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Tang R, Li A, Li Y, Deng G, Wang Y, Xiao Q, Zhang L, Luo Y. Dosimetric comparison of two dose expansion methods in intensity modulated radiotherapy for breast cancer. Radiat Oncol 2023; 18:23. [PMID: 36737788 PMCID: PMC9898932 DOI: 10.1186/s13014-023-02217-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To explore the dosimetric difference between IMRT-VB plan based on the establishment of external expansion structure and virtual bolus (VB) and IMRT-SF based on the skin flash (SF) tool of the Eclipse treatment planning system in postoperative chest wall target intensity modulation radiotherapy plan of breast cancer. METHODS Twenty patients with breast cancer were randomly selected as subjects to develop IMRT-VB plan based on virtual bolus and IMRT-SF plan based on skin flash tool of Eclipse treatment planning system. The planning target volume, monitor unit (MU) of every single treatment and the dosimetric parameters of organ at risk (OARs) were recorded. Paired t-test was used for normal distribution data while nonparametric paired Wilcoxon rank sum test was used for non-normal distribution data. RESULTS Both IMRT-VB and IMRT-SF plan can expand outward to the chest wall skin and meet the dose requirements of clinical prescription. The conformal index, the homogeneity index, D2%, D98% and D50% were significantly better in IMRT-SF plan than those in IMRT-VB plan (P < 0.05). The average MU of the IMRT-SF plan was much higher than that of the IMRT-VB plan (866.0 ± 68.1 MU vs. 760.9 ± 50.4 MU, P < 0.05). In terms of organ at risk protection, IMRT-SF plan had more advantages in the protection of ipsilateral lung and spinal cord than IMRT-VB plan (P < 0.05). CONCLUSION Our study indicated that IMRT-SF plan displayed clinical application superiority compared to IMRT-VB plan, and the operation steps of which are simpler and faster. Besides, IMRT-SF plan took advantages in achieve effective external expansion of skin dose intensity and OARs protection.
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Affiliation(s)
- Ran Tang
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Aimin Li
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Yingjing Li
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Guanhua Deng
- grid.490151.8Guangdong 999 Brain Hospital, Guangzhou, 510510 China
| | - Yufeng Wang
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Qing Xiao
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Luosheng Zhang
- grid.284723.80000 0000 8877 7471Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315 Guangdong China ,grid.284723.80000 0000 8877 7471Cancer Center, Southern Medical University, Guangzhou, 510315 China
| | - Yue Luo
- Integrated Hospital of Traditional Chinese Medicine, Southern Medical University, No.13 Shiliugang Road, Guangzhou, 510315, Guangdong, China. .,Cancer Center, Southern Medical University, Guangzhou, 510315, China.
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Ertan F, Sahin S, Azak C, Karakaya E, Altundag MB, Goksel F. Evaluation of the voluntary deep inspiration breath-hold reproducibility in left-sided breast radiotherapy. JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2022; 30:1057-1066. [PMID: 36155488 DOI: 10.3233/xst-221228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE Voluntary deep inspiration breath hold (v-DIBH) reduces cardiac dose during left-sided breast irradiation. The purpose of this study is to evaluate the reproducibility and variability of breath-hold level (BHL) using breath-hold curves and lateral kV setup images together. MATERIAL/METHOD A retrospective analysis of 30 left breast cancer patients treated using the v-DIBH technique in our department is performed. The BHL difference is measured from breath hold curves and lateral (LAT) kilo-Voltage (kV) setup images. The planning CT image and the selected treatment fraction data are collected. If the changes in BHL relate to the displacement of various bones in the kV setup, images are assessed. Furthermore, the maximum heart distance inside the treatment field is compared from LAT MV portal images. RESULTS The median and mean values of the BHL are nearly identical in different fractions (good reproducibility). However, the mean BHL values between planning and all measured fractions are statistically different; 16.3 vs. 20.8 mm for the planning and measured fractions (p < 0.001), which indicates that the variability of BHL is significantly different. CONCLUSION While reproducibility testing shows good agreement for inter-fractional breath-hold level, the variability between planning and fractions is relatively poor.
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Affiliation(s)
- Ferihan Ertan
- Dr. Abdurrahman Yurtaslan Ankara Oncology Teachingand Research Hospital, 06200, Ankara, Turkey
| | - Serdar Sahin
- Dr. Abdurrahman Yurtaslan Ankara Oncology Teachingand Research Hospital, 06200, Ankara, Turkey
| | - Can Azak
- Dr. Abdurrahman Yurtaslan Ankara Oncology Teachingand Research Hospital, 06200, Ankara, Turkey
| | - Ebru Karakaya
- Dr. Abdurrahman Yurtaslan Ankara Oncology Teachingand Research Hospital, 06200, Ankara, Turkey
| | - Muzaffer Bedri Altundag
- Dr. Abdurrahman Yurtaslan Ankara Oncology Teachingand Research Hospital, 06200, Ankara, Turkey
| | - Fatih Goksel
- Dr. Abdurrahman Yurtaslan Ankara Oncology Teachingand Research Hospital, 06200, Ankara, Turkey
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Hongo H, Tokuue K, Sakae T, Mase M, Omura M. Robust Treatment Planning in Intrafraction Motion Using TomoDirect™ Intensity-modulated Radiotherapy for Breast Cancer. In Vivo 2021; 35:2655-2659. [PMID: 34410953 DOI: 10.21873/invivo.12548] [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: 05/06/2021] [Revised: 05/25/2021] [Accepted: 06/11/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM To evaluate the robustness of radiotherapy treatment planning optimization for respiratory-moving breast cancer using fixed-angle beams planning TomoDirect™ intensity-modulated radiotherapy (IMRT). MATERIALS AND METHODS A minimax optimisation algorithm was applied to 10 breast cancer patients. Two sets of treatment plans with or without robust techniques were prepared considering anterior-posterior and head-tail movements due to respiration. Parameters were compared between treatment plans: 95% planned target volume (PTV) dose, conformal index and homogeneity index (HI), and organs at risk (OAR) parameters including the lung volume receiving 20 Gy or more (V20) and 5 Gy (V5). RESULTS Robust planning significantly improved parameters of 95% PTV dose and HI, without deteriorating V20 or V5 in the anterior-posterior movement, while it slightly improved 95% PTV and slightly deteriorated V20 in the head-tail movement. CONCLUSION Robust treatment planning improves coverage of targets moving because of respiration in the treatment of breast cancer using TomoDirect; however, normal lung doses should be cautiously evaluated on a case-by-case basis.
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Affiliation(s)
- Hideyuki Hongo
- Department of Radiation Oncology, Shonan Kamakura General Hospital, Kanagawa, Japan; .,Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
| | - Koichi Tokuue
- Department of Radiation Oncology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | | | - Misato Mase
- Department of Radiation Oncology, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Motoko Omura
- Department of Radiation Oncology, Shonan Kamakura General Hospital, Kanagawa, Japan
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Wang L, Qiu G, Yu J, Zhang Q, Man L, Chen L, Zhang X, Ren Q, Xu H, Hua X. Effect of auto flash margin on superficial dose in breast conserving radiotherapy for breast cancer. J Appl Clin Med Phys 2021; 22:60-70. [PMID: 34028963 PMCID: PMC8200433 DOI: 10.1002/acm2.13287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 02/15/2021] [Accepted: 04/25/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose To investigate the dose‐effect of Auto Flash Margin (AFM) on breast cancer's superficial tissues based on the Treatment Planning System (TPS) in the breast‐conserving radiotherapy plan. Methods A total of 16 breast‐conserving patients with early stage breast cancer were selected, using the X‐ray Voxel Monte Carlo (XVMC) algorithm. Then, every included case plan was designed using a 2 cm‐AFM (the value of AFM is 2 cm) and N‐AFM (without AFM). Under the condition of ensuring the same configuration of #MU and collimator, the absorbed dose after a simulated inspiratory motion was calculated again using the new plan center, which moved backward to the linac source. The dose difference between the measurement points between AFM and N‐AFM groups was compared. Results In the dose results, PTVV50Gy of the AFM group was superior to that of the N‐AFM group, PTVD2%, PTVDmean, Lung_IpsiV20Gy, Lung_IpsiDmean, and BodyDmax. Also, the dose results of the N‐AFM group were significantly higher than those of the AFM group. However, there was no significant difference between Lung_ContraV5Gy, HeartDmean, and Breast_ContraV10Gy in the two groups. In the collimator alignments at the same angle between groups, the AFM group formed an apparent air region outside the collimator compared with the N‐AFM group. In the XVMC algorithm feature parameter, the AFM group had less #MU, higher QE, and slightly longer optimization time. The #segments of both groups were close to the 240 control points preset by the plan. The validation results of EBT3 film in both groups were more significant than 95%, meeting the clinical plan's application requirements. The difference in film results between groups was mainly reflected in the dose distribution at the near‐source. 4DCT was used to summarize the maximum and minimum inspiratory motion distances of 7.31 ± 0.45 and 3.42 ± 0.91 mm respectively. Conclusions These results suggest that the AFM function application could significantly reduce the possibility of insufficient tumor target caused by inspiratory motion and ensure sufficient tumor target exposure.
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Affiliation(s)
- Lu Wang
- Department of Radiotherapy, Anshan Cancer Hospital, Anshan, Liaoning, China
| | - Gang Qiu
- Department of Oncology Ward 2, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Jianhe Yu
- Department of Oncology Ward 3, Xinghua People's Hospital, Taizhou, Jiangsu, China
| | - Qunhui Zhang
- Surgical oncology, Anshan Cancer Hospital, Anshan, Liaoning, China
| | - Li Man
- Medical oncology, Anshan Cancer Hospital, Anshan, Liaoning, China
| | - Li Chen
- Department of Radiotherapy, Anshan Cancer Hospital, Anshan, Liaoning, China
| | - Xiaoxiao Zhang
- Department of Radiotherapy, Anshan Cancer Hospital, Anshan, Liaoning, China
| | - Qun Ren
- Department of Oncology Ward 3, Xinghua People's Hospital, Taizhou, Jiangsu, China
| | - Hongxia Xu
- Department of Oncology Ward 3, Xinghua People's Hospital, Taizhou, Jiangsu, China
| | - Xiaolong Hua
- Department of Radiotherapy, Xinghua People's Hospital, Taizhou, Jiangsu, China
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Wang W, Yu T, Xu M, Shao Q, Zhang Y, Li J. Setup Error Assessment and Correction in Planar kV Image- Versus Cone Beam CT Image-Guided Radiation Therapy: A Clinical Study of Early Breast Cancer Treated With External Beam Partial Breast Irradiation. Technol Cancer Res Treat 2019; 18:1533033819853847. [PMID: 31159668 PMCID: PMC6552346 DOI: 10.1177/1533033819853847] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Objective: To compare differences in setup error assessment and correction between planar kilovolt images and cone beam computed tomography images for external beam partial breast irradiation during free breathing. Methods: Nineteen patients who received external beam partial breast irradiation after breast-conserving surgery were recruited. Interfraction setup error was acquired using planar kilovolt images and cone beam computed tomography. After online setup correction, the residual error was calculated, and the setup error was compared. The residual error and setup margin were quantified for planar kilovolt and cone beam computed tomography images. Results: The largest setup error was observed in the anteroposterior direction for both cone beam computed tomography and planar kilovolt imaging (−1.45 mm, 1.74 mm). The cone beam computed tomography–based setup error (systematic error [Σ]) was less than the planar kilovolt images based on Σ in the anteroposterior direction (–1.2 mm vs 2.00 mm; P = .005), and no significant differences were observed for random error (σ) in 3 dimensions (P = .948, .376, .314). After online setup correction, cone beam computed tomography significantly reduced the residual setup error compared with planar kilovolt images in the anteroposterior direction (Σ: −0.20 mm vs 0.50 mm, P = .008; σ: 0.45 mm vs 1.34 mm, P = .002). The cone beam computed tomography–based setup margin was smaller than the planar kilovolt image-based setup margin in the anteroposterior direction (−1.39 mm vs 5.57 mm, P = .003; 0.00 mm vs 3.20 mm, P = .003). Conclusions: Discrepancy between the setup errors observed with planar kilovolt and cone beam computed tomography was obvious in the anteroposterior direction. Compared to cone beam computed tomography, the elapsed treatment time was smaller when the initial alignment used kilovolt planar imaging. Whether using planar kilovolt or cone beam computed tomography, residual errors can be reduced to 1.5 mm for external beam partial breast irradiation procedures.
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Affiliation(s)
- Wei Wang
- 1 Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Ting Yu
- 1 Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China.,2 Department of Graduate School, Tianjin Medical University, Tianjin, China
| | - Min Xu
- 1 Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Qian Shao
- 1 Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Yingjie Zhang
- 1 Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Jianbin Li
- 1 Department of Radiation Oncology, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
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Antico M, Sasazawa F, Wu L, Jaiprakash A, Roberts J, Crawford R, Pandey AK, Fontanarosa D. Ultrasound guidance in minimally invasive robotic procedures. Med Image Anal 2019; 54:149-167. [DOI: 10.1016/j.media.2019.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/01/2019] [Accepted: 01/09/2019] [Indexed: 12/20/2022]
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Zhang HW, Hu B, Xie C, Wang YL. Dosimetric comparison of three intensity-modulated radiation therapies for left breast cancer after breast-conserving surgery. J Appl Clin Med Phys 2018. [PMID: 29524290 PMCID: PMC5978563 DOI: 10.1002/acm2.12287] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE This study aimed to evaluate dosimetric differences of intensity-modulated radiation therapy (IMRT) in target and normal tissues after breast-conserving surgery. METHODS IMRT five-field plan I, IMRT six-field plan II, and field-in-field-direct machine parameter optimization-IMRT plan III were designed for each of the 50 patients. One-way analysis of variance was performed to compare differences, and P < 0.05 was considered statistically significant. RESULTS Homogeneity index of plan III is lower than those of plans I and II. No difference was identified in conformity index of targets. Plan I exhibited difference in mean dose (Dmean ) for the heart (P < 0.05). Plan I featured smaller irradiation dose volumes in V5 , V20 (P < 0.05) of the left lung than II. Plan I exhibited significantly higher V5 in the right lung than plans II and III (P < 0.05). Under plan I, irradiation dose at V5 in the right breast is higher than that in plans II and III. Patients in plan III presented less total monitor unit and total treatment time than those in plans I and II (P < 0.05). CONCLUSION IMRT six-field plans II, and field-in-field-direct machine parameter optimization-IMRT plans III can reduce doses and volumes to the lungs and heart better while maintaining satisfying conformity index and homogeneity index of target. Nevertheless, plan II neglects target movements caused by respiration. In the same manner, plan III can substantially reduce MU and shorten patient treatment time. Therefore, plan III, which considers target movement caused by respiration, is a more practical radiation mode.
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Affiliation(s)
- Huai-Wen Zhang
- Department of Radiotherapy, Jiang-Xi Cancer Hospital, Nanchang, China
| | - Bo Hu
- Key Laboratory of Nondestructive Testing (Ministry of Education), Nanchang Hang Kong University, Nanchang, China
| | - Chen Xie
- Department of Radiotherapy, Jiang-Xi Cancer Hospital, Nanchang, China
| | - Yun-Lai Wang
- Department of Radiation Oncology, PLA General Hospital, Beijing, China
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8
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Ricotti R, Ciardo D, Fattori G, Leonardi MC, Morra A, Dicuonzo S, Rojas DP, Pansini F, Cambria R, Cattani F, Gianoli C, Spinelli C, Riboldi M, Baroni G, Orecchia R, Jereczek-Fossa BA. Intra-fraction respiratory motion and baseline drift during breast Helical Tomotherapy. Radiother Oncol 2017; 122:79-86. [DOI: 10.1016/j.radonc.2016.07.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 11/30/2022]
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Lowanichkiattikul C, Dhanachai M, Sitathanee C, Khachonkham S, Khaothong P. Impact of chest wall motion caused by respiration in adjuvant radiotherapy for postoperative breast cancer patients. SPRINGERPLUS 2016; 5:144. [PMID: 27026841 PMCID: PMC4764603 DOI: 10.1186/s40064-016-1831-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 02/15/2016] [Indexed: 12/29/2022]
Abstract
To determine the chest wall movement of each patient during deep inspiratory breath hold (DIBH) and expiratory breath hold (EBH) in postoperative breast cancer patients. Postoperative breast cancer patients who underwent CT simulation for 3D radiotherapy treatment planning during December 2012 to November 2013 were included. Before scanning the radio-opaque wire was placed on the surface for breast and chest wall visualization on CT images, then the patient underwent three phases of CT scanning (free breathing, DIBH, and EBH, respectively). The distances of chest wall motion at five reference points were calculated using the treatment planning system. 38 breast cancer patients who underwent surgery were included. Median age was 48.5 (28–85) years. Median BMI was 23.4 (16.6–38.3) kg/m2. Median lung volume was 3160.5 (1830.8–4754.0) cm3. Median Haller index was 2.43 (1.92–3.56). Median chest wall movement was wider in anteroposterior (A–P, 4.2–5.4 mm) than superoinferior (S–I, 2.5–2.6 mm) and mediolateral (M–L, 0.6–1.1 mm) dimension in all five measured points. There was no significant effect of the type of surgery, BMI, lung volume, and the Haller index on the distances of chest wall movement. Additional margins of 7, 5, and 2 mm to the A–P, S–I, and M–L dimension should adequately cover the extreme chest wall movement in 95 % of the patients. This study showed that the maximal movement of the chest wall during DIBH and EBH was greatest in the A–P axis followed by the S–I axis, while the M–L axis was minimally affected by respiration.
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Affiliation(s)
- C Lowanichkiattikul
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama Road VI, Rachathevi, Bangkok, 10400 Thailand
| | - M Dhanachai
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama Road VI, Rachathevi, Bangkok, 10400 Thailand
| | - C Sitathanee
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama Road VI, Rachathevi, Bangkok, 10400 Thailand
| | - S Khachonkham
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama Road VI, Rachathevi, Bangkok, 10400 Thailand
| | - P Khaothong
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama Road VI, Rachathevi, Bangkok, 10400 Thailand
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van Heijst TCF, Philippens MEP, Charaghvandi RK, den Hartogh MD, Lagendijk JJW, Desirée van den Bongard HJG, van Asselen B. Quantification of intra-fraction motion in breast radiotherapy using supine magnetic resonance imaging. Phys Med Biol 2016; 61:1352-70. [DOI: 10.1088/0031-9155/61/3/1352] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Samuel SR, Veluswamy SK, Maiya AG, Fernandes DJ, McNeely ML. Exercise-based interventions for cancer survivors in India: a systematic review. SPRINGERPLUS 2015; 4:655. [PMID: 26543789 PMCID: PMC4628608 DOI: 10.1186/s40064-015-1456-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 10/20/2015] [Indexed: 01/03/2023]
Abstract
Existing literature suggests that cancer survivors present with high rates of morbidity due to various treatment and disease induced factors. Research globally has shown exercise to be beneficial in improving treatment outcomes and quality of life. India has a high prevalence of cancer and not much is known about exercise interventions for cancer survivors in India. This review was planned to review the state of exercise based interventions for cancer survivors in India. A comprehensive literature search was performed in PubMed, CINAHL, EMBASE, Scopus, Cochrane Library, PEDro, IndMed, and Shoda Ganga. The search results were screened and data extracted by two independent reviewers. All eligible studies were assessed for methodological quality rating using Downs and Black checklist. Data was extracted using a pilot tested pro forma to summarize information on site and stage of cancer, type of exercise intervention and outcome measures. The review identified 13 studies, published from 1991 to 2013, after screening 4060 articles. Exercise interventions fell into one of three categories: (1) yoga-based, (2) physiotherapy-based and (3) speech therapy based interventions; and exclusively involved either breast or head and neck cancers. Studies were generally of low to moderate quality. A broad range of outcomes were found including symptoms, speech and swallowing, and quality of life and largely supported the benefits of exercise-based interventions. At present, research involving exercise-based rehabilitation interventions in India is limited in volume, quality and scope. With the growing burden of cancer in the country, there is an immediate need for research on exercise based interventions for cancer survivors within the sociocultural context of India.
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Affiliation(s)
- Stephen R Samuel
- Department of Physiotherapy, SOAHS, Manipal University, Manipal, India
| | - Sundar K Veluswamy
- Department of Physiotherapy, M S Ramaiah Medical College and Hospitals, MSR Nagar, MSR IT Post, Bangalore, 560054 Karnataka India
| | - Arun G Maiya
- Department of Physiotherapy, SOAHS, Manipal University, Manipal, India
| | - Donald J Fernandes
- Department of Radiotherapy and Oncology, Kasturba Medical College, Manipal University, Manipal, India
| | - Margaret L McNeely
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta Canada
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Tibdewal A, Munshi A, Pathak R, Misra S, Daptardar A, Singh V, Agarwal JP. Breath‐holding times in various phases of respiration and effect of respiratory training in lung cancer patients. J Med Imaging Radiat Oncol 2015; 59:520-526. [DOI: 10.1111/1754-9485.12324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 04/12/2015] [Indexed: 12/25/2022]
Affiliation(s)
- Anil Tibdewal
- Department of Radiation OncologyTata Memorial Hospital Mumbai India
| | - Anusheel Munshi
- Department of Radiation OncologyTata Memorial Hospital Mumbai India
| | - Rima Pathak
- Department of Radiation OncologyTata Memorial Hospital Mumbai India
| | - Shagun Misra
- Department of Radiation OncologyTata Memorial Hospital Mumbai India
| | | | - Vincent Singh
- Department of PhysiotherapyTata Memorial Hospital Mumbai India
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Chi F, Wu S, Zhou J, Li F, Sun J, Lin Q, Lin H, Guan X, He Z. Dosimetric comparison of moderate deep inspiration breath-hold and free-breathing intensity-modulated radiotherapy for left-sided breast cancer. Cancer Radiother 2015; 19:180-6. [DOI: 10.1016/j.canrad.2015.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 01/09/2015] [Accepted: 01/26/2015] [Indexed: 11/16/2022]
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Laaksomaa M, Kapanen M, Haltamo M, Skyttä T, Peltola S, Hyödynmaa S, Kellokumpu-Lehtinen PL. Determination of the optimal matching position for setup images and minimal setup margins in adjuvant radiotherapy of breast and lymph nodes treated in voluntary deep inhalation breath-hold. Radiat Oncol 2015; 10:76. [PMID: 25885270 PMCID: PMC4399145 DOI: 10.1186/s13014-015-0383-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/16/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Adjuvant radiotherapy (RT) of left-sided breast cancer is increasingly performed in voluntary deep inspiration breath-hold (vDIBH). The aim of this study was to estimate the reproducibility of breath-hold level (BHL) and to find optimal bony landmarks for matching of orthogonal setup images to minimise setup margins. METHODS 1067 sets of images with an orthogonal setup and tangential field from 67 patients were retrospectively analysed. Residual position errors were determined in the tangential treatment field images for different matches of the setup images. Variation of patient posture and BHL were analysed for position errors of the vertebrae, clavicula, ribs and sternum in the setup and tangential field images. The BHL was controlled with a Varian RPM® system. Setup margins were calculated using the van Herk's formula. Patients who underwent lymph node irradiation were also investigated. RESULTS For the breast alone, the midway compromise of the ribs and sternum was the best general choice for matching of the setup images. The required margins were 6.5 mm and 5.3 mm in superior-inferior (SI) and lateral/anterior-posterior (LAT/AP) directions, respectively. With the individually optimised image matching position also including the vertebrae, slightly smaller margins of 6.0 mm and 4.8 mm were achieved, respectively. With the individually optimised match, margins of 7.5 mm and 10.8 mm should be used in LAT and SI directions, respectively, for the lymph node regions. These margins were considered too large. The reproducibility of the BHL was within 5 mm in the AP direction for 75% of patients. CONCLUSIONS The smallest setup margins were obtained when the matching position of the setup images was individually optimised for each patient. Optimal match for the breast alone is not optimal for the lymph node region, and, therefore, a threshold of 5 mm was introduced for residual position errors of the sternum, upper vertebrae, clavicula and chest wall to retain minimal setup margins of 5 mm. Because random interfraction variation in patient posture was large, we recommend daily online image guidance. The BHL should be verified with image guidance.
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Affiliation(s)
- Marko Laaksomaa
- Department of Oncology, PO BOX 2000 (Teiskontie 35), Tampere University Hospital (TAUH), FI-33521, Tampere, Finland.
| | - Mika Kapanen
- Department of Oncology, PO BOX 2000 (Teiskontie 35), Tampere University Hospital (TAUH), FI-33521, Tampere, Finland.
- Department of Medical Physics, Tampere University Hospital (TAUH), PO BOX 2000, Teiskontie 35, FI-33521, Tampere, Finland.
| | - Mikko Haltamo
- Department of Oncology, PO BOX 2000 (Teiskontie 35), Tampere University Hospital (TAUH), FI-33521, Tampere, Finland.
| | - Tanja Skyttä
- Department of Oncology, PO BOX 2000 (Teiskontie 35), Tampere University Hospital (TAUH), FI-33521, Tampere, Finland.
| | - Seppo Peltola
- Department of Medical Physics, Tampere University Hospital (TAUH), PO BOX 2000, Teiskontie 35, FI-33521, Tampere, Finland.
| | - Simo Hyödynmaa
- Department of Medical Physics, Tampere University Hospital (TAUH), PO BOX 2000, Teiskontie 35, FI-33521, Tampere, Finland.
| | - Pirkko-Liisa Kellokumpu-Lehtinen
- Department of Oncology, PO BOX 2000 (Teiskontie 35), Tampere University Hospital (TAUH), FI-33521, Tampere, Finland.
- School of Medicine, University of Tampere, PO BOX 607, FI-33101, Tampere, Finland.
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Dosimetric comparison for volumetric modulated arc therapy and intensity-modulated radiotherapy on the left-sided chest wall and internal mammary nodes irradiation in treating post-mastectomy breast cancer. Radiol Oncol 2015; 49:91-8. [PMID: 25810708 PMCID: PMC4362613 DOI: 10.2478/raon-2014-0033] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 07/07/2014] [Indexed: 01/22/2023] Open
Abstract
Background The aim of the study was to evaluate the dosimetric benefit of applying volumetric modulated arc therapy (VMAT) on the post-mastectomy left-sided breast cancer patients, with the involvement of internal mammary nodes (IMN). Patients and methods The prescription dose was 50 Gy delivered in 25 fractions, and the clinical target volume included the left chest wall (CW) and IMN. VMAT plans were created and compared with intensity-modulated radiotherapy (IMRT) plans on Pinnacle treatment planning system. Comparative endpoints were dose homogeneity within planning target volume (PTV), target dose coverage, doses to the critical structures including heart, lungs and the contralateral breast, number of monitor units and treatment delivery time. Results VMAT and IMRT plans showed similar PTV dose homogeneity, but, VMAT provided a better dose coverage for IMN than IMRT (p = 0.017). The mean dose (Gy), V30 (%) and V10 (%) for the heart were 13.5 ± 5.0 Gy, 9.9% ± 5.9% and 50.2% ± 29.0% by VMAT, and 14.0 ± 5.4 Gy, 10.6% ± 5.8% and 55.7% ± 29.6% by IMRT, respectively. The left lung mean dose (Gy), V20 (%), V10 (%) and the right lung V5 (%) were significantly reduced from 14.1 ± 2.3 Gy, 24.2% ± 5.9%, 42.4% ± 11.9% and 41.2% ± 12.3% with IMRT to 12.8 ± 1.9 Gy, 21.0% ± 3.8%, 37.1% ± 8.4% and 32.1% ± 18.2% with VMAT, respectively. The mean dose to the contralateral breast was 1.7 ± 1.2 Gy with VMAT and 2.3 ± 1.6 Gy with IMRT. Finally, VMAT reduced the number of monitor units by 24% and the treatment time by 53%, as compared to IMRT. Conclusions Compared to 5-be am step-and-shot IMRT, VMAT achieves similar or superior target coverage and a better normal tissue sparing, with fewer monitor units and shorter delivery time.
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Laaksomaa M, Kapanen M, Skyttä T, Peltola S, Hyödynmaa S, Kellokumpu-Lehtinen PL. Estimation of optimal matching position for orthogonal kV setup images and minimal setup margins in radiotherapy of whole breast and lymph node areas. Rep Pract Oncol Radiother 2014; 19:369-75. [PMID: 25337409 DOI: 10.1016/j.rpor.2014.05.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/05/2014] [Accepted: 05/29/2014] [Indexed: 11/30/2022] Open
Abstract
AIM The aim was to find an optimal setup image matching position and minimal setup margins to maximally spare the organs at risk in breast radiotherapy. BACKGROUND Radiotherapy of breast cancer is a routine task but has many challenges. We investigated residual position errors in whole breast radiotherapy when orthogonal setup images were matched to different bony landmarks. MATERIALS AND METHODS A total of 1111 orthogonal setup image pairs and tangential field images were analyzed retrospectively for 50 consecutive patients. Residual errors in the treatment field images were determined by matching the orthogonal setup images to the vertebrae, sternum, ribs and their compromises. The most important region was the chest wall as it is crucial for the dose delivered to the heart and the ipsilateral lung. Inter-observer variation in online image matching was investigated. RESULTS The best general image matching position was the compromise of the vertebrae, ribs and sternum, while the worst position was the vertebrae alone (p ≤ 0.03). The setup margins required for the chest wall varied from 4.3 mm to 5.5 mm in the lung direction while in the superior-inferior (SI) direction the margins varied from 5.1 mm to 7.6 mm. The inter-observer variation increased the minimal margins by approximately 1 mm. The margin of the lymph node areas should be at least 4.8 mm. CONCLUSIONS Setup margins can be reduced by proper selection of a matching position for the orthogonal setup images. To retain the minimal margins sufficient, systematic error of the chest wall should not exceed 4 mm in the tangential field image.
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Affiliation(s)
- Marko Laaksomaa
- Department of Oncology, Tampere University Hospital (Tays), PO Box 2000 (Teiskontie 35), FI-33521 Tampere, Finland
| | - Mika Kapanen
- Department of Oncology, Tampere University Hospital (Tays), PO Box 2000 (Teiskontie 35), FI-33521 Tampere, Finland ; Department of Medical Physics, Tampere University Hospital (Tays), PO Box 2000 (Teiskontie 35), FI-33521 Tampere, Finland
| | - Tanja Skyttä
- Department of Oncology, Tampere University Hospital (Tays), PO Box 2000 (Teiskontie 35), FI-33521 Tampere, Finland
| | - Seppo Peltola
- Department of Medical Physics, Tampere University Hospital (Tays), PO Box 2000 (Teiskontie 35), FI-33521 Tampere, Finland
| | - Simo Hyödynmaa
- Department of Medical Physics, Tampere University Hospital (Tays), PO Box 2000 (Teiskontie 35), FI-33521 Tampere, Finland
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Quirk S, Conroy L, Smith WL. When is respiratory management necessary for partial breast intensity modulated radiotherapy: A respiratory amplitude escalation treatment planning study. Radiother Oncol 2014; 112:402-6. [PMID: 25236712 DOI: 10.1016/j.radonc.2014.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 07/15/2014] [Accepted: 08/07/2014] [Indexed: 10/24/2022]
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18
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Probst H, Bragg C, Dodwell D, Green D, Hart J. A systematic review of methods to immobilise breast tissue during adjuvant breast irradiation. Radiography (Lond) 2014. [DOI: 10.1016/j.radi.2013.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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Mills C, Loveridge A, Milligan A, Risius D, Scurr J. Can axes conventions of the trunk reference frame influence breast displacement calculation during running? J Biomech 2014; 47:575-8. [DOI: 10.1016/j.jbiomech.2013.11.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/20/2013] [Accepted: 11/24/2013] [Indexed: 10/25/2022]
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Yang TJ, Tao R, Elkhuizen PH, van Vliet-Vroegindeweij C, Li G, Powell SN. Tumor bed delineation for external beam accelerated partial breast irradiation: A systematic review. Radiother Oncol 2013; 108:181-9. [DOI: 10.1016/j.radonc.2013.05.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 05/12/2013] [Accepted: 05/12/2013] [Indexed: 11/15/2022]
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Wang W, Bin Li J, Hu HG, Sun T, Xu M, Fan TY, Shao Q. Evaluation of dosimetric variance in whole breast forward-planned intensity-modulated radiotherapy based on 4DCT and 3DCT. JOURNAL OF RADIATION RESEARCH 2013; 54:755-761. [PMID: 23349339 PMCID: PMC3709671 DOI: 10.1093/jrr/rrs143] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 12/26/2012] [Accepted: 12/28/2012] [Indexed: 06/01/2023]
Abstract
This study was performed to explore and compare the dosimetric variance caused by respiratory movement in the breast during forward-planned IMRT after breast-conserving surgery. A total of 17 enrolled patients underwent the 3DCT simulation scans followed by 4DCT simulation scans during free breathing. The treatment planning constructed using the 3DCT images was copied and applied to the end expiration (EE) and end inspiration (EI) scans and the dose distributions were calculated separately. CTV volume variance amplitude was very small (11.93 ± 28.64 cm(3)), and the percentage change of CTV volumes receiving 50 Gy and 55 Gy between different scans were all less than 0.8%. There was no statistically significant difference between EI and EE scans (Z =-0.26, P = 0.795). However, significant differences were found when comparing the Dmean at 3DCT planning with the EI and EE planning (P = 0.010 and 0.019, respectively). The homogeneity index at EI, EE and 3D plannings were 0.139, 0.141 and 0.127, respectively, and significant differences existed between 3D and EI, and between 3D and EE (P = 0.001 and 0.006, respectively). The conformal index (CI) increased significantly in 3D treatment planning (0.74 ± 0.07) compared with the EI and EE phase plannings (P = 0.005 and 0.005, respectively). The V30, V40, V50 and Dmean of the ipsilateral lung for EE phase planning were significantly lower than for EI (P = 0.001-0.042). There were no significant differences in all the DVH parameters for the heart among these plannings (P = 0.128-0.866). The breast deformation during respiration can be disregarded in whole breast IMRT. 3D treatment planning is sufficient for whole breast forward-planned IMRT on the basis of our DVH analysis, but 4D treatment planning, breath-hold, or respiratory gate may ensure precise delivery of radiation dose.
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Affiliation(s)
- Wei Wang
- Department of Radiation Oncology (Chest Section), Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
| | - Jian Bin Li
- Department of Radiation Oncology (Chest Section), Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
| | - Hong Guang Hu
- Department of Medical Physics, Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
| | - Tao Sun
- Department of Medical Physics, Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
| | - Min Xu
- Department of Radiation Oncology (Chest Section), Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
| | - Ting Yong Fan
- Department of Radiation Oncology (Chest Section), Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
| | - Qian Shao
- Department of Radiation Oncology (Chest Section), Shandong Cancer Hospital, 440 Jiyan Road, Jinan, Shandong, 250117, China
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22
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Quirk S, Becker N, Smith WL. External respiratory motion analysis and statistics for patients and volunteers. J Appl Clin Med Phys 2013; 14:4051. [PMID: 23470934 PMCID: PMC5714366 DOI: 10.1120/jacmp.v14i2.4051] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 09/20/2012] [Accepted: 10/12/2012] [Indexed: 12/25/2022] Open
Abstract
We analyzed a large patient and volunteer study of external respiratory motion in order to develop a population database of respiratory information. We analyzed 120 lung, liver, and abdominal patients and 25 volunteers without lung disease to determine the extent of motion using the Varian Real‐Time Position Management system. The volunteer respiratory motion was measured for both abdominal and thoracic placement of the RPM box. Evaluation of a subset of 55 patients demonstrates inter‐ and intrafraction variation over treatment. We also calculated baseline drift and duty cycle for patients and volunteers. The mean peak‐to‐peak amplitude (SD) for the patients was 1.0 (0.5) cm, and for the volunteers it was abdomen 0.8 (0.3) cm and thoracic 0.2 (0.2) cm. The mean period (SD) was 3.6 (1.0) s, 4.2 (1.1) s, and 4.1 (0.8) s, and the mean end exhale position (SD) was 60% (6), 58% (7), and 56% (7) for patient, volunteer abdomen, and volunteer thoracic, respectively. Baseline drift was greater than 0.5 cm for 40% of patients. We found statistically significant differences between the patient and volunteer groups. Peak‐to‐peak amplitude was significantly larger for patients than the volunteer abdominal measurement and the volunteer abdominal measurement is significantly larger than the volunteer thoracic measurement. The patient group also exhibited significantly larger baseline drift than the volunteer group. We also found that peak‐to‐peak amplitude was the most variable parameter for both intra‐ and interfraction motion. This database compilation can be used as a resource for expected motion when using external surrogates in radiotherapy applications. PACS number: 87.19.Wx, 87.55.Km
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Affiliation(s)
- Sarah Quirk
- Department of Medical Physics, University of Calgary, Calgary, AB, Canada.
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Set-up uncertainty during breast radiotherapy. Image-guided radiotherapy for patients with initial extensive variation. Strahlenther Onkol 2013; 189:315-20. [PMID: 23443609 DOI: 10.1007/s00066-012-0271-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 11/08/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE The aim of this work was to establish a customized strategy for image-guided radiotherapy during whole breast irradiation. Risk factors associated with extensive errors were assessed. METHODS AND MATERIALS A series of 176 consecutive breasts in 174 patients were retrospectively assessed. Electronic portal images from 914 medial and 807 lateral directions were reviewed. On the basis of the chest wall, the deviations between the simulation and each treatment were measured. The systematic (Σ) and random error (σ) of population, and the planning target volume (PTV) margin (2 Σ + 0.7σ) were calculated for each direction. Extensive set-up errors were defined as the fraction over the PTV margins in any direction. For extensive set-up errors, χ(2) tests and logistic regression analyses were conducted. RESULTS The medial and lateral PTV margins for the right-left, superior-inferior, and anterior-posterior axes and the rotation of collimator were 2.6 and 2.4 mm, 4.6 and 4.6 mm, and 3.1 and 3.3 mm and 2.8 and 2.9 ° and cut-off values for extensive errors were 3, 5, and 4 mm and 3 °, respectively. In χ(2) tests, tumor in upper outer quadrant (p = 0.012) and chest wall thickness ≥ 2.0 cm (p = 0.003) for medial portals and age group (p = 0.036) for lateral portals were associated with extensive errors. In multivariate tests, the extensive error on the initial fraction had a high probability of extensive set-up errors in both medial (OR = 4.26, p < 0.001) and lateral portals (OR = 3.07, p < 0.001). CONCLUSION In terms of the set-up uncertainty during breast irradiation, patients with extensive error in the initial treatment should be closely observed with serial image-guided radiotherapy.
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Evaluation of Dosimetric Consequences of Seroma Contour Variability in Accelerated Partial Breast Irradiation Using a Constructed Representative Seroma Contour. Int J Radiat Oncol Biol Phys 2012; 84:527-32. [DOI: 10.1016/j.ijrobp.2011.11.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 11/16/2011] [Accepted: 11/26/2011] [Indexed: 11/23/2022]
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Harris EJ, Donovan EM, Coles CE, de Boer HCJ, Poynter A, Rawlings C, Wishart GC, Evans PM. How does imaging frequency and soft tissue motion affect the PTV margin size in partial breast and boost radiotherapy? Radiother Oncol 2012; 103:166-71. [PMID: 22521748 DOI: 10.1016/j.radonc.2012.03.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 03/22/2012] [Accepted: 03/26/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE This study investigates (i) the effect of verification protocols on treatment accuracy and PTV margins for partial breast and boost breast radiotherapy with short fractionation schema (15 fractions), (ii) the effect of deformation of the excision cavity (EC) on PTV margin size, (iii) the imaging dose required to achieve specific PTV margins. METHODS AND MATERIALS Verification images using implanted EC markers were studied in 36 patients. Target motion was estimated for a 15 fraction partial breast regimen using imaging protocols based on on-line and off-line motion correction strategies (No Action Level (NAL) and the extended NAL (eNAL) protocols). Target motion was used to estimate a PTV margin for each protocol. To evaluate treatment errors due to deformation of the excision cavity, individual marker positions were obtained from 11 patients. The mean clip displacement and daily variation in clip position during radiotherapy were determined and the contribution of these errors to PTV margin calculated. Published imaging dose data were used to estimate total dose for each protocol. Finally the number of images required to obtain a specific PTV margin was evaluated and hence, the relationship between PTV margins and imaging dose was investigated. RESULTS The PTV margin required to account for excision cavity motion, varied between 10.2 and 2.4mm depending on the correction strategy used. Average clip movement was 0.8mm and average variation in clip position during treatment was 0.4mm. The contribution to PTV margin from deformation was estimated to be small, less than 0.2mm for both off-line and on-line correction protocols. CONCLUSION A boost or partial breast PTV margin of ∼10 mm, is possible with zero imaging dose and workload, however, patients receiving boost radiotherapy may benefit from a margin reduction of ∼4 mm with imaging doses from 0.4cGy to 25cGy using an eNAL protocol. PTV margin contributions from deformation errors are likely to be small in comparison to other sources of error, i.e., set up or delineation.
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Affiliation(s)
- Emma J Harris
- Joint Department of Physics, Institute of Cancer Research and Royal Marsden Hospital NHS Foundation Trust, Sutton, UK.
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26
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Using Respiratory Motion to Guide Planning Target Volume Margins for External Beam Partial Breast Irradiation. Int J Radiat Oncol Biol Phys 2012; 82:1303-6. [DOI: 10.1016/j.ijrobp.2011.11.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 11/07/2011] [Accepted: 11/13/2011] [Indexed: 11/18/2022]
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Bedi C, Kron T, Willis D, Hubbard P, Milner A, Chua B. Comparison of Radiotherapy Treatment Plans for Left-sided Breast Cancer Patients based on Three- and Four-dimensional Computed Tomography Imaging. Clin Oncol (R Coll Radiol) 2011; 23:601-7. [DOI: 10.1016/j.clon.2011.04.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 02/14/2011] [Accepted: 02/17/2011] [Indexed: 12/22/2022]
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Sankar A, Velmurugan J. Different intensity extension methods and their impact on entrance dose in breast radiotherapy: A study. J Med Phys 2011; 34:200-5. [PMID: 20098549 PMCID: PMC2807141 DOI: 10.4103/0971-6203.56079] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2009] [Revised: 03/29/2009] [Accepted: 04/26/2009] [Indexed: 12/04/2022] Open
Abstract
In breast radiotherapy, skin flashing of treatment fields is important to account for intrafraction movements and setup errors. This study compares the two different intensity extension methods, namely, Virtual Bolus method and skin flash tool method, to provide skin flashing in intensity modulated treatment fields. The impact of these two different intensity extension methods on skin dose was studied by measuring the entrance dose of the treatment fields using semiconductor diode detectors. We found no significant difference in entrance dose due to different methods used for intensity extension. However, in the skin flash tool method, selection of appropriate parameters is important to get optimum fluence extension.
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Affiliation(s)
- A Sankar
- Department of Radiation Therapy, Salmaniya Medical Complex, Salmaniya, Kingdom of Bahrain
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Veldeman L, De Gersem W, Speleers B, Truyens B, Van Greveling A, Van den Broecke R, De Neve W. Alternated prone and supine whole-breast irradiation using IMRT: setup precision, respiratory movement and treatment time. Int J Radiat Oncol Biol Phys 2011; 82:2055-64. [PMID: 21570208 DOI: 10.1016/j.ijrobp.2010.10.070] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 10/11/2010] [Accepted: 10/15/2010] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of this study was to compare setup precision, respiration-related breast movement and treatment time between prone and supine positions for whole-breast irradiation. METHODS AND MATERIALS Ten patients with early-stage breast carcinoma after breast-conserving surgery were treated with prone and supine whole breast-irradiation in a daily alternating schedule. Setup precision was monitored using cone-beam computed tomography (CBCT) imaging. Respiration-related breast movement in the vertical direction was assessed by magnetic sensors. The time needed for patient setup and for the CBCT procedure, the beam time, and the length of the whole treatment slot were also recorded. RESULTS Random and systematic errors were not significantly different between positions in individual patients for each of the three axes (left-right, longitudinal, and vertical). Respiration-related movement was smaller in prone position, but about 80% of observations showed amplitudes <1 mm in both positions. Treatment slots were longer in prone position (21.2 ± 2.5 min) than in supine position (19.4 ± 0.8 min; p = 0.044). CONCLUSION Comparison of setup precision between prone and supine position in the same patient showed no significant differences in random and systematic errors. Respiratory movement was smaller in prone position. The longer treatment slots in prone position can probably be attributed to the higher repositioning need.
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Affiliation(s)
- Liv Veldeman
- Department of Radiotherapy, Ghent University Hospital, Ghent, Belgium.
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Vicini F, Winter K, Wong J, Pass H, Rabinovitch R, Chafe S, Arthur D, Petersen I, White J, McCormick B. Initial efficacy results of RTOG 0319: three-dimensional conformal radiation therapy (3D-CRT) confined to the region of the lumpectomy cavity for stage I/ II breast carcinoma. Int J Radiat Oncol Biol Phys 2010; 77:1120-7. [PMID: 19910132 PMCID: PMC3365530 DOI: 10.1016/j.ijrobp.2009.06.067] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 06/11/2009] [Accepted: 06/12/2009] [Indexed: 12/24/2022]
Abstract
PURPOSE This prospective study (Radiation Therapy Oncology Group 0319) examines the use of three-dimensional conformal external beam radiotherapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI). Initial data on efficacy and toxicity are presented. METHODS AND MATERIALS Patients with Stage I or II breast cancer with lesions < or =3 cm, negative margins and with < or =3 positive nodes were eligible. The 3D-CRT was 38.5 Gy in 3.85 Gy/fraction delivered 2x/day. Ipsilateral breast, ipsilateral nodal, contralateral breast, and distant failure (IBF, INF, CBF, DF) were estimated using the cumulative incidence method. Mastectomy-free, disease-free, and overall survival (MFS, DFS, OS) were recorded. The National Cancer Institute Common Terminology Criteria for Adverse Events, version 3, was used to grade acute and late toxicity. RESULTS Fifty-eight patients were entered and 52 patients are eligible and evaluable for efficacy. The median age of patients was 61 years with the following characteristics: 46% tumor size <1 cm; 87% invasive ductal histology; 94% American Joint Committee on Cancer Stage I; 65% postmenopausal; 83% no chemotherapy; and 71% with no hormone therapy. Median follow-up is 4.5 years (1.7-4.8). Four-year estimates (95% CI) of efficacy are: IBF 6% (0-12%) [4% within field (0-9%)]; INF 2% (0-6%); CBF 0%; DF 8% (0-15%); MFS 90% (78-96%); DFS 84% (71-92%); and OS 96% (85-99%). Only two (4%) Grade 3 toxicities were observed. CONCLUSIONS Initial efficacy and toxicity using 3D-CRT to deliver APBI appears comparable to other experiences with similar follow-up. However, additional patients, further follow-up, and mature Phase III data are needed to evaluate the extent of application, limitations, and value of this particular form of APBI.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Female
- Follow-Up Studies
- Humans
- Mastectomy, Segmental
- Middle Aged
- Prospective Studies
- Radiotherapy, Conformal/adverse effects
- Radiotherapy, Conformal/methods
- Reproducibility of Results
- Survival Analysis
- Treatment Outcome
- Tumor Burden
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Affiliation(s)
- Frank Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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31
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Massaccesi M, Caravatta L, Cilla S, Digesù C, Deodato F, Macchia G, Picardi V, Piscopo A, DA Padula G, Ferrandina G, Scambia G, Valentini V, Cellini N, Piermattei A, Morganti AG. Active Breathing Coordinator in Adjuvant Three-Dimensional Conformal Radiotherapy of Early Stage Breast Cancer: A Feasibility Study. TUMORI JOURNAL 2010; 96:417-23. [DOI: 10.1177/030089161009600307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims To investigate the technical feasibility of utilizing the Active Breathing Coordinator for planning of postoperative three-dimensional conformal radiation therapy in patients with early stage breast cancer undergoing breast conservation therapy. Methods Patients with early stage breast cancer for whom adjuvant radiotherapy after breast-conserving surgery was planned were consecutively enrolled. Five sessions of simulation with the Active Breathing Coordinator were planned for each patient. Computed tomography for simulation was not acquired until a good level of compliance with the procedure was achieved by the patient. Patients who did not show a satisfactory level of compliance after the planned fifth session were defined as noncom-pliant. Two simulation computed tomography scans were acquired: the first without the Active Breathing Coordinator during free breathing, the second with the Active Breathing Coordinator. Forward intensity-modulated treatment plans were calculated. Mean lung dose (MLDipsilateral) and V30 (V30lung) for the ipsilateral lung and V30 for the heart (V30heart), were evaluated. Results Twenty consecutive patients were enrolled (6 with left-sided breast cancer and 14 with right-sided breast cancer). Eighteen of the patients completed the simulation computed tomography with the Active Breathing Coordinator after 1–5 sessions (median, 3). In 16 of the 18 patients, a reduction of V30lung was observed with the Active Breathing Coordinator. In 15 of the 18 patients, a reduction of MLDipsilateral was also observed. In 5 of the 6 patients with left-sided breast cancer, a reduction of V30heart was noted. Conclusions Routine application of the Active Breathing Coordinator in clinical practice is feasible, even though it requires an increased workload. Dosimetric results are encouraging in terms of a better sparing of the ipsilateral lung and the heart.
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Affiliation(s)
- Mariangela Massaccesi
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Luciana Caravatta
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Savino Cilla
- Physics Unit, “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Cinzia Digesù
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Francesco Deodato
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Gabriella Macchia
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Vincenzo Picardi
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Adele Piscopo
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Gilbert DA Padula
- Department of Radiation Oncology, The Lacks Cancer Center Saint Mary's Health Care, Grand Rapids, Michigan, USA
| | - Gabriella Ferrandina
- Gynecologic Oncology Unit, Department of Oncology, “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Giovanni Scambia
- Gynecology/Obstetrics Department, Policlinico A. Gemelli, Catholic University, Rome, Italy
| | - Vincenzo Valentini
- Radiotherapy Department, Policlinico A. Gemelli, Catholic University, Rome, Italy
| | - Numa Cellini
- Radiotherapy Department, Policlinico A. Gemelli, Catholic University, Rome, Italy
| | - Angelo Piermattei
- Physics Unit, “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
| | - Alessio G Morganti
- Radiotherapy Unit, Department of Oncology “John Paul II” Center for High Technology Research and Education in Biomedical Sciences, Catholic University, Campobasso, Italy
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32
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A method for patient set-up guidance in radiotherapy using augmented reality. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2009; 32:203-11. [DOI: 10.1007/bf03179240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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33
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Price GJ, Sharrock PJ, Marchant TE, Parkhurst JM, Burton D, Jain P, Price P, Moore CJ. An analysis of breast motion using high-frequency, dense surface points captured by an optical sensor during radiotherapy treatment delivery. Phys Med Biol 2009; 54:6515-33. [DOI: 10.1088/0031-9155/54/21/005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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34
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Ares C, Khan S, Macartain AM, Heuberger J, Goitein G, Gruber G, Lutters G, Hug EB, Bodis S, Lomax AJ. Postoperative proton radiotherapy for localized and locoregional breast cancer: potential for clinically relevant improvements? Int J Radiat Oncol Biol Phys 2009; 76:685-97. [PMID: 19615828 DOI: 10.1016/j.ijrobp.2009.02.062] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 02/23/2009] [Accepted: 02/24/2009] [Indexed: 02/01/2023]
Abstract
PURPOSE To study the potential reduction of dose to organs at risk (OARs) with intensity-modulated proton radiotherapy (IMPT) compared with intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) photon radiotherapy for left-sided breast cancer patients. METHODS AND MATERIALS Comparative treatment-planning was performed using planning computed tomography scans of 20 left-sided breast cancer patients. For each patient, three increasingly complex locoregional volumes (planning target volumes [PTVs]) were defined: whole breast (WB) or chest wall (CW) = (PTV1), WB/CW plus medial-supraclavicular (MSC), lateral-supraclavicular (LSC), and level III axillary (AxIII) nodes = (PTV2) and WB/CW+MSC+LSC+AxIII plus internal mammary chain = (PTV3). For each patient, 3D-CRT, IMRT, and IMPT plans were optimized for PTV coverage. Dose to OARs was compared while maintaining target coverage. RESULTS All the techniques met the required PTV coverage except the 3D-CRT plans for PTV3-scenario. All 3D-CRT plans for PTV3 exceeded left-lung V20. IMPT vs. 3D-CRT: significant dose reductions were observed for all OARs using IMPT for all PTVs. IMPT vs. IMRT: For PTV2 and PTV3, low (V5) left lung and cardiac doses were reduced by a factor >2.5, and cardiac doses (V22.5) were by a factor of >20 lower with IMPT compared with IMRT. CONCLUSIONS When complex-target irradiation is needed, 3D-CRT often compromises the target coverage and increases the dose to OARs; IMRT can provide better results but will increase the integral dose. The benefit of IMPT is based on improved target coverage and reduction of low doses to OARs, potentially reducing the risk of late-toxicity. These results indicate a potential role of proton-radiotherapy for extended locoregional irradiation in left breast cancer.
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Affiliation(s)
- Carmen Ares
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.
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35
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Surgical clips for position verification and correction of non-rigid breast tissue in simultaneously integrated boost (SIB) treatments. Radiother Oncol 2009; 90:110-5. [DOI: 10.1016/j.radonc.2008.10.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Revised: 10/02/2008] [Accepted: 10/04/2008] [Indexed: 11/21/2022]
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36
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Song T, Suh CO, Lee I, Jeong K, Keum K, Lee CG, Seong J, Cho JH. The Effect of Respiratory Motion on Forward Intensity Modulated Radiotherapy for Breast Cancer. Technol Cancer Res Treat 2008; 7:207-15. [DOI: 10.1177/153303460800700306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study evaluated the effect of respiratory movement on field-in-field (FIF) forward intensity-modulated radiotherapy (IMRT) for the treatment of breast cancer. FIF forward IMRT was performed on ten patients receiving radiotherapy to the whole breast after conservation surgery. Assuming that breast motion follows a sophisticated cyclic function, the changes in hot and cold region, dose homogeneity index (DHI), and skin dose were examined at different respiration amplitudes of 1 cm, 2 cm, and 3 cm. FIF forward IMRT significantly improved the hot region, DHI, and skin dose, but slightly worsened the cold region, compared to the two wedged tangential technique (TWT). Interestingly, we found that the respiration amplitude affected the DHI and cold region but had no effect on the hot region and skin dose. The DHI was slightly improved at 1 cm of amplitude probably due to the blurring effect, remained unchanged at 2 cm of amplitude, and was worsened at 3 cm of amplitude. FIF forward IMRT significantly increased the cold region at 2 cm and 3 cm of respiration amplitude compared to the TWT. At 3 cm of respiration amplitude, an average cold region of 3.27 cm3 was observed. In summary, our data indicate that during FIF forward IMRT, respiration movement has an important effect on various endpoints depending on the respiration amplitude of the patient.
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Affiliation(s)
- Taesoo Song
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Ikjae Lee
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Kyoungkeun Jeong
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Kichang Keum
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Chang Geol Lee
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Jinsil Seong
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
| | - Jae Ho Cho
- Department of Radiation Oncology Yonsei Cancer Center Yonsei University College of Medicine Seoul, South Korea
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Vicini FA, Chen P, Wallace M, Mitchell C, Hasan Y, Grills I, Kestin L, Schell S, Goldstein NS, Kunzman J, Gilbert S, Martinez A. Interim cosmetic results and toxicity using 3D conformal external beam radiotherapy to deliver accelerated partial breast irradiation in patients with early-stage breast cancer treated with breast-conserving therapy. Int J Radiat Oncol Biol Phys 2007; 69:1124-30. [PMID: 17967306 DOI: 10.1016/j.ijrobp.2007.04.033] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 04/18/2007] [Accepted: 04/20/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE We present our ongoing clinical experience utilizing three-dimensional (3D)-conformal radiation therapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI) in patients with early-stage breast cancer treated with breast-conserving therapy. METHODS AND MATERIALS Ninety-one consecutive patients were treated with APBI using our previously reported 3D-CRT technique. The clinical target volume consisted of the lumpectomy cavity plus a 10- to 15 -mm margin. The prescribed dose was 34 or 38.5 Gy in 10 fractions given over 5 consecutive days. The median follow-up was 24 months. Twelve patients have been followed for > or =4 years, 20 for > or =3.5 years, 29 for >3.0 years, 33 for > or =2.5 years, and 46 for > or =2.0 years. RESULTS No local recurrences developed. Cosmetic results were rated as good/excellent in 100% of evaluable patients at > or = 6 months (n = 47), 93% at 1 year (n = 43), 91% at 2 years (n = 21), and in 90% at > or =3 years (n = 10). Erythema, hyperpigmentation, breast edema, breast pain, telangiectasias, fibrosis, and fat necrosis were evaluated at 6, 24, and 36 months after treatment. All factors stabilized by 3 years posttreatment with grade I or II rates of 0%, 0%, 0%, 0%, 9%, 18%, and 9%, respectively. Only 2 patients (3%) developed grade III toxicity (breast pain), which resolved with time. CONCLUSIONS Delivery of APBI with 3D-CRT resulted in minimal chronic (> or =6 months) toxicity to date with good/excellent cosmetic results. Additional follow-up is needed to assess the long-term efficacy of this form of APBI.
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Affiliation(s)
- Frank A Vicini
- Department of Radiation Oncology, William Beaumont Hospital, Royal Oak, MI 48073, USA.
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Kim LH, Wong J, Yan D. On-Line Localization of the Lumpectomy Cavity Using Surgical Clips. Int J Radiat Oncol Biol Phys 2007; 69:1305-9. [DOI: 10.1016/j.ijrobp.2007.07.2365] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 07/23/2007] [Accepted: 07/24/2007] [Indexed: 11/24/2022]
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