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Shah C, Vicini F. Accelerated partial breast irradiation-Redefining the treatment target for women with early stage breast cancer. Breast J 2019; 25:408-417. [PMID: 30950133 DOI: 10.1111/tbj.13241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/07/2018] [Accepted: 06/19/2018] [Indexed: 01/19/2023]
Abstract
Following breast conserving surgery, the standard of care has been to deliver adjuvant radiation therapy directed to the whole breast (WBI) over a period of 3-7 weeks. Over the past decade, increasing data have supported the concept that treatment to the whole breast may not be required in selected patients, allowing for the emergence of partial breast irradiation (PBI). Multiple randomized trials with 5-10 years of follow-up have been published documenting the safety and efficacy associated with PBI using multiple techniques. Questions that remain to be answered include (a) what is the optimal PBI technique for each clinical scenario, (b) are there additional patients that can be effectively managed with PBI approaches, and (c) are there different techniques/dose schedules that allow for further reduction in treatment duration and/or toxicities? Partial breast irradiation represents a standard approach for appropriately selected patients. PBI provides comparable clinical outcomes to WBI while allowing for a reduction in the duration treatment and the potential for reduced toxicities. Future studies may also help to better define which patients require no radiation, PBI, hypofractionated WBI or conventional WBI, based upon patient, clinical, pathologic features as well as potentially using tumor genetics.
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Affiliation(s)
- Chirag Shah
- Department of Radiation Oncology, Cleveland Clinic, Taussig Cancer Institute, Cleveland, Ohio
| | - Frank Vicini
- 21st Century Oncology, Michigan Healthcare Professionals, Farmington Hills, Michigan
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2
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Brachytherapy in the treatment of breast cancer. Int J Clin Oncol 2017; 22:641-650. [PMID: 28664300 DOI: 10.1007/s10147-017-1155-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 06/14/2017] [Indexed: 11/10/2022]
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Akhtari M, Abboud M, Szeja S, Pino R, Lewis GD, Bass BL, Miltenburg DM, Butler EB, Teh BS. Clinical outcomes, toxicity, and cosmesis in breast cancer patients with close skin spacing treated with accelerated partial breast irradiation (APBI) using multi-lumen/catheter applicators. J Contemp Brachytherapy 2016; 8:497-504. [PMID: 28115955 PMCID: PMC5241383 DOI: 10.5114/jcb.2016.64830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/07/2016] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Accelerated partial breast irradiation (APBI) using a single-lumen device is associated with better cosmetic outcomes if the spacing between the applicator and skin is > 7 mm. However, there are no reports addressing the late toxicity and clinical outcomes in patients treated with single-entry multi-lumen/catheter applicators who had close skin spacing (7 mm or less). We undertook this study to report clinical outcome, acute and late toxicity as well as cosmesis of early stage breast cancer patients with close skin spacing treated with APBI using multi-lumen or multi-catheter devices. MATERIAL AND METHODS This is a retrospective study of all breast cancer patients who had undergone APBI using single-entry multi-lumen/catheter devices in a single institution between 2008 to 2012. The study was limited to those with ≤ 7 mm spacing between the device and skin. RESULTS We identified 37 patients and 38 lesions with skin spacing of ≤ 7 mm. Seven lesions (18%) had spacing of ≤ 3 mm. Median follow-up was 47.5 months. There was one case of ipsilateral breast recurrence and one ipsilateral axillary recurrence. Based on RTOG criteria, 22 treated lesions experienced grade 1 and 9 lesions experienced grade 2 toxicity. Twenty-one lesions experienced late grade 1 toxicity. One patient had to undergo mastectomy due to mastitis. Twenty-four treated breasts showed excellent and 11 had good cosmetic outcome. Overall cosmesis trended towards a significant correlation with skin spacing. However, all patients with ≤ 3 mm skin spacing experienced acute and late toxicities. CONCLUSIONS Accelerated partial breast irradiation can be safely performed in patients with skin spacing of ≤ 7 mm using single-entry multi-lumen/catheter applicators with excellent cosmetic outcomes and an acceptable toxicity profile. However, skin spacing of ≤ 3 mm is associated with acute and late toxicity and should be avoided if possible.
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Affiliation(s)
- Mani Akhtari
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Mirna Abboud
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Sean Szeja
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Ramiro Pino
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Gary D. Lewis
- Department of Radiation Oncology, University of Texas Medical Branch, Galveston, TX
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Barbara L. Bass
- Department of Surgery, Houston Methodist Hospital, Houston, TX
| | | | - E. Brian Butler
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
| | - Bin S. Teh
- Department of Radiation Oncology, Houston Methodist Hospital, Cancer Center and Research Institute, Houston, TX
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Shah S, Holzwanger E, Khwaja R, Fang D, Figueroa-Bodine J, Iannuzzi C, Shi C. A Single-Site Retrospective, Nonrandomized Study of Accelerated Partial Breast Irradiation Brachytherapy for Early-Stage Breast Cancer Treatment to Evaluate Local Tumor Control, Cosmetic Outcome, and Toxicities. Technol Cancer Res Treat 2016. [DOI: 10.1177/1533034615595724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Purpose: To evaluate the efficacy and safety of the accelerated partial breast irradiation brachytherapy with a combination of applicators at a community hospital cancer center. Methods and Materials: Between 2005 and 2009, 120 patients with early-stage breast cancer were being followed after treatment with accelerated partial breast irradiation brachytherapy using MammoSite, single or multilumen balloon, or Contura multilumen balloon. After their lumpectomy surgery, each patient was treated with Ir-192 high-dose rate unit following radiation therapy oncology group 0413 guidelines. The patients had multiple follow-ups at 6 months, 1 year, 2 years, 3 years, or more. Results: Based on the Harvard Breast Cosmesis Scale, 95.00% of patients described their cosmetic evaluation as the treated breast essentially the same as the opposite side (excellent) or minimal but identifiable effects were noticed from radiation (good). After a median follow-up of 36 months, the local recurrence rate was 1.66% and a disease-free survival is 98.3%. Forty-two patients reported 85 adverse events, which were fibrosis: 24.70%, hyperpigmentation: 20.00%, radiation skin reaction: 7.05%, seroma: 7.05%, breast pain: 7.05%, erythema: 5.88%, and other events were less than 5.00%. Of all the adverse events recorded, grade 1 to 3 events are 95.29% (n = 81), 2.35% (n = 2), and 2.35% (n = 2). There was no grade 4 or 5 events recorded. Conclusions: Our study has shown promising results for delivering radiation with MammoSite, single or multilumen balloon, or Contura multilumen balloon and has been successful in achieving local control in patients with early-stage breast cancer.
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Affiliation(s)
- Shalin Shah
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | - Erik Holzwanger
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | - Radhika Khwaja
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | - Deborah Fang
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
| | | | | | - Chengyu Shi
- Radiation Oncology, Saint Vincent’s Medical Center, Bridgeport, CT, USA
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Khan AJ, Ahlawat S, Goyal S. Novel and Highly Compressed Schedules for the Treatment of Breast Cancer. Semin Radiat Oncol 2015; 26:45-50. [PMID: 26617209 DOI: 10.1016/j.semradonc.2015.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our thinking about radiotherapy (RT) for early-stage breast cancer has evolved considerably over the last several years. Increasingly patients and physicians together are making the decision to use altered fractionation rather than standard 6-7 weeks of conventional whole breast treatment plus lumpectomy bed boost. Adjuvant hypofractionated whole breast irradiation is now viewed as a preferred strategy for many eligible women, and can be completed in 3-4 weeks. Adjuvant accelerated partial breast irradiation is another alternative that is typically delivered in 8-10 fractions over 4-5 days. With improvements in delivery techniques, there has been renewed interest in shortening treatment times even further, with novel intraoperative approaches and ultrashort courses of external beam RT. This article provides a summary of the status and future directions in intraoperative and ultrashort course RT schedules used in the treatment of breast cancer. Outlined are the benefits as well as the drawbacks of these techniques for abbreviated breast RT.
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Affiliation(s)
- Atif J Khan
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Stuti Ahlawat
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Sharad Goyal
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ; Department of Radiation Oncology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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Wobb JL, Chen PY, Shah C, Moran MS, Shaitelman SF, Vicini FA, Mbah AK, Lyden M, Beitsch P. Nomogram for Predicting the Risk of Locoregional Recurrence in Patients Treated With Accelerated Partial-Breast Irradiation. Int J Radiat Oncol Biol Phys 2015; 91:312-8. [DOI: 10.1016/j.ijrobp.2014.09.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/04/2014] [Accepted: 09/22/2014] [Indexed: 12/12/2022]
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Breast-Conservative Surgery Followed by Radiofrequency Ablation of Margins Decreases the Need for a Second Surgical Procedure for Close or Positive Margins. Clin Breast Cancer 2014; 14:346-51. [DOI: 10.1016/j.clbc.2014.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 02/07/2014] [Accepted: 02/12/2014] [Indexed: 01/27/2023]
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Czechura T, Winchester DJ, Pesce C, Huo D, Winchester DP, Yao K. Accelerated Partial-Breast Irradiation Versus Whole-Breast Irradiation for Early-Stage Breast Cancer Patients Undergoing Breast Conservation, 2003–2010: A Report from the National Cancer Data Base. Ann Surg Oncol 2013; 20:3223-32. [DOI: 10.1245/s10434-013-3154-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Indexed: 12/31/2022]
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Olivotto IA, Whelan TJ, Parpia S, Kim DH, Berrang T, Truong PT, Kong I, Cochrane B, Nichol A, Roy I, Germain I, Akra M, Reed M, Fyles A, Trotter T, Perera F, Beckham W, Levine MN, Julian JA. Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation therapy. J Clin Oncol 2013; 31:4038-45. [PMID: 23835717 DOI: 10.1200/jco.2013.50.5511] [Citation(s) in RCA: 275] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE To report interim cosmetic and toxicity results of a multicenter randomized trial comparing accelerated partial-breast irradiation (APBI) using three-dimensional conformal external beam radiation therapy (3D-CRT) with whole-breast irradiation (WBI). PATIENTS AND METHODS Women age > 40 years with invasive or in situ breast cancer ≤ 3 cm were randomly assigned after breast-conserving surgery to 3D-CRT APBI (38.5 Gy in 10 fractions twice daily) or WBI (42.5 Gy in 16 or 50 Gy in 25 daily fractions ± boost irradiation). The primary outcome was ipsilateral breast tumor recurrence (IBTR). Secondary outcomes were cosmesis and toxicity. Adverse cosmesis was defined as a fair or poor global cosmetic score. After a planned interim cosmetic analysis, the data, safety, and monitoring committee recommended release of results. There have been too few IBTR events to trigger an efficacy analysis. RESULTS Between 2006 and 2011, 2,135 women were randomly assigned to 3D-CRT APBI or WBI. Median follow-up was 36 months. Adverse cosmesis at 3 years was increased among those treated with APBI compared with WBI as assessed by trained nurses (29% v 17%; P < .001), by patients (26% v 18%; P = .0022), and by physicians reviewing digital photographs (35% v 17%; P < .001). Grade 3 toxicities were rare in both treatment arms (1.4% v 0%), but grade 1 and 2 toxicities were increased among those who received APBI compared with WBI (P < .001). CONCLUSION 3D-CRT APBI increased rates of adverse cosmesis and late radiation toxicity compared with standard WBI. Clinicians and patients are cautioned against the use of 3D-CRT APBI outside the context of a controlled trial.
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Affiliation(s)
- Ivo A Olivotto
- Ivo A. Olivotto, Tanya Berrang, Pauline T. Truong, Alan Nichol, Melanie Reed, and Wayne Beckham, British Columbia Cancer Agency; Ivo A. Olivotto, Tanya Berrang, and Pauline T. Truong, University of British Columbia; Wayne Beckham, University of Victoria, Victoria; Alan Nichol, University of British Columbia, Vancouver; Melanie Reed, University of British Columbia, Kelowna, British Columbia; Timothy J. Whelan, Do-Hoon Kim, Iwa Kong, and Mark N. Levine, Juravinski Cancer Centre; Timothy J. Whelan, Sameer Parpia, Do-Hoon Kim, Iwa Kong, Brandy Cochrane, Mark N. Levine, and Jim A. Julian, McMaster University; Timothy J. Whelan, Sameer Parpia, Brandy Cochrane, Mark N. Levine, and Jim A. Julian, Ontario Clinical Oncology Group, Hamilton; Anthony Fyles, Princess Margaret Hospital, University of Toronto, Toronto; Francisco Perera, London Regional Cancer Centre, University of Western Ontario, London, Ontario; Isabelle Roy, Hôpital Notre-Dame, University of Montreal, Montreal; Isabelle Germain, Hôtel-Dieu de Quebec, Laval University, Quebec City, Quebec; Mohamed Akra, Cancer Care Manitoba, University of Manitoba, Winnipeg, Manitoba; and Theresa Trotter, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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11
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Barry M, Ho A, Morrow M. The evolving role of partial breast irradiation in early-stage breast cancer. Ann Surg Oncol 2013; 20:2534-40. [PMID: 23463089 DOI: 10.1245/s10434-013-2923-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 01/24/2023]
Abstract
Whole breast irradiation (WBI) over 5-7 weeks has long been considered standard adjuvant treatment after breast-conserving surgery. Recently the concept of irradiating the whole breast has been challenged by accelerated partial breast irradiation (APBI), which exclusively targets the lumpectomy site plus margin. We review the evidence supporting APBI from modern clinical trials, the pros and cons of various APBI techniques, and the controversies regarding the applicability of APBI to specific patient groups.
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Affiliation(s)
- Mitchel Barry
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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12
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Gifford KA, Pacha O, Hebert AA, Nelson CL, Kirsner SM, Ballo MT, Bloom ES. A new paradigm for calculating skin dose. Brachytherapy 2013; 12:114-9. [DOI: 10.1016/j.brachy.2012.05.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 05/23/2012] [Accepted: 05/24/2012] [Indexed: 11/28/2022]
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Wilkinson JB, Beitsch PD, Shah C, Arthur D, Haffty BG, Wazer DE, Keisch M, Shaitelman SF, Lyden M, Chen PY, Vicini FA. Evaluation of current consensus statement recommendations for accelerated partial breast irradiation: a pooled analysis of William Beaumont Hospital and American Society of Breast Surgeon MammoSite Registry Trial Data. Int J Radiat Oncol Biol Phys 2012. [PMID: 23182700 DOI: 10.1016/j.ijrobp.2012.10.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine whether the American Society for Radiation Oncology (ASTRO) Consensus Statement (CS) recommendations for accelerated partial breast irradiation (APBI) are associated with significantly different outcomes in a pooled analysis from William Beaumont Hospital (WBH) and the American Society of Breast Surgeons (ASBrS) MammoSite® Registry Trial. METHODS AND MATERIALS APBI was used to treat 2127 cases of early-stage breast cancer (WBH, n=678; ASBrS, n=1449). Three forms of APBI were used at WBH (interstitial, n=221; balloon-based, n=255; or 3-dimensional conformal radiation therapy, n=206), whereas all Registry Trial patients received balloon-based brachytherapy. Patients were divided according to the ASTRO CS into suitable (n=661, 36.5%), cautionary (n=850, 46.9%), and unsuitable (n=302, 16.7%) categories. Tumor characteristics and clinical outcomes were analyzed according to CS group. RESULTS The median age was 65 years (range, 32-94 years), and the median tumor size was 10.0 mm (range, 0-45 mm). The median follow-up time was 60.6 months. The WBH cohort had more node-positive disease (6.9% vs 2.6%, P<.01) and cautionary patients (49.5% vs 41.8%, P=.06). The 5-year actuarial ipsilateral breast tumor recurrence (IBTR), regional nodal failure (RNF), and distant metastasis (DM) for the whole cohort were 2.8%, 0.6%, 1.6%. The rate of IBTR was not statistically higher between suitable (2.5%), cautionary (3.3%), or unsuitable (4.6%) patients (P=.20). The nonsignificant increase in IBTR for the cautionary and unsuitable categories was due to increased elsewhere failures and new primaries (P=.04), not tumor bed recurrence (P=.93). CONCLUSIONS Excellent outcomes after breast-conserving surgery and APBI were seen in our pooled analysis. The current ASTRO CS guidelines did not adequately differentiate patients at an increased risk of IBTR or tumor bed failure in this large patient cohort.
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Affiliation(s)
- J Ben Wilkinson
- Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
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Khan AJ, Vicini FA, Brown S, Haffty BG, Kearney T, Dale R, Lyden M, Arthur D. Dosimetric Feasibility and Acute Toxicity in a Prospective Trial of Ultrashort-Course Accelerated Partial Breast Irradiation (APBI) Using a Multi-Lumen Balloon Brachytherapy Device. Ann Surg Oncol 2012; 20:1295-301. [DOI: 10.1245/s10434-012-2671-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Indexed: 11/18/2022]
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Senthi S, Link E, Chua BH. Cosmetic Outcome and Seroma Formation After Breast-Conserving Surgery With Intraoperative Radiation Therapy Boost for Early Breast Cancer. Int J Radiat Oncol Biol Phys 2012; 84:e139-44. [DOI: 10.1016/j.ijrobp.2012.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 02/26/2012] [Accepted: 03/06/2012] [Indexed: 10/27/2022]
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Khan AJ, Haffty BG. Issues in the Curative Therapy of Breast Cancer in Elderly Women. Semin Radiat Oncol 2012; 22:295-303. [DOI: 10.1016/j.semradonc.2012.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Mukesh M, Harris E, Jena R, Evans P, Coles C. Relationship between irradiated breast volume and late normal tissue complications: a systematic review. Radiother Oncol 2012; 104:1-10. [PMID: 22682540 DOI: 10.1016/j.radonc.2012.04.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 03/29/2012] [Accepted: 04/30/2012] [Indexed: 12/25/2022]
Abstract
The concept of radiation dose-volume effect has been exploited in breast cancer as boost treatment for high risk patients and more recently in trials of Partial Breast Irradiation for low risk patients. However, there appears to be paucity of published data on the dose-volume effect of irradiation on breast tissue including the recently published report on Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC). This systematic review looks at the current literature for relationship between irradiated breast volume and normal tissue complications and introduces the concept of dose modulation.
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Affiliation(s)
- Mukesh Mukesh
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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Acute toxicity and early cosmetic outcome in patients treated with multilumen balloon brachytherapy with skin spacing ≤ 7.0 millimeters. J Contemp Brachytherapy 2012; 4:8-13. [PMID: 23346134 PMCID: PMC3551367 DOI: 10.5114/jcb.2012.27946] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Revised: 03/06/2012] [Accepted: 03/18/2012] [Indexed: 11/24/2022] Open
Abstract
Purpose To review institutional experience treating patients who underwent breast conserving surgery and adjuvant accelerated partial breast irradiation with multilumen balloon brachytherapy (MLB) with close skin spacing (≤7 mm). Material and methods Since July 2009, 26 patients with skin spacing ≤ 7.0 mm were treated with breast-conserving therapy and adjuvant MLB brachytherapy. Patients were treated with either the Contura or MammoSite ML catheter to a total dose of 34 Gy in 10 fractions. Patients were assessed for acute toxicity at the completion of treatment and 1-month post treatment. Cosmesis and late toxicity were assessed at three-month intervals thereafter. Results The median age of the patients was 56 years and median follow-up was 9 months. Sixteen patients had skin spacing of 5.0–7.0 mm, 10 with < 5.0 mm (median 5.8). The median percentage of the target (PTV_EVAL) receiving ≥ 95% of the prescription dose was 95.6%. The median volume of PTV_EVAL receiving ≥ 200% of the prescription dose was 6.1 cc. The maximum skin dose was 118.2% (median). The most commonly observed acute toxicity was grade 1-2 dermatitis (65.4%). The rate of post-treatment seroma and infection was 38.5% and 3.8%, respectively. Excellent/good cosmetic outcomes seen at the time of last follow-up was 92.3%. Conclusions MLB brachytherapy is safe and feasible in patients with close skin spacing, with acute toxicity and early cosmesis similar to other published series. These devices may broaden the application of balloon brachytherapy in patients previously excluded from this treatment based on anatomy.
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Local control, toxicity, and cosmesis in women >70 years enrolled in the American Society of Breast Surgeons accelerated partial breast irradiation registry trial. Int J Radiat Oncol Biol Phys 2012; 84:323-30. [PMID: 22361081 DOI: 10.1016/j.ijrobp.2011.12.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 11/25/2011] [Accepted: 12/06/2011] [Indexed: 12/24/2022]
Abstract
PURPOSE The American Society of Breast Surgeons enrolled women in a registry trial to prospectively study patients treated with the MammoSite Radiation Therapy System breast brachytherapy device. The present report examined the outcomes in women aged >70 years enrolled in the trial. METHODS AND MATERIALS A total of 1,449 primary early stage breast cancers were treated in 1,440 women. Of these, 537 occurred in women >70 years old. Fisher's exact test was performed to correlate age (≤ 70 vs. >70 years) with toxicity and with cosmesis. The association of age with local recurrence (LR) failure times was investigated by fitting a parametric model. RESULTS Older women were less likely to develop telangiectasias than younger women (7.9% vs. 12.4%, p = 0.0083). The incidence of other toxicities was similar. Cosmesis was good or excellent in 92% of the women >70 years old. No significant difference was found in LR as a function of age. The 5-year actuarial LR rate with invasive disease for the older vs. younger population was 2.79% and 2.92%, respectively (p = 0.5780). In women >70 years with hormone-sensitive tumors ≤ 2 cm who received hormonal therapy (n = 195), the 5-year actuarial rate of LR, overall survival, disease-free survival, and cause-specific survival was 2.06%, 89.3%, 87%, and 97.5%, respectively. These outcomes were similar in women who did not receive hormonal therapy. Women with small, estrogen receptor-negative disease had worse LR, overall survival, and disease-free survival compared with receptor-positive patients. CONCLUSIONS Accelerated partial breast irradiation with the MammoSite radiation therapy system resulted in low toxicity and produced similar cosmesis and local control at 5 years in women >70 years compared with younger women. This treatment should be considered as an alternative to omitting adjuvant radiotherapy for older women with small-volume, early-stage breast cancer.
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Khan AJ, Dale RG, Arthur DW, Haffty BG, Todor DA, Vicini FA. Ultrashort courses of adjuvant breast radiotherapy. Cancer 2011; 118:1962-70. [DOI: 10.1002/cncr.26457] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Revised: 06/15/2011] [Accepted: 06/27/2011] [Indexed: 11/07/2022]
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Kim Y, Trombetta MG. Objective method to report planner-independent skin/rib maximal dose in balloon-based high dose rate (HDR) brachytherapy for breast cancer. Med Phys 2011; 38:2053-7. [PMID: 21626938 DOI: 10.1118/1.3568927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE An objective method was proposed and compared with a manual selection method to determine planner-independent skin and rib maximal dose in balloon-based high dose rate (HDR) brachytherapy planning. METHODS The maximal dose to skin and rib was objectively extracted from a dose volume histogram (DVH) of skin and rib volumes. A virtual skin volume was produced by expanding the skin surface in three dimensions (3D) external to the breast with a certain thickness in the planning computed tomography (CT) images. Therefore, the maximal dose to this volume occurs on the skin surface the same with a conventional manual selection method. The rib was also delineated in the planning CT images and its maximal dose was extracted from its DVH. The absolute (Abdiff = [D(max) Man - D (max)DVH]) and relative (Rediff[%] = 100 x ([D(max)Man-D(max)DVH])/D(max)DVH) maximal skin and rib dose differences between the manual selection method (D(max)Man) and the objective method (D(max)DVH) were measured for 50 balloon-based HDR (25 MammoSite and 25 Contura) patients. RESULTS The average +/- standard deviation of maximal dose difference was 1.67% +/- 1.69% of the prescribed dose (PD). No statistical difference was observed between MammoSite and Contura patients for both Abdiff and Rediff[%] values. However, a statistically significant difference (p value < 0.0001) was observed in maximal rib dose difference compared with maximal skin dose difference for both Abdiff (2.30% +/- 1.71% vs 1.05% +/- 1.43%) and Rediff[%] (2.32% +/- 1.79% vs 1.21% +/- 1.41%). In general, rib has a more irregular contour and it is more proximally located to the balloon for 50 HDR patients. Due to the inverse square law factor, more dose difference was observed in higher dose range (D(max) > 90%) compared with lower dose range (D(max) < 90%): 2.16% +/- 1.93% vs 1.19% +/- 1.25% with p value of 0.0049. However, the Rediff[%] analysis eliminated the inverse square factor and there was no statistically significant difference (p value = 0.8931) between high and low dose ranges. CONCLUSIONS The objective method using volumetric information of skin and rib can determine the planner-independent maximal dose compared with the manual selection method. However, the difference was < 2% of PD, on average, if appropriate attention is paid to selecting a manual dose point in 3D planning CT images.
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Affiliation(s)
- Yongbok Kim
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania 15212, USA.
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Perioperative reductions in circulating lymphocyte levels predict wound complications after excisional breast cancer surgery. Ann Surg 2011; 253:360-4. [PMID: 21169805 DOI: 10.1097/sla.0b013e318207c139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Postoperative wound complications after excisional surgery for primary breast cancer can result in patients requiring additional treatments and delay adjuvant therapy and are associated with worse prognoses.We investigated factors that might predispose patients to wound complications. BACKGROUND A number of patient characteristics have been associated with wound complications, but there is currently no quantitative measure of the risk of their occurrence. Our hypothesis was that wound complications are related, in part, to the immune status of patients. METHODS We recruited patients undergoing surgery for primary breast cancer and determined their circulating levels of various immune cells shortly before and after surgery as a measure of immune status. RESULTS One hundred seventeen patients were recruited; 16 (13.7%) developed wound complications. The following patient and tumor characteristics were associated with higher wound complication rates: diabetes (P = 0.02); larger tumors (T2/3 vs T1; P = 0.02); metastatic axillary nodes (P = 0.006). With respect to immune status, no significant differences in preoperative levels of circulating immune cells were detected between patients who developed wound complications and those who did not. However, patients who developed complications showed greater reductions in lymphocyte levels 4 hours postoperatively than those who did not (P <0.001). Multivariate analyses demonstrated that falls in lymphocyte levels of greater than 20% or 50% 4 hours postoperatively acted as a significant and independent predictor of wound complications (P < 0.005 and P < 0.0001,respectively). CONCLUSIONS Perioperative changes in lymphocyte levels could provide a practical predictive marker for wound complications on which selective antibiotic prophylaxis could be based.
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Lin R, Tripuraneni P. Radiation therapy in early-stage invasive breast cancer. Indian J Surg Oncol 2011; 2:101-11. [PMID: 22693401 DOI: 10.1007/s13193-011-0048-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2009] [Accepted: 01/06/2010] [Indexed: 10/18/2022] Open
Abstract
The treatment of breast cancer involves a multi-disciplinary approach with radiation therapy playing a key role. Breast-conserving surgery has been an option for women with early-stage breast cancer for over two decades now. Multiple randomized trials now have demonstrated the efficacy of breast-conserving surgery followed by radiation therapy. With the advancements in breast imaging and the successful campaign for early detection of breast cancer, more women today are found to have early-stage small breast cancers. Patient factors (breast size, tumor location, history of prior radiation therapy, preexisting conditions such as collagen vascular disease, age, having prosthetically augmented breasts), pathological factors (margin status, tumor size, presence of extensive intraductal component requiring multiple surgical excisions), as well as patient preference are all taken into consideration prior to surgical management of breast cancer. Whole-breast fractionated radiation therapy between 5 and 7 weeks is considered as the standard of care treatment following breast-conserving surgery. However, new radiation treatment strategies have been developed in recent years to provide alternatives to the conventional 5-7 week whole-breast radiation therapy for some patients. Accelerated partial breast radiation therapy (APBI) was introduced because the frequency of breast recurrences outside of the surgical cavity has been shown to be low. This technique allows treatments to be delivered quicker (usually 1 week, twice daily) to a limited volume. Often times, this treatment involves the use of a brachytherapy applicator to be placed into the surgical cavity following breast-conserving surgery. Accelerated hypofractionated whole-breast irradiation may be another faster way to deliver radiation therapy following breast-conserving surgery. This journal article reviews the role of radiation therapy in women with early-stage breast cancer addressing patient selection in breast-conserving therapy, a review of pertinent trials in breast-conserving therapy, as well as the different treatment techniques available to women following breast-conserving surgery.
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Affiliation(s)
- Ray Lin
- Department of Radiation Oncology, Scripps Clinic and Scripps Green Hospital, La Jolla, CA USA
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Abstract
Whole breast irradiation (WBI) is the standard after breast conservation surgery. However, WBI in selected patients has been questioned. Accelerated partial breast irradiation (APBI) focuses treatment on the lumpectomy bed. Many modalities of delivering APBI have been developed: multicatheter interstitial brachytherapy, MammoSite balloon catheter, single insertion multicatheter devices, three-dimensional conformal external-beam radiation therapy and intraoperative techniques. Numerous studies of APBI have demonstrated excellent local control and cosmetic outcomes in early-stage breast cancer patients.
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Ouhib Z, Benda R, Kasper M, Vargas C, Kyriacou A, Lyden M. Accurate verification of balloon rotation correction for the Contura multilumen device for accelerated partial breast irradiation. Brachytherapy 2011; 10:325-30. [PMID: 21236737 DOI: 10.1016/j.brachy.2010.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 12/06/2010] [Accepted: 12/08/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE To validate a method of accurately confirming the orientation of the Contura multilumen balloon catheter before each fraction and to determine if any residual device rotation remains after adjustment. METHODS AND MATERIALS Sixteen patients underwent CT scans before each treatment with accelerated partial breast irradiation. Before acquisition of CT scans for planning, each patient had a skin mark drawn to align with Lumen #1 (the Contura [SenoRx, Inc., Irvine, CA] has a black line on the shaft of the applicator to identify this lumen). In addition, a CT spot marker was used as a fixed reference point on the patient's skin. CT markers (used for lumen identification and reconstruction) were also used as additional reference points for distance measurements. The distances measured from the CT spot marker to the three reproducible points on the CT markers were used for balloon rotation verification. These measurements were performed for each daily fraction on reproducible CT axial views. RESULTS Three hundred eighteen measurements were obtained. Median residual rotation for all cases was 0.2mm (standard deviation=0.797). Later fractions and skin spacing changes over time were associated with slightly greater residual rotation (Fraction #1 vs. Fraction #10, 0.1 vs. 0.3mm, p=0.05; and skin spacing change ≤2 vs. >2mm, 0.2 vs. 0.5mm, p=0.0019, respectively). CONCLUSIONS These results confirm external alignment of a skin mark with Lumen #1 (on the Contura catheter) is an accurate and reliable method to align the balloon before treatment and that no significant internal device rotation (0.2mm) is likely to occur.
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Affiliation(s)
- Zoubir Ouhib
- Department of Radiation Oncology, Lynn Cancer Institute, Boca Raton, FL 33484, USA.
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Brown S, McLaughlin M, Pope DK, Haile K, Hughes L, Israel PZ, Lyden M. A dosimetric comparison of the Contura multilumen balloon breast brachytherapy catheter vs. the single-lumen MammoSite balloon device in patients treated with accelerated partial breast irradiation at a single institution. Brachytherapy 2011; 10:68-73. [DOI: 10.1016/j.brachy.2010.01.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Revised: 12/22/2009] [Accepted: 01/05/2010] [Indexed: 10/19/2022]
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Improvements in Critical Dosimetric Endpoints Using the Contura Multilumen Balloon Breast Brachytherapy Catheter to Deliver Accelerated Partial Breast Irradiation: Preliminary Dosimetric Findings of a Phase IV Trial. Int J Radiat Oncol Biol Phys 2011; 79:26-33. [DOI: 10.1016/j.ijrobp.2009.10.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/13/2009] [Accepted: 10/14/2009] [Indexed: 11/23/2022]
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Wilder RB, Curcio LD, Khanijou RK, Eisner ME, Kakkis JL, Chittenden L, Agustin J, Lizarde J, Mesa AV, Macedo JC, Ravera J, Tokita KM. Preliminary Results in 173 Breast Cancer Patients Treated with Post-Lumpectomy MammoSite Single-Lumen Brachytherapy or Multi-Catheter Brachytherapy. Breast J 2010; 16:581-6. [DOI: 10.1111/j.1524-4741.2010.00977.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Vicini F, Beitsch P, Quiet C, Gittleman M, Zannis V, Fine R, Whitworth P, Kuerer H, Haffty B, Keisch M, Lyden M. Five-year analysis of treatment efficacy and cosmesis by the American Society of Breast Surgeons MammoSite Breast Brachytherapy Registry Trial in patients treated with accelerated partial breast irradiation. Int J Radiat Oncol Biol Phys 2010; 79:808-17. [PMID: 20472364 DOI: 10.1016/j.ijrobp.2009.11.043] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 11/02/2009] [Accepted: 11/16/2009] [Indexed: 12/18/2022]
Abstract
PURPOSE To present 5-year data on treatment efficacy, cosmetic results, and toxicities for patients enrolled on the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. METHODS AND MATERIALS A total of 1440 patients (1449 cases) with early-stage breast cancer receiving breast-conserving therapy were treated with the MammoSite device to deliver accelerated partial-breast irradiation (APBI) (34 Gy in 3.4-Gy fractions). Of 1449 cases, 1255 (87%) had invasive breast cancer (IBC) (median size, 10 mm) and 194 (13%) had ductal carcinoma in situ (DCIS) (median size, 8 mm). Median follow-up was 54 months. RESULTS Thirty-seven cases (2.6%) developed an ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial rate of 3.80% (3.86% for IBC and 3.39% for DCIS). Negative estrogen receptor status (p=0.0011) was the only clinical, pathologic, or treatment-related variable associated with IBTR for patients with IBC and young age (<50 years; p=0.0096) and positive margin status (p=0.0126) in those with DCIS. The percentage of breasts with good/excellent cosmetic results at 60 months (n=371) was 90.6%. Symptomatic breast seromas were reported in 13.0% of cases, and 2.3% developed fat necrosis. A subset analysis of the first 400 consecutive cases enrolled was performed (352 with IBC, 48 DCIS). With a median follow-up of 60.5 months, the 5-year actuarial rate of IBTR was 3.04%. CONCLUSION Treatment efficacy, cosmesis, and toxicity 5 years after treatment with APBI using the MammoSite device are good and similar to those reported with other forms of APBI with similar follow-up.
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Affiliation(s)
- Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48072, USA.
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Ahmed HM, DiPiro PJ, Devlin PM, Nguyen ML, Bellon JR. Mammographic Appearance Following Accelerated Partial Breast Irradiation by Using MammoSite Brachytherapy. Radiology 2010; 255:362-8. [DOI: 10.1148/radiol.10091625] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Skandarajah AR, Mann GB. Do all patients require radiotherapy after breast-conserving surgery? Cancers (Basel) 2010; 2:740-51. [PMID: 24281092 PMCID: PMC3835102 DOI: 10.3390/cancers2020740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 04/19/2010] [Accepted: 04/26/2010] [Indexed: 11/24/2022] Open
Abstract
Radiotherapy following breast conservation is routine in the treatment of breast cancer. This creates a large demand for radiotherapy services with implicit cost effects and potential morbidity to patients. Radiotherapy is administered to decrease local recurrence, but is radiotherapy required for all breast cancers? A literature search using the Medline and Ovid databases was conducted between 1965 and 2010 using the terms ‘role of radiotherapy’, ‘early breast cancer’, and omission of radiotherapy’. Papers with clinical trials published in English in adult humans were included. Fourteen randomized controlled trials were included. Local recurrence rates range from 0.8–35% in patients in whom radiotherapy was omitted. Low risk characteristics include older age, small tumor size, no lymphovascular invasion and low to moderate grade. At present, there is no clearly defined low risk group of patients in whom radiotherapy can be omitted.
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Affiliation(s)
- Anita R. Skandarajah
- Department of Surgery, The University of Melbourne, Parkville, 3050, Australia
- Author to whom correspondence should be addressed; E-Mail:
| | - G. Bruce Mann
- The Breast Service, The Royal Melbourne and Royal Women’s Hospital, Parkville 3050, Australia; E-Mail:
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Shaitelman SF, Vicini FA. Status of Accelerated Partial Breast Irradiation. CURRENT BREAST CANCER REPORTS 2010. [DOI: 10.1007/s12609-010-0011-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Dosimetric Improvements in Balloon Based Brachytherapy Using the Contura ® Multi-Lumen Balloon (MLB) Catheter to Deliver Accelerated Partial Breast Irradiation. J Contemp Brachytherapy 2010; 2:1-8. [PMID: 28031736 PMCID: PMC5183641 DOI: 10.5114/jcb.2010.13716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 03/15/2010] [Indexed: 11/17/2022] Open
Abstract
Purpose Preliminary dosimetric findings in patients managed with the Contura® Multi-Lumen Balloon (MLB) breast brachytherapy catheter to deliver accelerated partial breast irradiation (APBI) on a multi-institutional phase IV registry trial were reviewed. Material and methods CT-based 3D planning with dose optimization was performed for all patients. For the study, new ideal dosimetric goals were developed: 1) ≥ 95% of the prescribed dose (PD) covering ≥ 90% of the target volume (TV), 2) a maximum skin dose ≤ 125% of the PD, 3) maximum rib dose ≤ 145% of the PD, and 4) the V150 ≤ 50 cc and V200 ≤ 10 cc. The frequency of concurrently achieving these dosimetric goals using the Contura® MLB was investigated. Results 194 cases were evaluable. Employing the MLB, all ideal dosimetric criteria were achieved in 76% of cases. Evaluating dosimetric criteria separately, 90% and 89% of cases met the new ideal skin and rib dose criteria, respectively. In 96%, ideal TV coverage goals were achieved and in 96%, dose homogeneity criteria (V150 and V200) were met. For skin spacing ≥ 5-7 mm, the median skin dose was 121% of the PD and when < 5 mm, the median skin dose was 124.4%. For rib distancees < 5 mm, the median rib dose was reduced to 136.4% of the PD. For skin spacing < 7 mm and distance to rib < 5 mm, the median skin and rib doses were concurrently limited to 121% and 142.8% of the PD, respectively. Conclusions The Contura® MLB catheter provides potential improvements in dosimetric capabilities (i.e., reduced skin and rib doses and improved TV coverage) in many clinical scenarios.
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