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Sfarad HK, Allweis TM. Postoperative Complications Following Lumpectomy With Intraoperative X-Ray Radiation Therapy: A Retrospective Comparative Study. Clin Breast Cancer 2024; 24:237-242. [PMID: 38233254 DOI: 10.1016/j.clbc.2023.12.005] [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: 07/25/2023] [Revised: 10/28/2023] [Accepted: 12/16/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Lumpectomy with intraoperative radiation (IORT) is a relatively new modality for the treatment of early breast cancer. IORT delivers targeted radiation to the tumor bed and obviates the need for external beam radiation (EBRT) in 85% of the cases. IORT is being used increasingly around the world, however information regarding early and late postoperative complications associated with the procedure is limited. AIM To describe and compare complication rates after lumpectomy and IORT with those seen after lumpectomy and EBRT or lumpectomy alone. METHODS Clinical, demographic, and histopathological data were collected from electronic medical records and a retrospectively maintained database. Postoperative complications were compared for patients undergoing lumpectomy with IORT, lumpectomy with EBRT, and lumpectomy alone over the same period. RESULTS A total of 445 patients were included in the study: 113 underwent lumpectomy with IORT, 253 had lumpectomy followed by EBRT, and 79 had Lumpectomy alone. Postoperative seroma was documented in 74 patients (65%) after IORT,87 (34%) after EBRT, and 9 (11%) after lumpectomy alone (P = .000). Surgical site infection requiring antibiotic treatment was diagnosed in 26 patients (23%) after IORT, 38 (15%) after EBRT, and 5 (6%) after lumpectomy alone (P = .013). Postoperative erythema was documented in 39 patients (34%) after IORT, 40 (16%) after EBRT, and 5 (6%) after lumpectomy alone (P = .000). Postoperative minor complications such as scar and breast deformity, edema, Mondor's syndrome, and chronic tenderness, were documented in 62 patients (55%) after IORT, 119 (47%) after EBRT, and 13 (17%) after lumpectomy alone (P = .000). The average follow-up was 14 months. CONCLUSIONS IORT is associated with an increased rate of postoperative complications compared to EBRT or lumpectomy alone. Most complications are minor and transient. We hypothesize that the increased occurrence of complications may also be attributed to overreporting, which is associated with the introduction of a new technology. Educating physicians and patients about potential complications and their course may help establish expectations and improve the management of postoperative complications.
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Affiliation(s)
| | - Tanir M Allweis
- Department of Breast Surgery, Hadassah Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Silverstein MJ, Kim B, Lin K, Lloyd S, Snyder L, Khan S, Kramme K, Chen P. Risk-Adapted Intraoperative Radiation Therapy (IORT) for Breast Cancer: A Novel Analysis. Ann Surg Oncol 2023; 30:6079-6088. [PMID: 37464138 PMCID: PMC10495476 DOI: 10.1245/s10434-023-13897-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Randomized trials have shown that risk-adapted intraoperative radiation therapy (IORT) after breast-conserving surgery for low-risk breast cancer patients is a safe alternative to whole-breast radiation therapy (WBRT). The risk-adapted strategy allows additional WBRT for predefined high-risk pathologic characteristics discovered on final histopathology. The greater the percentage of patients receiving WBRT, the lower the recurrence rate. The risk-adapted strategy, although important and necessary, can make IORT appear better than it actually is. METHODS Risk-adapted IORT was used to treat 1600 breast cancers. They were analyzed by the intention-to-treat method and per protocol to better understand the contribution of IORT with and without additional whole-breast treatment. Any ipsilateral breast tumor event was considered a local recurrence. RESULTS During a median follow-up period of 63 months, local recurrence differed significantly between the patients who received local treatment and those who received whole-breast treatment. For 1393 patients the treatment was local treatment alone. These patients experienced 79 local recurrences and a 5-year local recurrence probability of 5.95 %. For 207 patients with high-risk final histopathology, additional whole-breast treatment was administered. They experienced two local recurrences and a 5-year local recurrence probability of 0.5 % (p = 0.0009). CONCLUSIONS Whole-breast treatment works well at reducing local recurrence, and it is a totally acceptable and necessary addition to IORT as part of a risk-adapted program. However, the more whole-breast treatment that is given, the more it dilutes the original plan of simplifying local treatment and the less we understand exactly what IORT contributes to local control as a stand-alone treatment.
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Affiliation(s)
- Melvin J Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA.
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Brian Kim
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Kevin Lin
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Shane Lloyd
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Katherine Kramme
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Peter Chen
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
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Jørgensen MG, Gözeri E, Petersen TG, Sørensen JA. Surgical-site infection is associated with increased risk of breast cancer-related lymphedema: A nationwide cohort study. Clin Breast Cancer 2023:S1526-8209(23)00085-X. [PMID: 37095025 DOI: 10.1016/j.clbc.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Surgical-site infection (SSI) is one of the most common short-term complications following breast cancer treatment and can inhibit lymphatic drainage. It is currently not known whether SSI increases the risk of long-term breast cancer-related lymphedema (BCRL). Thus, the objective of this study was to examine the association between surgical-site infection and the risk of BCRL METHODS: This nationwide study identified all patients treated for unilateral, primary invasive, nonmetastatic breast cancer in Denmark between January 1, 2007, and December 31, 2016 (n = 37,937). A redemption of antibiotics after breast cancer treatment was used as a disease proxy for SSI, included as a time-varying exposure. The risk of BCRL was analyzed up to 3 years after breast cancer treatment using multivariate Cox regression and adjusted for cancer treatment, demographics, comorbidities, and socioeconomic variables. RESULTS There were 10,368 (27.33%) patients with a SSI and 27,569 (72.67%) without a SSI (incidence rate per 100 patients, 33.10 (95%CI, 32.47-33.75). The BCRL incidence rate per 100 person-years for patients with SSI was 6.72 (95%CI: 6.41-7.05) and 4.86 (95%CI: 4.70-5.02) for patients without an SSI. There was an overall significant increased risk of BCRL in patients with an SSI (adjusted HR, 1.11; 95%CI: 1.04-1.17), with the highest risk 3 years after breast cancer treatment (adjusted HR, 1.28; 95%CI: 1.08-1.51) CONCLUSION: This large nationwide cohort study showed that SSI was associated with an overall 10% increased risk of BCRL. These findings may be used to identify patients at high risk of BCRL that would benefit from enhanced BCRL surveillance.
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Affiliation(s)
- Mads G Jørgensen
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
| | - Ebru Gözeri
- University of Copenhagen, Copenhagen, Denmark
| | - Tanja G Petersen
- OPEN, Open Patient data Explorative Network, Odense University Hospital, Odense, Denmark
| | - Jens A Sørensen
- Department of Plastic Surgery, Research Unit for Plastic Surgery, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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Anderson B, Arthur D, Hannoun-Levi JM, Kamrava M, Khan A, Kuske R, Scanderbeg D, Shah C, Shaitelman S, Showalter T, Vicini F, Wazer D, Yashar C. Partial breast irradiation: An updated consensus statement from the American brachytherapy society. Brachytherapy 2022; 21:726-747. [PMID: 36117086 DOI: 10.1016/j.brachy.2022.07.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques. METHODS Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed. RESULTS The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion. CONCLUSIONS This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities.
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Affiliation(s)
- Bethany Anderson
- Department of Human Oncology, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | | | - Atif Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert Kuske
- Arizona Breast Cancer Specialists, Scottsdale, AZ
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland, OH
| | - Simona Shaitelman
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Timothy Showalter
- Department of Radiation Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | | | - David Wazer
- Department of Radiation Oncology, Tufts Medical Center, Boston, MA
| | - Catheryn Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA
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Silverstein MJ, Epstein MS, Chen P, Lin K, Khan S, Snyder L, Coleman C, Guerra L, Dehkordi-Vakil F, Kim B. Recurrence and Survival Rates for 1400 Early Breast Tumors Treated with Intraoperative Radiation Therapy (IORT). Ann Surg Oncol 2022; 29:3726-3736. [PMID: 35066721 PMCID: PMC8783657 DOI: 10.1245/s10434-021-11295-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/14/2021] [Indexed: 01/01/2023]
Abstract
Introduction Intraoperative radiotherapy (IORT) permits accurate delivery of radiation therapy directly to the tumor bed. We report local, regional, and distant recurrence data along with overall and breast cancer-specific survival for 1400 tumors treated with x-ray IORT. Methods A total of 1367 patients with 1400 distinct tumors were enrolled in a registry trial. All received breast conservation surgery and low-energy 50 kV x-ray IORT. To be eligible for excision plus IORT as the only local treatment, histopathology had to confirm tumor size ≤30 mm, margins ≥2 mm, negative lymph nodes, and no extensive lymphovascular invasion. Patients who failed any parameters were referred for additional surgery and/or whole breast radiation therapy (WBRT). Results There were 64 ipsilateral local recurrences, 60 were in the IORT only group, 7 axillary recurrences, and 7 distant recurrences. Forty-one local recurrences were within the same quadrant as the index cancer. Twenty-three were in different quadrants. With 62 months of median follow-up, the 5-year Kaplan–Meier probability of any event for all 1400 tumors was 5.27%. For 1175 patients who received IORT only, it was 5.98%. For favorable subtypes, it ranged from 2.41 to 4.31%. Multivariate analysis revealed that biologic subtype luminal A and the addition of WBRT significantly reduced the risk of local recurrence. Conclusions The local, regional, and distant recurrence rates observed were comparable to those reported in the literature for IORT but higher than those reported for standard forms of WBRT, hypofractionated treatment, or APBI. IORT benefits include convenience, decreased exposure to medical environments, and low complication rates.
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Affiliation(s)
- Melvin J Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA.
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA.
| | - Melinda S Epstein
- Hoag Department of Clinical Research, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Peter Chen
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Kevin Lin
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, 90033, USA
| | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Colleen Coleman
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Lisa Guerra
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
| | - Farideh Dehkordi-Vakil
- Center for Statistical Consulting, University of California, Irvine, Irvine, CA, 92697, USA
| | - Brian Kim
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, 92663, USA
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Silverstein MJ, Epstein MS, Chen P, Lin K, Kim B. ASO Author Reflections: 1400 IORT Cases—A Christmas Miracle. Ann Surg Oncol 2022; 29:3737-3738. [DOI: 10.1245/s10434-021-11319-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 11/18/2022]
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Vicini F, Broughman J, Halima A, Mayo Z, Obi E, Al-Hilli Z, Arthur D, Wazer D, Shah C. Delivery of Adjuvant Radiation in 5 Days or Less After Lumpectomy for Breast Cancer: A Systematic Review. Int J Radiat Oncol Biol Phys 2021; 112:1090-1104. [PMID: 34921906 DOI: 10.1016/j.ijrobp.2021.11.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Recent data have been published supporting the application of ultra-short radiation therapy (RT) regimens for women with early stage breast cancer following breast conserving surgery (BCS). What has remained controversial is whether and how to apply accelerated whole breast irradiation (AWBI) or accelerated partial breast irradiation (APBI) approaches in these patients, as well as the consideration of intraoperative RT (IORT) for this population. METHODS We performed a systematic review of the literature searching for randomized and prospective data published evaluating ultra-short RT delivered in 5-days or less with APBI, AWBI, or IORT. RESULTS We identified two randomized studies applying AWBI (n=5,011 patients) with 5 to 10 year follow up, which supported the use of ultra-short course AWBI (5 fractions in one week) as compared to hypofractionated WBI. We identified six randomized trials evaluating APBI (as compared to WBI) in 5 days or less (n= 8,415) with numerous (n=55) prospective studies as well, with the data supporting short course APBI as compared to WBI. Finally, we identified two randomized trials evaluating IORT; however, both trials demonstrated elevated rates of recurrence with IORT as compared to WBI. CONCLUSIONS The current body of data available for ultra-short adjuvant RT regimens delivered in 5-days or less after BCS overwhelming support their utilization. While data for both exists, APBI regimens have, by far, greater numbers of patients and longer follow-up as compared to AWBI. Also, given increased rates of recurrence seen with IORT with long-term follow-up, this should not be considered a standard approach at this time.
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Affiliation(s)
| | - James Broughman
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ahmed Halima
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zachary Mayo
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Obi
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Zahraa Al-Hilli
- Department of General Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas Arthur
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - David Wazer
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
| | - Chirag Shah
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
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Chi MS, Ko HL, Chen CC, Hsu CH, Chen LK, Cheng FTF. Single institute experience of intraoperative radiation therapy in early-stage breast cancer. Medicine (Baltimore) 2021; 100:e27842. [PMID: 34797318 PMCID: PMC8601266 DOI: 10.1097/md.0000000000027842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 11/01/2021] [Indexed: 01/05/2023] Open
Abstract
Intraoperative radiation therapy (IORT) is an alternative to whole breast irradiation in selected early-stage breast cancer patients. In this single institute analysis, we report the preliminary results of IORT given by Axxent Electronic Brachytherapy (eBT) system.Patients treated with lumpectomy and eBT within a minimum follow-up period of 12 months were analyzed. Eligible criteria include being over the age of 45, having unifocal invasive ductal carcinoma (IDC) or ductal carcinoma in situ <3 cm in diameter, not exhibiting lymph node involvement on preoperative images, and negative sentinel lymph node biopsy. The eBT was given by preloaded radiation plans to deliver a single fraction of 20 Gray (Gy) right after lumpectomy.From January 2016 to April 2019, a total of 103 patients were collected. There were 78 patients with IDC and 25 with ductal carcinoma in situ. At a mean follow-up time of 31.1 months (range, 14.5-54.0 months), the local control rate was 98.1%. Two IDC patients had tumor recurrences (1 local and 1 regional failure). Post-IORT radiotherapy was given to 4 patients. There were no cancer related deaths, no distant metastases, and treatment side effects greater than grade 3 documented.We report the largest single institute analysis using the eBT system in Taiwan. The low recurrence and complication rates at a 31.1 month follow-up time support the use of the eBT system in selected early-stage breast cancer patients.
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MESH Headings
- Aged
- Aged, 80 and over
- Brachytherapy
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Follow-Up Studies
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local
- Treatment Outcome
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Affiliation(s)
- Mau-Shin Chi
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Hui-Ling Ko
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chang-Cheng Chen
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chung-Hsien Hsu
- Department of Radiation Therapy and Oncology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Liang-Kuang Chen
- Department of Diagnostic Radiology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Fiona Tsui-Fen Cheng
- Department of General Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
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Jambhekar A, Wong A, Taback B, Rao R, Horowitz D, Connolly E, Wiechmann L. Complication Rates After IntraOperative Radiation Therapy: Do Applicator Size and Distance to Skin Matter? J Surg Res 2021; 268:440-444. [PMID: 34416416 DOI: 10.1016/j.jss.2021.06.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/02/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intraoperative radiation therapy (IORT) has gained popularity for early stage breast cancer treatment. Few studies have examined the relationship between complications and both demographic and technical factors. The objective of the current study was to determine if applicator size or distances to the skin were significant risk factors for complications. METHODS Data was prospectively collected on patients who underwent lumpectomy followed by IORT from November 1, 2013 to August 31, 2018. Exclusion criteria included any prior radiation exposure or personal history of breast cancer. Comorbid conditions such as body mass index, diabetes, and smoking as well as technical specifications such as applicator size and distances to the skin were included for investigation. Student's t-test, Fisher's exact test, and odds ratios were utilized for statistical analysis. RESULTS The study was comprised of 219 patients. None developed Clavien-Dindo grade 2 or above complications. Of 21.0% (n = 46) had minor complications. The most common complication was a palpable breast seroma (n = 37). Diabetes was the only comorbid condition with increased risk for complications (OR 3.2; 95% CI1.3-7.5; P = 0.008). The applicator sizes and average skin distances were similar between groups. Surprisingly, the closest skin distance was not a significant risk factor for post-operative complications (1.4 +/- 1.6 versus 1.4 +/- 1.9 cm; P = 1.0). CONCLUSION Neither applicator size nor the closest skin distance were associated with increased complications. Traditionally described risk factors such as BMI and smoking were not predictive. This data provides support for potentially expanding the utilization for IORT without increasing complications.
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Affiliation(s)
- Amani Jambhekar
- Breast Surgery Division, Columbia University Medical Center, New York, New York
| | - Abby Wong
- Breast Surgery Division, Columbia University Medical Center, New York, New York
| | - Bret Taback
- Breast Surgery Division, Columbia University Medical Center, New York, New York
| | - Roshni Rao
- Breast Surgery Division, Columbia University Medical Center, New York, New York
| | - David Horowitz
- Breast Surgery Division, Columbia University Medical Center, New York, New York
| | - Eileen Connolly
- Breast Surgery Division, Columbia University Medical Center, New York, New York
| | - Lisa Wiechmann
- Breast Surgery Division, Columbia University Medical Center, New York, New York.
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Utilization of Forearm Crutches to Avoid Lymphedema After Breast Cancer Lymph Node Surgery. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2021. [DOI: 10.1097/jat.0000000000000180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lalchandani P, Sila C, Ozao-Choy J, Dauphine C. Initiation of an Intraoperative Radiotherapy Program at a Safety net Hospital: What Is the Impact of an Intraoperative Radiotherapy Program in Underserved Patients With Early Breast Cancer? Am Surg 2020; 87:833-838. [PMID: 33228433 DOI: 10.1177/0003134820956351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Intraoperative radiotherapy (IORT) can allow for single-dose radiation treatment following breast conservation therapy in low-risk patients with early breast cancer, in lieu of a traditional 6-week course of whole breast radiotherapy (WBRT). The objective of this study was to analyze the uptake and utilization of an IORT program in a safety-net hospital. MATERIALS AND METHODS A retrospective review was conducted for all patients who underwent IORT from September 2014 to June 2018. Patient demographics, tumor characteristics, and IORT outcomes were analyzed. The proportion of patients undergoing IORT were determined to assess utilization and uptake. RESULTS There were 27 female patients that received IORT, 23 (85.2%) of which required no further radiotherapy. Three (7.4%) patients had positive axillary lymph nodes and/or positive margins requiring subsequent WBRT. One patient (3.7%) developed an in-breast recurrence distant from the lumpectomy site 23 months after IORT. Ten patients (37.0%) developed a postoperative complication, including 5 seromas and 6 wound complications (superficial infections and/or wound necrosis). Overall, in the 46-month study period, IORT accounted for only 6.4% of 423 operations. Still, 27 of 29 (93.1%) patients who met eligibility criteria for IORT underwent the procedure. DISCUSSION Although IORT comprised only 6.4% of all cases due to higher rates of mastectomy rates and advanced disease in our population, there was a high uptake of IORT among patients who met eligibility criteria for the procedure. Major complication rates of IORT were low, and most patients successfully completed radiotherapy in 1 intraoperative dose.
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Affiliation(s)
- Priti Lalchandani
- Department of Surgery, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Chad Sila
- Department of Radiology, Division of Radiation Oncology, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Junko Ozao-Choy
- Department of Surgery, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Christine Dauphine
- Department of Surgery, David Geffen School of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
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12
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Post IORT seroma complication in breast cancer surgery. JOURNAL OF RADIOTHERAPY IN PRACTICE 2020. [DOI: 10.1017/s1460396920000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Intraoperative radiotherapy (IORT) has gained popularity over recent years due to its impact on shortening the radiotherapy treatment time for early breast cancer. It has certainly proven effective as an exclusive treatment or when combined with whole breast irradiation (WBIR). Seroma is a common non-life-threatening complication that may delay treatment and impose challenges on radiological diagnostic follow-up.Aim:To review and compare the occurrence of seroma in patients who received exclusive IORT or when combined with WBIR and to outline the diagnostic challenges encountered during radiological follow-up.Materials and methods:Based on strict selection criteria, all eligible patients who received IORT ± WBIR treatment between 2012 and 2019 in a university hospital setting were included. Demographic data, histological diagnosis, tumour size, tumour grade, lymphovascular invasion, nodal status, receptor status, treatment with neoadjuvant hormonal chemotherapy, applicator size, dose used, duration of radiotherapy treatment, timing of seroma development and duration of seroma were documented. Both clinical and radiological follow-up were exercised in all patients.Results:The total number of patients treated with breast conserving surgery (BCS) and IORT was 86. Age ranged between 31 and 75 years with the median age of 51 years. Patients treated exclusively with IORT were 39 (45%) while those who received the IORT as a boost were 47 (55%). Seroma was observed in 39(45%) of both IORT and IORT\WBIR patients. Those included 15(38%) of the exclusive IORT treated patients and 24 (62%) of those treated as a boost. Duration of asymptomatic seroma ranged from 6 months to 6 years. Repeated aspiration was performed in 2 (5%) patients. Postoperative seroma occurred independent of age histological diagnosis, tumour size, tumour grade, lymphovascular invasion, nodal status, receptor status, treatment with neoadjuvant hormonal\chemotherapy, applicator size, dose used or duration of radiotherapy treatment. All reviewed patients have shown increased risk of developing seroma; however, an increased incidence of seroma in the IORT + WBIR treated patients was higher than those who received exclusive IORT treatment.Conclusion:Postoperative seroma is a common non-life-threatening entity that occasionally may lead to delay in the subsequent treatment plan. IORT is a safe modality with many benefits; however, it may increase the risk of seroma formation independent of the clinical parameters. Promoting the expertise in post IORT breast imaging aids in overcoming diagnostic challenges.
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Tejera Hernández AA, Vega Benítez VM, Rocca Cardenas JC, Ortega Pérez N, Rodriguez Ibarria N, Díaz Chico JC, García-Granados Alayón JJ, Pérez Correa P, Hernández Hernández JR. Complications and local relapse after intraoperative low-voltage X-ray radiotherapy in breast cancer. Ann Surg Treat Res 2020; 98:299-306. [PMID: 32528909 PMCID: PMC7263891 DOI: 10.4174/astr.2020.98.6.299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/08/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose To study those factors that influence the occurrence of surgical complications and local relapse in patients intervened for breast cancer and receiving intraoperative radiotherapy. Methods Observational study on patients intervened for breast cancer with conservative surgery and intraoperative radiotherapy with low-voltage X-ray energy source (INTRABEAM), from 2015 to 2017 with 24 months minimum follow-up. Variables possibly associated to the occurrence of postoperative complications were analyzed with the Student t-test and the Fisher exact test; P < 0.05 considered significant. Subsequently, the construction of multiple multivariate analysis models began, thus building a logistic regression analysis using the IBM SPSS Statistics ver. 23 software. Local relapse was described. Results The study included 102 patients, mean age of 61.2 years; mean global size of tumor, 12.2 mm. Complications occurred in 29.4%. Fibrosis was the most frequently observed complication, followed by postoperative seroma. Using a 45 mm or larger applicator were significantly associated with the occurrence of complications. Tumor size 2 cm or larger and reintervention showed borderline significant association. Only one case of local relapse was observed. Conclusion Certain factors may increase the risk of complication after the use of intraoperative radiotherapy. Using external complementary radiotherapy does not seem to increase the rate of complications. Select patients and the involvement of a multidisciplinary team are essential for achieving good results.
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Affiliation(s)
- Ana Alicia Tejera Hernández
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,General Surgery Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Víctor Manuel Vega Benítez
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,General Surgery Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | - Neith Ortega Pérez
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,General Surgery Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Nieves Rodriguez Ibarria
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,Therapeutic Radiation and Oncology Department, Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas, Spain
| | | | - Juan José García-Granados Alayón
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,Service of Radiophysics and Radiological Protection, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
| | - Pedro Pérez Correa
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,General Surgery Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Juan Ramón Hernández Hernández
- Faculty of Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas, Spain.,General Surgery Department, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
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Silverstein MJ. Elevating your breast program to the next level. Breast J 2020; 26:5-10. [PMID: 31960552 DOI: 10.1111/tbj.13721] [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: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/27/2022]
Abstract
This paper describes a series of steps taken to elevate the Hoag Breast Program to the next level. The hope is that some of our ideas will be useful to you and your breast program.
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The American Brachytherapy Society consensus statement for electronic brachytherapy. Brachytherapy 2019; 18:292-298. [DOI: 10.1016/j.brachy.2018.10.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
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Risk analysis of electronic intraoperative radiation therapy for breast cancer. Brachytherapy 2019; 18:271-276. [DOI: 10.1016/j.brachy.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 11/22/2022]
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Application of 21-gene recurrence score results and ASTRO suitability criteria in breast cancer patients treated with intraoperative radiation therapy (IORT). Am J Surg 2018; 216:689-693. [DOI: 10.1016/j.amjsurg.2018.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/29/2018] [Accepted: 07/14/2018] [Indexed: 11/20/2022]
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Silverstein MJ, Epstein M, Kim B, Lin K, Khan S, Snyder L, Guerra L, Coleman C, Chen P. Intraoperative Radiation Therapy (IORT): A Series of 1000 Tumors. Ann Surg Oncol 2018; 25:2987-2993. [PMID: 29968030 DOI: 10.1245/s10434-018-6614-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Two prospective, randomized trials, TARGIT-A and ELIOT, have shown intraoperative radiation therapy to be a safe alternative, with a low-risk of local recurrence, compared with whole breast radiation therapy, following breast-conserving surgery, for selected low-risk patients. We report the first 1000 tumors treated with this modality at our facility. METHODS A total of 1000 distinct breast cancers in 984 patients (16 bilateral) were treated with breast conserving surgery and X-ray IORT from June 2010 to August 2017. Patients were enrolled in an IORT registry trial. Local recurrence was the primary endpoint. RESULTS There have been 28 ipsilateral local recurrences, ten DCIS and 18 invasive. Four local recurrences were within the IORT field, 13 outside of the IORT field but within the same quadrant as the index cancer, and 11 were new cancers in different quadrants. There have been four regional nodal recurrences and one distant recurrence. There have been no breast cancer related deaths and 14 non-breast cancer deaths. With a median follow-up of 36 months, Kaplan-Meier analysis projects 3.9% of patients will recur locally at 4 years. This includes all ipsilateral events in all quadrants. CONCLUSIONS The local, regional, and distant recurrence rates observed in this trial were comparable to those of the prospective randomized TARGIT-A and ELIOT trials. The low complication rates previously reported by our group as well as the low recurrence rates reported in this study support the cautious use and continued study of X-ray IORT in women with low-risk breast cancer.
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Affiliation(s)
- Melvin J Silverstein
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA. .,Keck School of Medicine, University of Southern California, Los Angeles, USA.
| | - Melinda Epstein
- Department of Clinical Research, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Brian Kim
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Kevin Lin
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Sadia Khan
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Lincoln Snyder
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Lisa Guerra
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Colleen Coleman
- Department of Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Peter Chen
- Department of Radiation Oncology, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
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Shao S, Gao Y, Liu J, Tian M, Gou Q, Su X. Ferulic Acid Mitigates Radiation Injury in Human Umbilical Vein Endothelial Cells In Vitro via the Thrombomodulin Pathway. Radiat Res 2018; 190:298-308. [DOI: 10.1667/rr14696.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Shuai Shao
- National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, Beijing 100088, China
| | - Yue Gao
- Beijing Institute of Radiation Medicine, Beijing 100850, China
| | - Jianxiang Liu
- National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, Beijing 100088, China
| | - Mei Tian
- National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, Beijing 100088, China
| | - Qiao Gou
- National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, Beijing 100088, China
| | - Xu Su
- National Institute for Radiological Protection, Chinese Center for Disease Control and Prevention, Beijing 100088, China
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Acute toxicity of intraoperative radiotherapy and external beam-accelerated partial breast irradiation in elderly breast cancer patients. Breast Cancer Res Treat 2018; 169:549-559. [PMID: 29460031 PMCID: PMC5953978 DOI: 10.1007/s10549-018-4712-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/03/2018] [Indexed: 12/27/2022]
Abstract
Background and purpose We investigated the acute toxicity of accelerated partial breast irradiation using external beam (EB-APBI) or intraoperative radiotherapy (IORT) techniques in elderly breast cancer patients. Materials and methods Women ≥ 60 years with unifocal breast tumors of ≤ 30 mm were eligible for this prospective multi-center cohort study. IORT was applied with electrons following lumpectomy (23.3 Gy). EB-APBI was delivered using 3D-CRT or IMRT in 10 daily fractions of 3.85 Gy within 6 weeks after surgery. Acute toxicity was scored using the CTCAE v3.0 at 3 months after treatment. Patient-reported symptoms were analyzed using visual analogue scales (VAS) for pain and fatigue (scale 0–10), and single items from the EORTC QLQ-C30 and Breast Cancer questionnaires. Results In total, 267 (IORT) and 206 (EB-APBI) patients were available for toxicity analysis. More patients experienced ≥ grade 2 CTCAE acute toxicity in the IORT group (10.4% IORT and 4.9% EB-APBI; p = 0.03); grade 3 toxicity was low (3.3% IORT and 1.5% EB-APBI; ns); and no grade 4 toxicity occurred. EB-APBI patients experienced less fatigue direct postoperatively (EORTC p < 0.00, VAS p < 0.00). After 3 months only pain, according to the VAS scale, was significantly worse in the EB-APBI group (p < 0.00). Conclusion Acute toxicity after IORT and EB-APBI treatment is acceptable.
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The American Brachytherapy Society consensus statement for accelerated partial-breast irradiation. Brachytherapy 2018; 17:154-170. [DOI: 10.1016/j.brachy.2017.09.004] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/11/2017] [Accepted: 09/18/2017] [Indexed: 12/29/2022]
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Silverstein MJ, Epstein MS, Lin K, Chen P, Khan S, Snyder L, Guerra LE, De Leon C, Mackintosh R, Coleman C, Lopez J, Kim B. Intraoperative Radiation Using Low-Kilovoltage X-Rays for Early Breast Cancer: A Single Site Trial. Ann Surg Oncol 2017; 24:3082-3087. [DOI: 10.1245/s10434-017-5934-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/25/2022]
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Kim Y, Huynh JWY, Gonzalez VJ. Evaluation of impact of an external breast shield (FlexiShield) in electronic brachytherapy for breast IORT: A phantom study. Brachytherapy 2017; 16:597-607. [PMID: 28237430 DOI: 10.1016/j.brachy.2017.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 01/18/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate Axxent (iCAD, Inc., San Jose, CA) electronic brachytherapy balloon deformation and its dosimetric impact because of an external flexible shield (FlexiShield [FS]; iCAD, Inc.). METHODS AND MATERIALS Prostheses breast tissue phantom overlaid three spherical balloon applicators to simulate three clinical scenarios depending on minimum skin-to-balloon surface spacing (SS): balloon with SS of 2 cm, 1 cm, and balloon with 1 cm SS and touching the chest wall. Two sets of megavoltage CT (MVCT) scans were obtained with or without FS for 15 different sizes of balloons. For 45 pairs of MVCT scans, balloon deformation was measured in superior-inferior (dSI) dimension on coronal and sagittal planes and anterior-posterior (dAP) and lateral (dLAT) dimensions on the equatorial plane of balloon. SS was also compared. A treatment plan was made on each MVCT scan. Doses at four balloon surface points and skin were compared. Conformity index value was also compared to evaluate three-dimensional dose distribution. Clinically, 20 Gy was prescribed to the surface of balloon. RESULTS Balloon deformation was observed with compression in SI and AP dimensions and expansion in lateral dimension. Average SI compression was 0.5 mm. Average dLat - dAP was 2.4 mm, which resulted in elevated point doses at AP dimension by 10.8% of prescribed dose and reduced point doses at lateral dimension by 4.6%. FS decreased SS by 1.8 mm, increasing skin dose by 1.2 Gy, on average. Conformity index value was decreased from 0.922 to 0.908, on average. CONCLUSIONS This phantom study demonstrates that use of skin shielding during breast intraoperative radiation therapy can cause balloon deformation and SS reduction, resulting in dosimetric changes that are disregarded in current practice.
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Affiliation(s)
- Yongbok Kim
- Department of Radiation Oncology, The University of Arizona, Tucson, AZ.
| | | | - Victor J Gonzalez
- Department of Radiation Oncology, The University of Arizona, Tucson, AZ
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Abstract
Solid tumors are much more common than hematologic malignancies. Although severe and prolonged neutropenia is uncommon, several factors increase the risk of infection in patients with solid tumors, and the presence of multiple risk factors in the same patient is not uncommon. These include obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces, and treatment-related factors such as chemotherapy, radiation, diagnostic and/or therapeutic surgical procedures, and the increasing use of medical devices such as various catheters, stents, and prostheses. Common sites of infection include the skin and skin structures (including surgical site infections), the bloodstream (including infections associated with central venous catheters), the lungs, the hepato-biliary and intestinal tracts, and the urinary tract, and include distinct clinical syndromes such as post-obstructive pneumonia, obstructive uropathy, and neutropenic enterocolitis. The epidemiology of most of these infections is changing with resistant organisms [MRSA, Pseudomonas aeruginosa, extended spectrum beta-lactamase (ESBL)-producing organisms] being isolated more often than in the past. Polymicrobial infections now predominate when deep tissue sites are involved. Conservative management of most of these infections (antibiotics, fluid and electrolyte replacement, bowel rest when needed) is generally effective, with surgical intervention being reserved for the drainage of deep abscesses, or to deal with complications such as intestinal obstruction or hemorrhage. Infected prostheses often need to be removed. Reactivation of certain viral infections (HBV, HCV, and occasionally CMV) has become an important issue, and screening, prevention and treatment strategies are being developed. Infection prevention, infection control, and antimicrobial stewardship are important strategies in the overall management of infections in patients with solid tumors. Occasionally, infections mimic solid tumors and cause diagnostic and therapeutic challenges.
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