detection and management of cancer therapy-related cardiovascular toxicities, and optimization of cardiovascular risk factor control. By highlighting the gaps in knowledge in some areas, this review aims to emphasize the critical role of cardio-oncology research in ensuring the holistic well-being of patients with breast cancer.
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Affiliation(s)
- Teresa López-Fernández
- Cardiology Department, La Paz University Hospital, IdiPAZ Research Institute, C/Paseo de la Castellana n° 261, 28046 Madrid, Spain
- Cardiology Department, Quironsalud University Hospital, C. Diego de Velázquez, 1, 28223 Pozuelo de Alarcón, Madrid, Spain
| | - Irene Marco
- Cardiology Department, La Paz University Hospital, IdiPAZ Research Institute, C/Paseo de la Castellana n° 261, 28046 Madrid, Spain
| | - Marianne C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Ana Barac
- Inova ScharHeart and Vascular, Inova Schar Cancer Institute, Fall Church, VA, USA
| | - Jutta Bergler-Klein
- Department of Cardiology, University Clinic of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences 'M. Serio', Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Jessica M Scott
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Cardinale
- Cardioncology Unit, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Susan Dent
- Wilmot Cancer Institute, Department of Medicine, University of Rochester, Rochester, NY, USA
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5
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Rodin D, Glicksman RM, Hepel JT, Huber K, Kirova Y, Loap P, Rakovitch E. Early-Stage Breast Cancer: A Critical Review of Current and Emerging Practice. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03293-0. [PMID: 39237044 DOI: 10.1016/j.ijrobp.2024.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/05/2024] [Accepted: 08/09/2024] [Indexed: 09/07/2024]
Abstract
Breast-conserving surgery followed by adjuvant radiation to reduce the risk of ipsilateral breast tumor recurrence is the mainstay of treatment for early-stage breast cancer (ESBC). However, improved understanding of the heterogeneity of the clinical and molecular characteristics of ESBC has led to greater efforts to personalize approaches to treatment. Furthermore, advances in the understanding of the radiobiology of breast cancer have led to several practice-changing trials on the effectiveness and tolerability of moderate and ultrahypofractionated radiation. Here, we review the recent evidence and ongoing research in the radiotherapeutic management of ESBC, including the use of boost for high-risk disease and opportunities for accelerated fractionation, partial breast irradiation, and radiation omission for low-risk disease. We also discuss how molecular profiling can inform decision-making and new opportunities for primary radiation therapy and reirradiation.
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Affiliation(s)
- Danielle Rodin
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Ontario, Canada.
| | - Rachel M Glicksman
- Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island
| | - Kathryn Huber
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Tufts University, Boston, Massachusetts
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Eileen Rakovitch
- Department of Radiation Oncology, University of Toronto, Ontario, Canada; Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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6
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Civil YA, Vasmel JE, Charaghvandi RK, Houweling AC, Vreuls CPH, van Diest PJ, Witkamp AJ, Doeksen A, van Dalen T, Felderhof J, van Dam I, Slotman BJ, Kirby AM, Verkooijen HM, van der Velde S, van der Leij F, van den Bongard HJGD. Preoperative Magnetic Resonance Guided Single-Dose Partial Breast Irradiation: 5-Year Results of the Prospective Single-Arm ABLATIVE Trial. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03147-X. [PMID: 39098432 DOI: 10.1016/j.ijrobp.2024.07.2326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/03/2024] [Accepted: 07/18/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE Preoperative partial breast irradiation (PBI) can increase accuracy of target volume definition and decrease irradiated volumes compared with postoperative PBI. In the ABLATIVE trial (NCT02316561), 15 of 36 patients achieved pathologic complete response 6 to 8 months after preoperative PBI and breast-conserving surgery (BCS). We now present the 5-year results. METHODS AND MATERIALS The ABLATIVE trial is a Dutch prospective cohort study conducted in 4 hospitals. Women aged ≥50 years with unifocal, nonlobular breast cancer, estrogen receptor-positive, HER2-negative, and a tumor negative sentinel node were treated between 2015 and 2018 with preoperative single-dose PBI followed by BCS after 6 or 8 months. The primary endpoint was pathologic complete response. Secondary endpoints were annually evaluated oncological outcomes, toxicity, cosmetic outcome (assessed by patients and physicians), and quality of life. RESULTS Thirty-six patients were treated with BCS 6 (n = 15) and 8 (n = 21) months following PBI. Median tumor size was 13 mm (IQR 9-16 mm). After a median follow-up of 5.5 years (IQR, 5.1-6.0), 2 (6%) patients had ipsilateral breast events and 2 (6%) distant metastases. The 5-year overall survival was 94% (95% CI, 87-100). The 5-year cumulative incidence of clinician-reported grade 1/2 breast fibrosis and breast discomfort/pain were 94%/6% and 75%/6%, respectively. The proportion of patients (very) satisfied with the cosmetic results was 89% at baseline and 78% at 5 years. Cosmetic results evaluated using the BCCT.core software were excellent or good in all patients. The 4-year median global quality of life score was 83 (IQR, 67-92), similar to baseline (83; IQR, 75-83; P = .42). CONCLUSIONS Preoperative single-dose PBI and BCS may be an oncologically safe treatment with mild late toxicity and no decline in cosmetic results and quality of life during 5 years of follow-up. This means that preoperative instead of standard postoperative irradiation has the potential to challenge the current clinical practice.
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Affiliation(s)
- Yasmin A Civil
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life/Cancer Biology and Immunology, Amsterdam, The Netherlands.
| | - Jeanine E Vasmel
- Department of Radiation Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Ramona K Charaghvandi
- Department of Radiation Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Arjen J Witkamp
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Annemiek Doeksen
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thijs van Dalen
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Joeke Felderhof
- Department of Radiation Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Iris van Dam
- Department of Radiation Oncology, UMC Utrecht, Utrecht, The Netherlands
| | - Ben J Slotman
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life/Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - Anna M Kirby
- Royal Marsden NHS Foundation Trust/The Institute of Cancer Research, Sutton, United Kingdom
| | | | - Susanne van der Velde
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - H J G Desirée van den Bongard
- Department of Radiation Oncology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Cancer Treatment and Quality of Life/Cancer Biology and Immunology, Amsterdam, The Netherlands
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7
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Aristei C, Camilli F, Epifani V, Borghesi S, Palumbo I, Bini V, Poortmans P. A systematic review and meta-analysis of intraoperative electron radiation therapy delivered with a dedicated mobile linac for partial breast irradiation in early breast cancer. Breast 2024; 76:103759. [PMID: 38851057 PMCID: PMC11219955 DOI: 10.1016/j.breast.2024.103759] [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: 02/17/2024] [Revised: 05/28/2024] [Accepted: 06/03/2024] [Indexed: 06/10/2024] Open
Abstract
•PBI is valid alternative to WBI in patients at low-risk of local relapse. •PBI is delivered by means of various techniques, one of which is IOeRT. •After IOeRT, an unexpectedly high LR rate was observed in the only phase III RCT. •Patient selection impacts on LR rates after IOeRT. •With appropriate patient selection IOeRT outcomes overlap with other RT techniques.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy; Radiation Oncology Section, Perugia General Hospital, Perugia, Italy.
| | - Federico Camilli
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Valeria Epifani
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Simona Borghesi
- Radiation Oncology Unit of Arezzo-Valdarno, Azienda USL Toscana Sud Est, Arezzo, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia, Perugia, Italy; Radiation Oncology Section, Perugia General Hospital, Perugia, Italy
| | - Vittorio Bini
- Internal Medicine, Endocrine and Metabolic Science Section, University of Perugia, Perugia, Italy
| | - Philip Poortmans
- University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium; Iridium Netwerk, Department of Radiation Oncology, Antwerp, Belgium
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8
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Aznar MC, Bergler-Klein J, Boriani G, Cutter DJ, Hurkmans C, Levis M, López-Fernández T, Lyon AR, Maraldo MV. Cardiovascular toxicities of radiotherapy: From practical issues to new perspectives. Radiother Oncol 2024; 197:110336. [PMID: 38797493 DOI: 10.1016/j.radonc.2024.110336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Affiliation(s)
- Marianne C Aznar
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, the United Kingdom of Great Britain and Northern Ireland.
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural SciencesUniversity of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - David J Cutter
- Nuffield Department of Population Health, University of Oxford, Oxford, the United Kingdom of Great Britain and Northern Ireland; Oxford Cancer and Haematology Centre, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, the United Kingdom of Great Britain and Northern Ireland
| | - Coen Hurkmans
- Dept of Radiation Therapy, Catharina Hospital Eindhoven, the Netherlands; Dept of Electrical Engineering and Dept of Applied Physics, Technical University Eindhoven, the Netherlands
| | - Mario Levis
- Department of Oncology, University of Turin, Turin, Italy
| | - Teresa López-Fernández
- Cardiology Department, Cardio-Oncology Unit, La Paz University Hospital, IdiPAZ Research Institute, Madrid, Spain; Cardiology Department, Cardio-Oncology Unit, Quironsalud Madrid University Hospital, Madrid, Spain
| | - Alexander R Lyon
- Cardio-Oncology Service, Royal Brompton Hospital, London, the United Kingdom of Great Britain and Northern Ireland
| | - Maja V Maraldo
- Dept of Oncology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark; Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Høgsbjerg KW, Maae E, Nielsen MH, Stenbygaard L, Pedersen AN, Yates E, Berg M, Lorenzen EL, Jensen I, Josipovic M, Thomsen MS, Offersen BV. Benefit of respiratory gating in the Danish Breast Cancer Group partial breast irradiation trial. Radiother Oncol 2024; 194:110195. [PMID: 38442840 DOI: 10.1016/j.radonc.2024.110195] [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: 08/23/2023] [Revised: 12/18/2023] [Accepted: 02/27/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND AND PURPOSE Partial breast irradiation (PBI)has beenthe Danish Breast Cancer Group(DBCG) standard for selected breast cancer patients since 2016 based onearlyresults from the DBCG PBI trial.During trial accrual, respiratory-gated radiotherapy was introduced in Denmark. This study aims to investigate the effect of respiratory-gating on mean heart dose (MHD). PATIENTS AND METHODS From 2009 to 2016 the DBCG PBI trial included 230 patientswith left-sided breast cancer receiving external beam PBI, 40 Gy/15 fractions/3 weeks.Localization of the tumor bed on the planning CT scan, the use of respiratory-gating, coverage of the clinical target volume (CTV), and doses to organs at risk were collected. RESULTS Respiratory-gating was used in 123 patients (53 %). In 176 patients (77 %) the tumor bed was in the upper and in 54 patients (23 %) in the lower breast quadrants. The median MHD was 0.37 Gy (interquartile range 0.26-0.57 Gy), 0.33 Gy (0.23-0.49 Gy) for respiratory-gating, and 0.49 Gy (0.31-0.70 Gy) for free breathing, p < 0.0001. MHD was < 1 Gy in 206 patients (90 %) and < 2 Gy in 221 patients (96 %). Respiratory-gating led to significantly lower MHD for upper-located, but not for lower-located tumor beds, however, all MHD were low irrespective of respiratory-gating. Respiratory-gating did not improve CTV coverage or lower lung doses. CONCLUSIONS PBI ensured a low MHD for most patients. Adding respiratory-gating further reduced MHD for upper-located but not for lower-located tumor beds but did not influence target coverage or lung doses. Respiratory-gating is no longer DBCG standard for left-sided PBI.
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Affiliation(s)
- Kristine W Høgsbjerg
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Else Maae
- Department of Oncology, Vejle Hospital, University of Southern Denmark, Beriderbakken 4, 7100 Vejle, Denmark.
| | - Mette H Nielsen
- Department of Oncology, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark.
| | - Lars Stenbygaard
- Department of Oncology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark.
| | - Anders N Pedersen
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Esben Yates
- Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Martin Berg
- Department of Medical Physics, Vejle Hospital, University of Southern Denmark, Beriderbakken 4, Vejle, Denmark.
| | - Ebbe L Lorenzen
- Laboratory of Radiation Physics, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark.
| | - Ingelise Jensen
- Department of Medical Physics, Aalborg University Hospital, Hobrovej 18-22, 9100 Aalborg, Denmark.
| | - Mirjana Josipovic
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark.
| | - Mette S Thomsen
- Department of Medical Physics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark; Department of Oncology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
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10
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Leonardi MC, Zerella MA, Lazzeroni M, Fusco N, Veronesi P, Galimberti VE, Corso G, Dicuonzo S, Rojas DP, Morra A, Gerardi MA, Lorubbio C, Zaffaroni M, Vincini MG, Orecchia R, Jereczek-Fossa BA, Magnoni F. Tools to Guide Radiation Oncologists in the Management of DCIS. Healthcare (Basel) 2024; 12:795. [PMID: 38610216 PMCID: PMC11011767 DOI: 10.3390/healthcare12070795] [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: 02/01/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
Similar to invasive breast cancer, ductal carcinoma in situ is also going through a phase of changes not only from a technical but also a conceptual standpoint. From prescribing radiotherapy to everyone to personalized approaches, including radiotherapy omission, there is still a lack of a comprehensive framework to guide radiation oncologists in decision making. Many pieces of the puzzle are finding their place as high-quality data mature and are disseminated, but very often, the interpretation of risk factors and the perception of risk remain very highly subjective. Sharing the therapeutic choice with patients requires effective communication for an understanding of risks and benefits, facilitating an informed decision that does not increase anxiety and concerns about prognosis. The purpose of this narrative review is to summarize the current state of knowledge to highlight the tools available to radiation oncologists for managing DCIS, with an outlook on future developments.
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Affiliation(s)
- Maria Cristina Leonardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Alessia Zerella
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Nicola Fusco
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Pathology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy
| | - Paolo Veronesi
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Viviana Enrica Galimberti
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Giovanni Corso
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Marianna Alessandra Gerardi
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Chiara Lorubbio
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Mattia Zaffaroni
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Maria Giulia Vincini
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
| | - Roberto Orecchia
- Scientific Directorate, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy;
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (M.C.L.); (S.D.); (D.P.R.); (A.M.); (M.A.G.); (C.L.); (M.Z.); (M.G.V.); (B.A.J.-F.)
- Department of Oncology and Hemato-Oncology, University of Milan, 20141 Milan, Italy; (N.F.); (P.V.); (G.C.)
| | - Francesca Magnoni
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, 20141 Milan, Italy; (V.E.G.); (F.M.)
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11
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Hardy-Abeloos C, Xiao J, Oh C, Barbee D, Shah B, Maisonet O, Perez C, Adams S, Schnabel F, Axelrod D, Guth A, Karp N, Cahlon O, Gerber N. Effectiveness and toxicity of five-fraction prone accelerated partial breast irradiation. Breast Cancer Res Treat 2024; 204:485-495. [PMID: 38183516 DOI: 10.1007/s10549-023-07190-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/16/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Our institution was an early adopter of 5-fraction accelerated partial breast irradiation (ABPI) to treat women with early-stage breast cancer. This study reports long-term oncologic and cosmetic outcomes. METHODS We included patients receiving APBI 600 cGy × 5 fx delivered every other day or every day between 2010 and 2022. Logistic regression models were used to identify factors associated with development of late toxicities, clinician, and patient-rated cosmesis. Kaplan-Meier methodology was used to calculate overall survival (OS), disease-free survival (DFS), and locoregional recurrence-free survival (LR-RFS). RESULTS 442 patients received APBI either daily (56%) or every other day (44%) in the prone position (92%). At a median follow-up of 48 months (range: 5.96-155 months), 12 (2.7%) patients developed a local recurrence (LR). Out of 258 patients with > 3-month toxicity data available, the most common late grade ≥ 2 adverse event was breast fibrosis (6.2%). On multivariate analysis, daily APBI treatment (vs every other day) did not correlate with an increased risk of any late grade ≥ 2 toxicity though it did correlate with a lower risk of any late grade ≥ 2 fibrosis. Overall, at a median follow-up of 80 months, the rates of good-excellent physician and patient-rated cosmesis were 95% and 85%, respectively, with no difference between patients treated on consecutive vs. every other day. On multivariate analysis, patients who did not receive any adjuvant therapy were at increased risk of developing a LR. Five-year OS, LRFS, and DFS were 97.2%, 97.7%, and 89.5%, respectively. CONCLUSIONS Five-fraction APBI delivered primarily in the prone position either daily or every other day was effective with low rates of local recurrence, minimal toxicity, and excellent cosmesis at long-term follow-up.
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Affiliation(s)
- Camille Hardy-Abeloos
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Julie Xiao
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Cheongeun Oh
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - David Barbee
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Bhartesh Shah
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Olivier Maisonet
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Carmen Perez
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Sylvia Adams
- Department of Medical Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Freya Schnabel
- Department of Surgical Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgical Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Amber Guth
- Department of Surgical Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Nolan Karp
- Department of Plastic Surgery, NYU Grossman School of Medicine, New York, NY, USA
| | - Oren Cahlon
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA
| | - Naamit Gerber
- Department of Radiation Oncology, NYU Grossman School of Medicine, New York, NY, USA.
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12
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Søndergaard SR, Bechmann T, Maae E, Nielsen AWM, Nielsen MH, Møller M, Timm S, Lorenzen EL, Berry LL, Zachariae R, Offersen BV, Steffensen KD. Shared decision making with breast cancer patients - does it work? Results of the cluster-randomized, multicenter DBCG RT SDM trial. Radiother Oncol 2024; 193:110115. [PMID: 38316191 DOI: 10.1016/j.radonc.2024.110115] [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: 11/05/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND AND PURPOSE Shared decision making (SDM) is a patient engaging process advocated especially for preference-sensitive decisions, such as adjuvant treatment after breast cancer. An increasing call for patient engagement in decision making highlights the need for a systematic SDM approach. The objective of this trial was to investigate whether the Decision Helper (DH), an in-consultation patient decision aid, increases patient engagement in decisions regarding adjuvant whole breast irradiation. MATERIAL AND METHODS Oncologists at four radiotherapy units were randomized to practice SDM using the DH versus usual practice. Patient candidates for adjuvant whole breast irradiation after breast conserving surgery for node-negative breast cancer were eligible. The primary endpoint was patient-reported engagement in the decision process assessed with the Shared Decision Making Questionnaire (SDM-Q-9) (range 0-100, 4 points difference considered clinical relevant). Other endpoints included oncologist-reported patient engagement, decisional conflict, fear of cancer recurrence, and decision regret after 6 months. RESULTS Of the 674 included patients, 635 (94.2%) completed the SDM-Q-9. Patients in the intervention group reported higher level of engagement (median 80; IQR 68.9 to 94.4) than the control group (71.1; IQR 55.6 to 82.2; p < 0.0001). Oncologist-reported patient engagement was higher in the invention group (93.3; IQR 82.2 to 100) compared to control group (73.3; IQR 60.0 to 84.4) (p < 0.0001). CONCLUSION Patient engagement in medical decision making was significantly improved with the use of an in-consultation patient decision aid compared to standard. The DH on adjuvant whole breast irradiation is now recommended as standard of care in the Danish guideline.
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Affiliation(s)
- Stine Rauff Søndergaard
- Department of Oncology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark; Center for Shared Decision Making, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; OPEN, Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark.
| | - Troels Bechmann
- Department of Oncology, Regional Hospital West Jutland, Herning, Denmark
| | - Else Maae
- Department of Oncology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark
| | - Anders W Mølby Nielsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mette Møller
- Department of Oncology, Aalborg University Hospital, Aalborg, Denmark
| | - Signe Timm
- Department of Oncology, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | | | | | - Robert Zachariae
- Department of Psychology and Behavioral Sciences, Aarhus University, Aarhus, Denmark; Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Karina Dahl Steffensen
- Center for Shared Decision Making, Lillebaelt Hospital - University Hospital of Southern Denmark, Vejle, Denmark; Institute of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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13
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Maraldo MV, Offersen BV. Radiotherapy for breast cancer. Ugeskr Laeger 2024; 186:V02230106. [PMID: 38533873 DOI: 10.61409/v02230106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
In early breast cancer, adjuvant moderately hypofractionated regimens are recommended for both whole breast, partial breast and locoregional irradiation which abbreviates the overall treatment time, as argued in this review. Gating is recommended as well as the use of a simultaneous integrated boost when indicated. A tangential field set-up is standard, however, for challenging cases volumetric modulated arc therapy techniques, or referral for proton therapy, may be considered. In the metastatic setting, stereotactic radiotherapy is a promising treatment option for oligometastatic disease.
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Affiliation(s)
- Maja Vestmø Maraldo
- Afdeling for Kræftbehandling, Københavns Universitetshospital - Rigshospitalet
| | - Birgitte Vrou Offersen
- Kræftafdelingen, Aarhus Universitetshospital
- Institut for Klinisk Medicin, Aarhus Universitet
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14
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Shaitelman SF, Anderson BM, Arthur DW, Bazan JG, Bellon JR, Bradfield L, Coles CE, Gerber NK, Kathpal M, Kim L, Laronga C, Meattini I, Nichols EM, Pierce LJ, Poppe MM, Spears PA, Vinayak S, Whelan T, Lyons JA. Partial Breast Irradiation for Patients With Early-Stage Invasive Breast Cancer or Ductal Carcinoma In Situ: An ASTRO Clinical Practice Guideline. Pract Radiat Oncol 2024; 14:112-132. [PMID: 37977261 DOI: 10.1016/j.prro.2023.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE This guideline provides evidence-based recommendations on appropriate indications and techniques for partial breast irradiation (PBI) for patients with early-stage invasive breast cancer and ductal carcinoma in situ. METHODS ASTRO convened a task force to address 4 key questions focused on the appropriate indications and techniques for PBI as an alternative to whole breast irradiation (WBI) to result in similar rates of ipsilateral breast recurrence (IBR) and toxicity outcomes. Also addressed were aspects related to the technical delivery of PBI, including dose-fractionation regimens, target volumes, and treatment parameters for different PBI techniques. The guideline is based on a systematic review provided by the Agency for Healthcare Research and Quality. Recommendations were created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS PBI delivered using 3-dimensional conformal radiation therapy, intensity modulated radiation therapy, multicatheter brachytherapy, and single-entry brachytherapy results in similar IBR as WBI with long-term follow-up. Some patient characteristics and tumor features were underrepresented in the randomized controlled trials, making it difficult to fully define IBR risks for patients with these features. Appropriate dose-fractionation regimens, target volume delineation, and treatment planning parameters for delivery of PBI are outlined. Intraoperative radiation therapy alone is associated with a higher IBR rate compared with WBI. A daily or every-other-day external beam PBI regimen is preferred over twice-daily regimens due to late toxicity concerns. CONCLUSIONS Based on published data, the ASTRO task force has proposed recommendations to inform best clinical practices on the use of PBI.
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Affiliation(s)
- Simona F Shaitelman
- Department of Breast Radiation Oncology, University of Texas MD - Anderson Cancer Center, Houston, Texas.
| | - Bethany M Anderson
- Department of Radiation Oncology, University of Wisconsin, Madison, Wisconsin
| | - Douglas W Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia
| | - Jose G Bazan
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Jennifer R Bellon
- Department of Radiation Oncology, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa Bradfield
- American Society for Radiation Oncology, Arlington, Virginia
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Naamit K Gerber
- Department of Radiation Oncology, New York University Grossman School of Medicine, New York, New York
| | - Madeera Kathpal
- Department of Radiation Oncology, Duke University Wake County Campus, Raleigh, North Carolina
| | - Leonard Kim
- Department of Radiation Oncology, MD - Anderson Cancer Center at Cooper, Camden, New Jersey
| | - Christine Laronga
- Department of Breast Oncology, Moffitt Cancer Center, Tampa, Florida
| | - Icro Meattini
- Department of Radiation Oncology, University of Florence, Florence, Italy
| | - Elizabeth M Nichols
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew M Poppe
- Department of Radiation Oncology, Huntsman Cancer Institute, Salt Lake City, Utah
| | - Patricia A Spears
- Patient Representative, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Shaveta Vinayak
- Department of Medical Oncology, University of Washington, Seattle, Washington
| | - Timothy Whelan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Janice A Lyons
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Cleveland, Ohio
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15
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Yeh J, Chew G, Ng SL, Ooi WM, Loh SW, Hyett A, Leech T, Bevington E, Huynh J, Sim J, Foroudi F, Ng SP, Chao M. Stabilised Hyaluronic Acid (sHA) gel as a novel marker for breast cancer tumour bed cavity: Surgical feasibility. Clin Transl Radiat Oncol 2024; 45:100745. [PMID: 38406647 PMCID: PMC10885548 DOI: 10.1016/j.ctro.2024.100745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction Consistent delineation of the breast conserving surgery (BCS) tumour bed (TB) for breast cancer remains a challenge for radiation oncologists. Accurate delineation allows for better local control and reduces toxicity when planning partial breast or TB boost radiation therapy (RT). Methods In the operating theatre (OT) breast surgeons inserted stabilised hyaluronic acid (sHA) gel as small drops approximately one cm into the walls surrounding the resection cavity. Surgical feasibility was determined by the rate of successful sHA gel insertion procedure, the ease of insertion as rated by surgeons, the time required for insertion procedure, the quantity used, and any adverse events (AE) relating to sHA gel insertion. Results Thirty-five patients were enrolled. All patients underwent sHA gel insertion successfully. The procedure added a median of 2.8 min to the OT time and was rated as 'easy' in 89 % of patients. There were no immediate AE in OT. Five (14 %) patients experienced a grade 2 or higher AE. Three of the five patients were prescribed oral antibiotics for breast infection. Two of the five patients experienced a grade 3 AE - haematoma which required evacuation in OT day 1 post-BCS, and infected seroma which required drainage and washout in OT 2 months post-BCS. All five patients recovered and underwent the planned adjuvant therapies for their BC. The AE data reflects common risks with standard BCS and are not clearly attributed to sHA gel insertion alone. Conclusion We show that sHA gel is surgically feasible as a marker to help define the TB cavity for post-BCS adjuvant MRI-based RT planning.
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Affiliation(s)
- Janice Yeh
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Grace Chew
- Department of Breast Surgery, Austin Health, Victoria, Australia
- University of Melbourne, Victoria, Australia
| | - Suat Li Ng
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Wei Ming Ooi
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Su-Wen Loh
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Anthony Hyett
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Tristan Leech
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Elaine Bevington
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Jenny Huynh
- Department of Breast Surgery, Austin Health, Victoria, Australia
| | - Jenny Sim
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Farshad Foroudi
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
| | - Sweet Ping Ng
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
- University of Melbourne, Victoria, Australia
| | - Michael Chao
- Department of Radiation Oncology, Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Victoria, Australia
- Department of Medical Imaging and Radiation Sciences, Monash University, Clayton, Victoria, Australia
- Genesis Care, Ringwood Private Hospital, Victoria, Australia
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16
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O'Brien DR, Boe L, Montagna G, Mueller B, Chino F, Cuaron J, Choi JI, Xu A, Bernstein M, McCormick B, Powell S, Khan AJ, Braunstein LZ. Accelerated Partial Breast Irradiation for HER2-Positive Early-Stage Breast Cancer. Int J Radiat Oncol Biol Phys 2024; 118:468-473. [PMID: 37791937 DOI: 10.1016/j.ijrobp.2023.08.062] [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: 06/23/2023] [Revised: 08/21/2023] [Accepted: 08/27/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE HER2-positive (HER2+) breast cancer historically exhibited the most adverse local outcomes and, consequently, has had limited representation among trials of partial breast irradiation (PBI). We hypothesized that with contemporary HER2-targeted agents, patients may now exhibit excellent disease control outcomes after adjuvant PBI. METHODS AND MATERIALS Using a prospectively maintained institutional database, we identified patients with HER2+ breast cancer treated with breast conserving surgery (BCS) and PBI from 2000 to 2022. Salient clinicopathologic and treatment parameters were collected. All patients received external beam PBI to 40 Gy in 10 daily fractions. Cumulative incidence functions were calculated to estimate the incidence of local recurrence (LR) with the competing risk of death. RESULTS We identified 1248 patients who underwent PBI at our institution, of whom the study cohort comprised 52 (4%) with HER2+ breast cancer (median age, 64 years; range, 44-87). Nearly all had T1 tumors (98%; median size, 12 mm [range, 1-21 mm]). Most had estrogen receptor positive disease (88%), and all patients had negative surgical margins. Nearly all underwent sentinel node biopsy (94%), with the remainder undergoing no surgical axillary evaluation. Forty-two (81%) received chemotherapy; 40 (77%), hormone therapy; and 42 (81%), HER2-directed therapy, most commonly trastuzumab. At 143.8 person-years of follow-up (range, 7-226 months for each patient), we observed 2 LR events at 14 and 26 months, respectively, yielding a 2-year LR rate of 3.8%. No regional or distant recurrences were observed, nor were any breast-specific mortality events. Two deaths were observed, both without evidence of disease. CONCLUSIONS Among a cohort of patients with HER2+ early-stage breast cancer managed with BCS and PBI, we observed a 2-year LR rate of 3.8%, with no regional or distant recurrences and excellent overall survival. These findings require confirmation with longer follow-up among larger cohorts but appear consistent with the excellent results of contemporary randomized trials of PBI unselected for HER2 status.
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Affiliation(s)
| | | | - Giacomo Montagna
- Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | - Amy Xu
- Departments of Radiation Oncology
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17
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Chang JS, Lee J, Vicini FA, Kim JS, Kim J, Choi SH, Lee IJ, Kim YB. Large institutional experience of early outcomes and dosimetric findings with postoperative stereotactic partial breast irradiation in breast cancer. Radiother Oncol 2024; 191:110066. [PMID: 38142936 DOI: 10.1016/j.radonc.2023.110066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/17/2023] [Indexed: 12/26/2023]
Abstract
PURPOSE To analyze the dosimetric and toxicity outcomes of patients treated with postoperative stereotactic partial breast irradiation (S-PBI). METHODS We identified 799 women who underwent S-PBI at our institution between January 2016 and December 2022. The most commonly used dose-fraction and technique were 30 Gy in 5 fractions (91.7 %) and a robotic stereotactic radiation system with real-time tracking (83.7 %). The primary endpoints were dosimetric parameters and radiation-related toxicities. For comparison, a control group undergoing ultra-hypofractionated whole breast irradiation (UF-WBI, n = 468) at the same institution was selected. RESULTS A total of 815 breasts from 799 patients, with a median planning target volume (PTV) volume of 89.6 cm3, were treated with S-PBI. Treatment plans showed that the mean and maximum doses received by the PTV were 96.2 % and 104.8 % of the prescription dose, respectively. The volume of the ipsilateral breast that received 50 % of the prescription dose was 32.3 ± 8.9 %. The mean doses for the ipsilateral lung and heart were 2.5 ± 0.9 Gy and 0.65 ± 0.39 Gy, respectively. Acute toxicity occurred in 175 patients (21.5 %), predominantly of grade 1. Overall rate of late toxicity was 4 % with a median follow-up of 31.6 months. Compared to the UF-WBI group, the S-PBI group had comparably low acute toxicity (21.5 % vs. 25.2 %, p = 0.12) but significantly lower dosimetric parameters for all organs-at-risks (all p < 0.05). CONCLUSION In this large cohort, S-PBI demonstrated favorable dosimetric and toxicity profiles. Considering the reduced radiation exposure to surrounding tissues, external beam PBI with advanced techniques should at least be considered over traditional WBI-based approaches for PBI candidates.
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Affiliation(s)
- Jee Suk Chang
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Jeongshim Lee
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea; Inha University Hospital, Inha University College of Medicine, Incheon, Republic of Korea
| | - Frank A Vicini
- Department of Radiation Oncology, Michigan Healthcare Professionals, Farmington Hills, MI, USA
| | - Jin Sung Kim
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seo Hee Choi
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ik Jae Lee
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
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18
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Baumann M, Bacchus C, Aznar MC, Coppes RP, Deutsch E, Georg D, Haustermans K, Hoskin P, Krause M, Lartigau EF, Lee AWM, Löck S, Offersen BV, Thwaites DI, van der Heide UA, Valentini V, Overgaard J. Clinical research for global needs of radiation oncology. Radiother Oncol 2024; 190:110076. [PMID: 38157941 DOI: 10.1016/j.radonc.2023.110076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
| | - Carol Bacchus
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Marianne C Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, The Christie NHS Foundation Trust, United Kingdom
| | - Rob P Coppes
- Departments of Radiation Oncology and Biomedical Sciences of Cells & Systems, Section Molecular Cell Biology, University of Groningen, University Medical Center Groningen, the Netherlands
| | - Eric Deutsch
- Department of Radiation Oncology, Institut d'Oncologie Thoracique (IOT), Gustave Roussy, France
| | - Dietmar Georg
- Division Medical Radiation Physics, Department of Radiation Oncology, Medical University of Vienna/AKH, Wien, Austria
| | - Karin Haustermans
- Department of Radiation Oncology, University Hospitals Leuven, Belgium
| | - Peter Hoskin
- Mount Vernon Cancer Centre and University of Manchester, United Kingdom
| | - Mechthild Krause
- Department of Radiotherapy and Radiation Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany; OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany
| | - Eric F Lartigau
- Academic Department of Radiotherapy, Oscar Lambret Comprehensive Cancer Center, Lille, France
| | - Anne W M Lee
- Department of Clinical Oncology, University of Hong Kong - Shenzhen Hospital and University of Hong Kong, China
| | - Steffen Löck
- OncoRay - National Center for Radiation Research in Oncology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Helmholtz-Zentrum Dresden - Rossendorf, Germany
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - David I Thwaites
- Institute of Medical Physics, School of Physics, The University of Sydney, Australia; Radiotherapy Research Group, Leeds Institute of Medical Research, St James's Hospital and University of Leeds, United Kingdom
| | - Uulke A van der Heide
- Department of Radiation Oncology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | | | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
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19
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Ravani LV, Calomeni P, Wang M, Deng D, Speers C, Zaorsky NG, Shah C. Comparison of partial-breast irradiation and intraoperative radiation to whole-breast irradiation in early-stage breast cancer patients: a Kaplan-Meier-derived patient data meta-analysis. Breast Cancer Res Treat 2024; 203:1-12. [PMID: 37736843 DOI: 10.1007/s10549-023-07112-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/24/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE Partial breast irradiation (PBI) and intraoperative radiation (IORT) represent alternatives to whole breast irradiation (WBI) following breast conserving surgery. However, data is mixed regarding outcomes. We therefore performed a pooled analysis of Kaplan-Meier-derived patient data from randomized trials to evaluate the hypothesis that PBI and IORT have comparable long-term rates of ipsilateral breast tumor recurrence as WBI. METHODS In February, 2023, PubMed, EMBASE and Cochrane Central were systematically searched for randomized phase 3 trials of early-stage breast cancer patients undergoing breast-conserving surgery with PBI or IORT as compared to WBI. Time-to-event outcomes of interest included ipsilateral breast tumor recurrence (IBTR), overall survival (OS) and distant disease-free survival (DDFS). Statistical analysis was performed with R Statistical Software. RESULTS Eleven randomized trials comprising 15,460 patients were included; 7,675 (49.6%) patients were treated with standard or moderately hypofractionated WBI, 5,413 (35%) with PBI and 2,372 (15.3%) with IORT. Median follow-up was 9 years. PBI demonstrated comparable IBTR risk compared with WBI (HR 1.20; 95% CI 0.95-1.52; p = 0.12) with no differences in OS (HR 1.02; 95% CI 0.90-1.16; p = 0.70) or DDFS (HR 1.15; 95% CI 0.81-1.64; p = 0.43). In contrast, patients treated with IORT had a higher IBTR risk (HR 1.46; 95% CI 1.23-1.72; p < 0.01) compared with WBI with no difference in OS (HR 0.98; 95% CI 0.84-1.14; p = 0.81) or DDFS (HR 0.91; 95% CI 0.76-1.09; p = 0.31). CONCLUSION For patients with early-stage breast cancer following breast-conserving surgery, PBI demonstrated no difference in IBTR as compared to WBI while IORT was inferior to WBI with respect to IBTR.
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Affiliation(s)
| | - Pedro Calomeni
- University of Sao Paulo Medical School, São Paulo, Brazil
| | - Ming Wang
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Daxuan Deng
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, PA, USA
| | - Corey Speers
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicholas G Zaorsky
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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20
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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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21
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Curigliano G, Burstein HJ, Gnant M, Loibl S, Cameron D, Regan MM, Denkert C, Poortmans P, Weber WP, Thürlimann B. Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023. Ann Oncol 2023; 34:970-986. [PMID: 37683978 DOI: 10.1016/j.annonc.2023.08.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
The 18th St Gallen International Breast Cancer Conference held in March 2023, in Vienna, Austria, assessed significant new findings for local and systemic therapies for early breast cancer with a focus on the evaluation of multimodal treatment options. The emergence of more effective, innovative agents in both the preoperative (primary or neoadjuvant) and post-operative (adjuvant) settings has underscored the pivotal role of a multidisciplinary approach in treatment decision making, particularly when selecting systemic therapy for an individual patient. The importance of multidisciplinary discussions regarding the clinical benefits of interventions was explicitly emphasized by the consensus panel as an integral part of developing an optimal treatment plan with the 'right' degree of intensity and duration. The panelists focused on controversies surrounding the management of common ductal/no special type and lobular breast cancer histology, which account for the vast majority of breast tumors. The expert opinion of the panelists was based on interpretations of available data, as well as current practices in their professional environments, personal and socioeconomic factors affecting patients, and cognizant of varying reimbursement and accessibility constraints around the world. The panelists strongly advocated patient participation in well-designed clinical studies whenever feasible. With these considerations in mind, the St Gallen Consensus Conference aims to offer guidance to clinicians regarding appropriate treatments for early-stage breast cancer and assist in balancing the realistic trade-offs between treatment benefit and toxicity, enabling patients and clinicians to make well-informed choices through a shared decision-making process.
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Affiliation(s)
- G Curigliano
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Milan; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
| | - H J Burstein
- Medical Oncology, Dana-Farber Cancer Institute, Boston; Harvard Medical School, Boston, USA.
| | - M Gnant
- Comprehensive Cancer Center, Medical University of Vienna, Vienna; Austrian Breast and Colorectal Cancer Study Group, Vienna, Austria
| | - S Loibl
- Center for Hematology and Oncology Bethanien, Frankfurt; German Breast Group, Neu-Isenburg, Germany
| | - D Cameron
- Edinburgh Cancer Research Centre, University of Edinburgh and NHS Lothian, Edinburgh, UK
| | - M M Regan
- International Breast Cancer Study Group Statistical Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
| | - C Denkert
- Institut für Pathologie, Philipps-Universität Marburg und Universitätsklinikum Marburg, Marburg, Germany
| | - P Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Wilrijk-Antwerp; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium
| | - W P Weber
- Department of Surgery, University Hospital Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel, Switzerland
| | - B Thürlimann
- SwissBreastCare, Bethanienspital, Zürich, Switzerland; SONK Foundation, St. Gallen, Switzerland
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22
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Byun HK, Chang JS, Kim H, Kim J, Han MC, Kim SY, Park RH, Kim CJ, Kim YB. Cosmetic Outcome and Toxicity After Stereotactic Accelerated Partial Breast Irradiation in Early Breast Cancer: A Prospective Observational Cohort Study. Int J Radiat Oncol Biol Phys 2023; 117:690-700. [PMID: 37201757 DOI: 10.1016/j.ijrobp.2023.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/19/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE The aim of this work was to prospectively evaluate the toxicity and cosmetic outcomes of 5-fraction, stereotactic, accelerated partial breast irradiation (APBI). METHODS AND MATERIALS This prospective observational cohort study enrolled women who underwent APBI for invasive carcinoma or carcinoma in situ of the breast. APBI was delivered using a CyberKnife M6 robotic radiosurgery system at 30 Gy in 5 nonconsecutive, once-daily fractions. Women undergoing whole breast irradiation (WBI) were also enrolled for comparison. Patient-reported and physician-assessed adverse events were recorded. Breast fibrosis was measured using a tissue compliance meter, and breast cosmesis was assessed using BCCT.core (an automatic, computer-based software). Outcomes were collected until 24 months posttreatment according to the study protocol. RESULTS In total, 204 patients (APBI, n = 103; WBI, n = 101) were enrolled. Regarding patient-reported outcomes, the APBI group reported significantly less skin dryness (6.9% vs 18.3%; P = .015), radiation skin reaction (9.9% vs 23.5%; P = .010), and breast hardness (8.0% vs 20.4%; P = .011) at 6 months than the WBI group. On physician assessment, the APBI group had significantly less dermatitis at 12 months (1.0% vs 7.2%; P = .027) than the WBI group. Any severe toxicities after APBI were rare in patient-reported outcomes (score ≥3, 3.0%) and physician assessments (grade ≥3, 2.0%). In the uninvolved quadrants, measured fibrosis in the APBI group was significantly lower than that in the WBI group at 6 (P = .001) and 12 (P = .029) months but not at 24 months. In the involved quadrant, measured fibrosis in the APBI group was not significantly different from that in the WBI group at any time. Cosmetic outcomes in the APBI group were mostly excellent or good (77.6%) at 24 months, and there was no significant cosmetic detriment from the baseline. CONCLUSIONS Stereotactic APBI was associated with less fibrosis in the uninvolved breast quadrants than WBI. Patients showed minimal toxicity and no detrimental effects on cosmesis after APBI.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
| | - Hojin Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jihun Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Min Cheol Han
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Se Young Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ryeong Hwang Park
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Claire Jieun Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, South Korea.
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23
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Krogh SL, Brink C, Lorenzen EL, Samsøe E, Vogelius IR, Zukauskaite R, Vrou Offersen B, Eriksen JG, Hansen O, Johansen J, Olloni A, Ruhlmann CH, Hoffmann L, Nissen HD, Skovmos Nielsen M, Andersen K, Grau C, Hansen CR. A national repository of complete radiotherapy plans: design, Results, and experiences. Acta Oncol 2023; 62:1161-1168. [PMID: 37850659 DOI: 10.1080/0284186x.2023.2270143] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND Previously, many radiotherapy (RT) trials were based on a few selected dose measures. Many research questions, however, rely on access to the complete dose information. To support such access, a national RT plan database was created. The system focuses on data security, ease of use, and re-use of data. This article reports on the development and structure, and the functionality and experience of this national database. METHODS AND MATERIALS A system based on the DICOM-RT standard, DcmCollab, was implemented with direct connections to all Danish RT centres. Data is segregated into any number of collaboration projects. User access to the system is provided through a web interface. The database has a finely defined access permission model to support legal requirements. RESULTS Currently, data for more than 14,000 patients have been submitted to the system, and more than 50 research projects are registered. The system is used for data collection, trial quality assurance, and audit data set generation.Users reported that the process of submitting data, waiting for it to be processed, and then manually attaching it to a project was resource intensive. This was accommodated with the introduction of triggering features, eliminating much of the need for users to manage data manually. Many other features, including structure name mapping, RT plan viewer, and the Audit Tool were developed based on user input. CONCLUSION The DcmCollab system has provided an efficient means to collect and access complete datasets for multi-centre RT research. This stands in contrast with previous methods of collecting RT data in multi-centre settings, where only singular data points were manually reported. To accommodate the evolving legal environment, DcmCollab has been defined as a 'data processor', meaning that it is a tool for other research projects to use rather than a research project in and of itself.
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Affiliation(s)
- Simon Long Krogh
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Carsten Brink
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ebbe Laugaard Lorenzen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Eva Samsøe
- Department of Oncology, Radiotherapy, Zealand University Hospital, Naestved, Denmark
| | | | - Ruta Zukauskaite
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
- Danish Center for Particle Therapy, Aarhus, Denmark
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Olfred Hansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Jørgen Johansen
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Agon Olloni
- Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - Lone Hoffmann
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Dahl Nissen
- Department of Oncology, University Hospital of Southern Denmark, Vejle, Denmark
| | | | - Karen Andersen
- Department of Oncology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Rønn Hansen
- Laboratory of Radiation Physics, Department of Oncology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Center for Particle Therapy, Aarhus, Denmark
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24
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Lange T, Knöchelmann AC, Bremer M. [Adjuvant radiation therapy for breast cancer]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023; 63:693-702. [PMID: 37581632 DOI: 10.1007/s00117-023-01198-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
Adjuvant radiotherapy is an integral part of multimodal therapy for early breast cancer. It contributes to the reduction of local recurrences across all disease stages. (Moderate) hypofractionated whole-breast irradiation is the standard of care. In low-risk situations, partial breast irradiation can be an option. The indication for adjuvant radiotherapy after mastectomy or additional irradiation of regional lymph nodes depends on the patient's individual risk profile. Long-term results of treatment and further development of irradiation techniques now allow shorter, individualized and well-tolerated treatments with the aim of therapy de-escalation.
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Affiliation(s)
- Tim Lange
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland.
| | - Anne Caroline Knöchelmann
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
| | - Michael Bremer
- Klinik für Strahlentherapie und Spezielle Onkologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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25
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Haussmann J, Budach W, Corradini S, Krug D, Bölke E, Tamaskovics B, Jazmati D, Haussmann A, Matuschek C. Whole Breast Irradiation in Comparison to Endocrine Therapy in Early Stage Breast Cancer-A Direct and Network Meta-Analysis of Published Randomized Trials. Cancers (Basel) 2023; 15:4343. [PMID: 37686620 PMCID: PMC10487067 DOI: 10.3390/cancers15174343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Multiple randomized trials have established adjuvant endocrine therapy (ET) and whole breast irradiation (WBI) as the standard approach after breast-conserving surgery (BCS) in early-stage breast cancer. The omission of WBI has been studied in multiple trials and resulted in reduced local control with maintained survival rates and has therefore been adapted as a treatment option in selected patients in several guidelines. Omitting ET instead of WBI might also be a valuable option as both treatments have distinctly different side effect profiles. However, the clinical outcomes of BCS + ET vs. BCS + WBI have not been formally analyzed. METHODS We performed a systematic literature review searching for randomized trials comparing BCS + ET vs. BCS + WBI in low-risk breast cancer patients with publication dates after 2000. We excluded trials using any form of chemotherapy, regional nodal radiation and mastectomy. The meta-analysis was performed using a two-step process. First, we extracted all available published event rates and the effect sizes for overall and breast-cancer-specific survival (OS, BCSS), local (LR) and regional recurrence, disease-free survival, distant metastases-free interval, contralateral breast cancer, second cancer other than breast cancer and mastectomy-free interval as investigated endpoints and compared them in a network meta-analysis. Second, the published individual patient data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) publications were used to allow a comparison of OS and BCSS. RESULTS We identified three studies, including a direct comparison of BCS + ET vs. BCS + WBI (n = 1059) and nine studies randomizing overall 7207 patients additionally to BCS only and BCS + WBI + ET resulting in a four-arm comparison. In the network analysis, LR was significantly lower in the BCS + WBI group in comparison with the BCS + ET group (HR = 0.62; CI-95%: 0.42-0.92; p = 0.019). We did not find any differences in OS (HR = 0.93; CI-95%: 0.53-1.62; p = 0.785) and BCSS (OR = 1.04; CI-95%: 0.45-2.41; p = 0.928). Further, we found a lower distant metastasis-free interval, a higher rate of contralateral breast cancer and a reduced mastectomy-free interval in the BCS + WBI-arm. Using the EBCTCG data, OS and BCSS were not significantly different between BCS + ET and BCS + WBI after 10 years (OS: OR = 0.85; CI-95%: 0.59-1.22; p = 0.369) (BCSS: OR = 0.72; CI-95%: 0.38-1.36; p = 0.305). CONCLUSION Evidence from direct and indirect comparison suggests that BCS + WBI might be an equivalent de-escalation strategy to BCS + ET in low-risk breast cancer. Adverse events and quality of life measures have to be further compared between these approaches.
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Affiliation(s)
- Jan Haussmann
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Wilfried Budach
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, Ludwig-Maximilians-University (LMU), 81377 Munich, Germany;
| | - David Krug
- Department of Radiation Oncology, University Hospital Schleswig-Holstein, 24105 Kiel, Germany;
| | - Edwin Bölke
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Balint Tamaskovics
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Danny Jazmati
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
| | - Alexander Haussmann
- Division of Physical Activity, Prevention and Cancer, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Christiane Matuschek
- Department of Radiation Oncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University, 40225 Düsseldorf, Germany; (J.H.); (W.B.); (B.T.); (D.J.); (C.M.)
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Abstract
Breast cancer is the most prevalent cancer in women, and the second leading cause of cancer death in women in the United States. Radiation therapy is an important component in the multimodal management of breast cancer, including early stage and locally advanced breast cancers, as well as metastatic cases. Breast cancer radiation therapy has seen significant advancements over the past 20 years. This article discusses the latest advances in the radiotherapeutic management of breast cancer, especially focusing on the technological advances in radiation treatment planning and techniques that have exploited the understanding of radiation biology.
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Affiliation(s)
- Rituraj Upadhyay
- Department of Radiation Oncology, The Ohio State University Medical Center, The Arthur G. James Cancer Hospital D259, 460 W 10th Avenue, Columbus, OH 43210, USA
| | - Jose G Bazan
- Department of Radiation Oncology, The Ohio State University Medical Center, The Arthur G. James Cancer Hospital and Solove Research Institute, The Ohio State University Comprehensive Cancer Center, 1145 Olentangy River Road, Columbus, OH 43212, USA.
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Gil GOB, de Andrade WP, Diniz PHC, Cantidio FS, Queiroz IN, Gil MLBV, Almeida CAM, Caldeira PPR, Regalin M, Silva-Filho AL. A phase II randomized clinical trial to assess toxicity and quality of life of breast cancer patients with hypofractionated versus conventional fractionation radiotherapy with regional nodal irradiation in the context of COVID-19 crisis. Front Oncol 2023; 13:1202544. [PMID: 37388233 PMCID: PMC10301738 DOI: 10.3389/fonc.2023.1202544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023] Open
Abstract
Purpose This study, conducted during the COVID-19 crisis, primarily aimed to compare the acute toxicity between conventional fractionated radiation therapy (CF-RT) with hypofractionated radiation therapy (HF-RT) among patients who underwent breast-conserving surgery or mastectomy in whom breast or chest wall and regional nodal irradiation (RNI) were indicated. The secondary endpoints were both acute and subacute toxicity, cosmesis, quality of life, and lymphedema features. Methods In this open and non-inferiority randomized trial, patients (n = 86) were randomly allocated 2:1 in the CF-RT arm (n = 33; 50 Gy/25 fractions ± sequential boost [10 Gy/5 fractions]) versus the HF-RT arm (n = 53; 40 Gy/15 fractions ± concomitant boost [8 Gy/15 fractions]). Toxic effects and cosmesis evaluation used the Common Terminology Criteria for Adverse Events, version 4.03 (CTCAE) and the Harvard/National Surgical Adjuvant Breast and Bowel Project (NSABP)/Radiation Therapy Oncology Group (RTOG) scale. For the patient-reported quality of life (QoL), the European Organisation for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-C30) and the breast cancer-specific supplementary questionnaire (QLQ-BR23) were used. Lymphedema was assessed by comparing volume differences between the affected and contralateral arms using the Casley-Smith formula. Results Grade 2 and grade 3 dermatitis were lower with HF-RT than with CF-RT (28% vs. 52%, and 0% vs. 6%, respectively; p = 0.022). HF-RT had a lower rate of grade 2 hyperpigmentation (23% vs. 55%; p = 0.005), compared to CF-RT. No other differences in overall rates of physician-assessed grade 2 or higher and grade 3 or higher acute toxicity between HF-RT and CF-RT were registered. There was no statistical difference between groups regarding cosmesis, lymphedema rate (13% vs. 12% HF-RT vs. CF-RT; p = 1.000), and functional and symptom scales, during both the irradiation period and after 6 months of the end of treatment. The results revealed that the subset of patients up to 65 years or older did not show a statistical difference between both arm fractionation schedules (p > 0.05) regarding skin rash, fibrosis, and lymphedema. Conclusion HF-RT was non-inferior to CF-RT, and moderate hypofractionation showed lower rates of acute toxicity, with no changes in quality-of-life outcomes. Clinical trial registration ClinicalTrials.gov, identifier NCT40155531.
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Affiliation(s)
- Gabriel Oliveira Bernardes Gil
- Department of Radiation Oncology, Rede Mater Dei and Hospital da Baleia, Belo Horizonte, Minas Gerais, Brazil
- Gynecology Department, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, São Paulo, Brazil
| | - Warne Pedro de Andrade
- Gynecology Department, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, São Paulo, Brazil
- ONCOBIO, Grupo Oncoclinicas, Department of Gynecology and Obstetrics of the School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paulo Henrique Costa Diniz
- Department of Oncology, Rede Mater Dei, Belo Horizonte, Minas Gerais, Brazil
- Department of Internal Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Farley Soares Cantidio
- Department of Radiation Oncology, Rede Mater Dei and Hospital da Baleia, Belo Horizonte, Minas Gerais, Brazil
| | - Izabella Nobre Queiroz
- Department of Radiation Oncology, Hospital da Baleia, Belo Horizonte, Minas Gerais, Brazil
| | | | | | | | - Marcos Regalin
- Department of Radiation Oncology, Rede Mater Dei and Hospital da Baleia, Belo Horizonte, Minas Gerais, Brazil
| | - Agnaldo Lopes Silva-Filho
- Gynecology Department, Universidade Estadual Paulista “Júlio de Mesquita Filho”, Botucatu, São Paulo, Brazil
- Department of Radiation Oncology, Rede Mater Dei, Belo Horizonte, Minas Gerais, Brazil
- Department of Gynecology and Obstetrics of the School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Ott OJ, Stillkrieg W, Lambrecht U, Schweizer C, Lamrani A, Sauer TO, Strnad V, Bert C, Hack CC, Beckmann MW, Fietkau R. External-Beam-Accelerated Partial-Breast Irradiation Reduces Organ-at-Risk Doses Compared to Whole-Breast Irradiation after Breast-Conserving Surgery. Cancers (Basel) 2023; 15:3128. [PMID: 37370738 DOI: 10.3390/cancers15123128] [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: 04/05/2023] [Revised: 05/19/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
In order to evaluate organ-at-risk (OAR) doses in external-beam-accelerated partial-breast irradiation (APBI) compared to standard whole-breast irradiation (WBI) after breast-conserving surgery. Between 2011 and 2021, 170 patients with early breast cancer received APBI within a prospective institutional single-arm trial. The prescribed dose to the planning treatment volume was 38 Gy in 10 fractions on 10 consecutive working days. OAR doses for the contralateral breast, the ipsilateral, contralateral, and whole lung, the whole heart, left ventricle (LV), and the left anterior descending coronary artery (LAD), and for the spinal cord and the skin were assessed and compared to a control group with real-world data from 116 patients who underwent WBI. The trial was registered at the German Clinical Trials Registry, DRKS-ID: DRKS00004417. Compared to WBI, APBI led to reduced OAR doses for the contralateral breast (0.4 ± 0.6 vs. 0.8 ± 0.9 Gy, p = 0.000), the ipsilateral (4.3 ± 1.4 vs. 9.2 ± 2.5 Gy, p = 0.000) and whole mean lung dose (2.5 ± 0.8 vs. 4.9 ± 1.5 Gy, p = 0.000), the mean heart dose (1.6 ± 1.6 vs. 1.7 ± 1.4 Gy, p = 0.007), the LV V23 (0.1 ± 0.4 vs. 1.4 ± 2.6%, p < 0.001), the mean LAD dose (2.5 ± 3.4 vs. 4.8 ± 5.5 Gy, p < 0.001), the maximum spinal cord dose (1.5 ± 1.1 vs. 4.5 ± 5.7 Gy, p = 0.016), and the maximum skin dose (39.6 ± 1.8 vs. 49.1 ± 5.8 Gy, p = 0.000). APBI should be recommended to suitable patients to minimize the risk of secondary tumor induction and the incidence of consecutive major cardiac events.
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Affiliation(s)
- Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Wilhelm Stillkrieg
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Ulrike Lambrecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Claudia Schweizer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Allison Lamrani
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Tim-Oliver Sauer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Carolin C Hack
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
- Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Matthias W Beckmann
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
- Department of Gynecology and Obstetrics, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, 91054 Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
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Brunt AM, Haviland JS. Hypofractionation: The standard for external beam breast irradiation. Breast 2023; 69:410-416. [PMID: 37120889 PMCID: PMC10172745 DOI: 10.1016/j.breast.2023.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023] Open
Abstract
This overview provides the historical perspective of external beam breast hypofractionation over the last 50 years. It highlights the serious harm suffered by patients with breast cancer in the 1970's and 1980's because of new hypofractionation regimens based on a theoretical radiobiology model being adopted into clinical practice to solve a resource issue without testing within clinical trials and without the essential radiotherapy quality assurance. It then describes the high-quality clinical trials comparing 3-week with 5-week standard of care regimens that were initiated based on a strong scientific rationale for hypofractionation in breast cancer. Today, there are still challenges with universal implementation of the results of these moderate hypofractionation studies, but there is now a substantial body of evidence to support 3-week breast radiotherapy with several large randomised trials still to report. The limit of breast hypofractionation is then explored and randomised trials investigating 1-week radiotherapy are described. This approach is now standard of care in many countries for whole or partial breast radiotherapy and chest wall radiotherapy without immediate reconstruction. It also has the advantage of reducing burden of treatment for patients and providing cost-effective care. Further research is needed to establish the safety and efficacy of 1-week breast locoregional radiotherapy and following immediate breast reconstruction. In addition, clinical studies are required to determine how a tumour bed boost for patients with breast cancer at higher risk of relapse can be incorporated simultaneously into a 1-week radiotherapy schedule. As such, the breast hypofractionation story is still unfolding.
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Affiliation(s)
- Adrian Murray Brunt
- David Weatherall Building, School of Medicine, University of Keele, Keele, Staffordshire, ST5 5BG, UK; Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, Sutton, London, UK.
| | - Joanne Susan Haviland
- Clinical Trials and Statistics Unit (ICR-CTSU), The Institute of Cancer Research, Sutton, London, UK.
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30
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Holm Milo ML, Slot Møller D, Bisballe Nyeng T, Hoffmann L, Dahl Nissen H, Jensen I, Laugaard Lorenzen E, Bech Jellesmark Thorsen L, Melgaard Nielsen K, Paaske Johnsen S, Brink Valentin J, Alsner J, Vrou Offersen B. Radiation dose to heart and cardiac substructures and risk of coronary artery disease in early breast cancer patients: A DBCG study based on modern radiation therapy techniques. Radiother Oncol 2023; 180:109453. [PMID: 36642388 DOI: 10.1016/j.radonc.2022.109453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/10/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) has been reported as a late effect following radiation therapy (RT) of early breast cancer (BC). This study aims to report individual RT doses to the heart and cardiac substructures in patients treated with CT-based RT and to investigate if a dose-response relationship between RT dose and CAD exists using modern radiation therapy techniques. METHODS Patients registered in the Danish Breast Cancer Group database from 2005 to 2016 with CT-based RT were eligible. Among 15,765 patients, the study included 204 with CAD after irradiation (cases) and 408 matched controls. Individual planning CTs were retrieved, the heart and cardiac substructures were delineated and dose-volume parameters were extracted. RESULTS The median follow-up time was 7.3 years (IQR: 4.6-10.0). Among cases, the median mean heart dose was 1.6 Gy (IQR 0.2-6.1) and 0.8 Gy (0.1-2.9) for left-sided and right-sided patients, respectively (p < 0.001). The highest RT doses were observed in the left ventricle and left anterior descending coronary artery for left-sided RT and in the right atrium and the right coronary artery after right-sided RT. The highest left-minus-right dose-difference was located in the distal part of the left anterior descending coronary artery where also the highest left-versus-right ratio of events was observed. However, no significant difference in the distribution of CAD was observed by laterality. Furthermore, no significant differences in the dose-volume parameters were observed for cases versus controls. CONCLUSIONS CAD tended to occur in the part of the heart with the highest left-minus- right dose difference, however, no significant risk of CAD was observed at 7 years' median follow-up.
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Affiliation(s)
- Marie Louise Holm Milo
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aalborg University Hospital, Denmark.
| | - Ditte Slot Møller
- Department of Medical Physics, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | | | - Lone Hoffmann
- Department of Medical Physics, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, Aarhus, Denmark
| | | | - Ingelise Jensen
- Department of Medical Physics, Aalborg University Hospital, Denmark
| | | | - Lise Bech Jellesmark Thorsen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aarhus University Hospital, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University Hospital, Denmark
| | - Jan Alsner
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Birgitte Vrou Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark; Department of Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, Aarhus, Denmark
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31
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Yu CX. Radiotherapy of early‐stage breast cancer. PRECISION RADIATION ONCOLOGY 2023. [DOI: 10.1002/pro6.1183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Affiliation(s)
- Cedric X. Yu
- Radiation Oncology University of Maryland School of Medicine Baltimore Maryland USA
- Xcision Medical Systems Columbia Maryland USA
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32
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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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Volume matters: Breast induration is associated with irradiated breast volume in the Danish Breast Cancer Group phase III randomized Partial Breast Irradiation trial. Radiother Oncol 2022; 177:231-235. [PMID: 36265685 DOI: 10.1016/j.radonc.2022.09.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/22/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE The relation between breast induration grade 2-3 at 3 years after radiation therapy and irradiated breast volume was investigated for patients in the Danish Breast Cancer Group (DBCG) Partial Breast Irradiation (PBI) trial. METHODS Treatment plan data was obtained from the Danish radiotherapy plan database. Dosimetric parameters for breast and organs at risk were determined. Breast induration data was obtained from the DBCG database. The volume of the whole breast (CTVp_breast) treated to various dose levels was determined for treatment plans in both arms. Logistic regression was used to assess the frequency of induration on breast volume irradiated to ≥40 Gy. RESULTS PBI and WBI was given to 433 and 432 patients, respectively. Median and interquartile ranges (IQR) for CTVp_breast were 710 mL (467-963 mL; PBI) and 666 mL (443-1012 mL; WBI) (p = 0.98). Median and IQR for CTVp_breast treated to ≥40 Gy was 24.9% (18.6-32.6%; PBI) and 59.8% (53.6-68.5%; WBI). Grade 2-3 induration was observed in 5% (PBI) and 10% (WBI) of the patients. A dose-response relationship was established between irradiated breast volume and frequency of breast induration. From the model, 5% and 10% risks of breast induration were observed for ≥40 Gy delivered to CTVp_breast volumes of 177 mL (95%CI, 94-260 mL) and 426 mL (95%CI, 286-567 mL), respectively. CONCLUSION The frequency of breast induration increased significantly with increasing irradiated breast volume, strongly favouring small volumes and PBI. Thus, treated breast volume - not the breast size itself - is the risk factor for induration. This is the first report directly linking the 40 Gy irradiated breast volume to breast induration.
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Offersen BV, Overgaard M, Overgaard J. Breast cancer radiotherapy: Is it time to rethink the indication? Radiother Oncol 2022; 177:238-239. [PMID: 36265681 DOI: 10.1016/j.radonc.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/07/2022]
Affiliation(s)
| | - Marie Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Jens Overgaard
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark.
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35
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Kaidar-Person O, Gentilini O, Poortmans P. Not only volumes matter for breast radiation therapy. Radiother Oncol 2022; 177:236-237. [PMID: 36334693 DOI: 10.1016/j.radonc.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Affiliation(s)
- Orit Kaidar-Person
- Breast Cancer Radiation Therapy Unit, Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel1; Department of Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Oreste Gentilini
- Breast Surgery, San Raffaele University and Research Hospital, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Netwerk, Antwerp 2610, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium.
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