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Saadatmand P, Mahdavi SR, Nikoofar A, Jazaeri SZ, Ramandi FL, Esmaili G, Vejdani S. A dosiomics model for prediction of radiation-induced acute skin toxicity in breast cancer patients: machine learning-based study for a closed bore linac. Eur J Med Res 2024; 29:282. [PMID: 38735974 PMCID: PMC11089719 DOI: 10.1186/s40001-024-01855-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/23/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Radiation induced acute skin toxicity (AST) is considered as a common side effect of breast radiation therapy. The goal of this study was to design dosiomics-based machine learning (ML) models for prediction of AST, to enable creating optimized treatment plans for high-risk individuals. METHODS Dosiomics features extracted using Pyradiomics tool (v3.0.1), along with treatment plan-derived dose volume histograms (DVHs), and patient-specific treatment-related (PTR) data of breast cancer patients were used for modeling. Clinical scoring was done using the Common Terminology Criteria for Adverse Events (CTCAE) V4.0 criteria for skin-specific symptoms. The 52 breast cancer patients were grouped into AST 2 + (CTCAE ≥ 2) and AST 2 - (CTCAE < 2) toxicity grades to facilitate AST modeling. They were randomly divided into training (70%) and testing (30%) cohorts. Multiple prediction models were assessed through multivariate analysis, incorporating different combinations of feature groups (dosiomics, DVH, and PTR) individually and collectively. In total, seven unique combinations, along with seven classification algorithms, were considered after feature selection. The performance of each model was evaluated on the test group using the area under the receiver operating characteristic curve (AUC) and f1-score. Accuracy, precision, and recall of each model were also studied. Statistical analysis involved features differences between AST 2 - and AST 2 + groups and cutoff value calculations. RESULTS Results showed that 44% of the patients developed AST 2 + after Tomotherapy. The dosiomics (DOS) model, developed using dosiomics features, exhibited a noteworthy improvement in AUC (up to 0.78), when spatial information is preserved in the dose distribution, compared to DVH features (up to 0.71). Furthermore, a baseline ML model created using only PTR features for comparison with DOS models showed the significance of dosiomics in early AST prediction. By employing the Extra Tree (ET) classifiers, the DOS + DVH + PTR model achieved a statistically significant improved performance in terms of AUC (0.83; 95% CI 0.71-0.90), accuracy (0.70), precision (0.74) and sensitivity (0.72) compared to other models. CONCLUSIONS This study confirmed the benefit of dosiomics-based ML in the prediction of AST. However, the combination of dosiomics, DVH, and PTR yields significant improvement in AST prediction. The results of this study provide the opportunity for timely interventions to prevent the occurrence of radiation induced AST.
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Affiliation(s)
- Pegah Saadatmand
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seied Rabi Mahdavi
- Department of Medical Physics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
- Radiation Biology Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Alireza Nikoofar
- Department of Radiation Oncology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Seyede Zohreh Jazaeri
- Department of Neuroscience, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
- Division of NeuroscienceCellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Soheil Vejdani
- Department of Radiation Oncology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Radiation Oncology, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, Iran
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Gueiderikh A, Kirova Y. Radio-induced lung injury after breast helicoidal tomotherapy: long term safety. Acta Oncol 2023; 62:942-943. [PMID: 37527196 DOI: 10.1080/0284186x.2023.2238557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/06/2023] [Indexed: 08/03/2023]
Affiliation(s)
- A Gueiderikh
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Y Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
- University Versailles St Quentin, St Quentin, France
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Quintin K, Loap P, Fourquet A, Kirova Y. Late hepatic toxicity after breast cancer intensity-modulated radiotherapy using helicoidal tomotherapy. Cancer Radiother 2023:S1278-3218(23)00073-2. [PMID: 37179220 DOI: 10.1016/j.canrad.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Helical tomotherapy (HT) is a rotational intensity-modulated radiation therapy (IMRT) technique that allows target conformal irradiation and efficient organs at risk (OAR) sparing in the case of complex target volumes and specific anatomic considerations, but increases the "low-dose bath" to non-target volumes. The aim of this study was to analyze the delayed hepatotoxicity after rotational IMRT (HT) radiation therapy for non-metastatic breast cancer. PATIENTS AND METHODS This single-center retrospective study included all non-metastatic breast cancer patients with a normal pre-radiotherapy biological hepatic function who were treated with tomotherapy between January 2010 and January 2021 and for whom the dosimetric parameters for the whole liver were assessable. A logistic regression analysis was employed. The selected covariates for the multivariate analysis were those with a P-value that was less or equal to 0.20 in the univariate analysis. RESULTS Forty-nine patients were included in this study: 11 patients (22%) received Trastuzumab for 1 year in tumors with an HER2-expression; 27 patients (55%) received radiation therapy for cancer of the right or bilateral breasts; 43 patients (88%) received lymph node irradiation and 41 patients (84%) received a tumor bed boost. Mean and maximum doses to the liver were 2.8Gy [0.3-16.6] and 26.9Gy [0.7-51.7], respectively. With a median follow-up after irradiation was 5.4 years (range, 6 to 115 months), 11 patients (22%) had developed delayed low grade biological hepatic abnormalities: all patients had grade 1 delayed hepatotoxicity; 3 patients (6%) had additional grade 2 delayed hepatotoxicity. There was no hepatotoxicity at grade 3 or higher. According to the univariate and multivariate analysis, Trastuzumab was a significant predictive variable of late biological hepatotoxicity (OR=4.4 [1.01-20.18], P=0.04). No other variable was statistically associated with delayed biological hepatotoxicity. CONCLUSION Delayed hepatotoxicity after multimodal non-metastatic breast cancer management including rotational IMRT was negligible. Consequently, the liver doesn't have to be considered like an organ-at-risk in the analysis of breast cancer radiotherapy but future prospectives studies are needed to confirm these findings.
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Affiliation(s)
- K Quintin
- Département d'oncologie radiothérapie, institut Curie, Paris, France
| | - P Loap
- Département d'oncologie radiothérapie, institut Curie, Paris, France
| | - A Fourquet
- Département d'oncologie radiothérapie, institut Curie, Paris, France
| | - Y Kirova
- Département d'oncologie radiothérapie, institut Curie, Paris, France.
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Zolcsak Z, Loap P, Fourquet A, Kirova Y. Long-term follow-up results of intensity-modulated radiotherapy with helicoïdal tomotherapy for non-metastatic breast cancers: Single centre experience. Cancer Radiother 2022; 26:654-662. [DOI: 10.1016/j.canrad.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 01/19/2023]
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Belaidi L, Loap P, Kirova Y. Do We Need to Delineate the Humeral Head in Breast Cancer Patients? Cancers (Basel) 2022; 14:496. [PMID: 35158764 PMCID: PMC8833338 DOI: 10.3390/cancers14030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Humeral heads can be unintentionally exposed during breast radiotherapy, particularly when regional lymph nodes are targeted. Moreover, rotational intensity-modulated radiation therapy techniques, such as helical tomotherapy (HT), increase the low-dose bath, the consequences of which are subject to debate. The aim of this study was to analyze late adverse events involving humeral heads occurring after adjuvant locoregional breast radiotherapy with HT. This single-center retrospective study included 159 breast cancer patients locoregionally irradiated, including the regional lymph nodes, in an adjuvant setting with HT at Institut Curie (Paris, France), between January 2010 and 2016. After a median delay of 48 months, six patients (3.8%) developed localized bone pain, three (1.9%) developed a shoulder functional limitation and one (0.6%) developed a traumatic humeral head fracture. The average mean and maximum doses to humeral heads were 9.18 Gy and 24.41 Gy, respectively, and were not statistically associated with humeral head adverse events. Adverse events were statistically more frequent after mastectomy than after breast-conserving surgery. Berg's level 1 and 2/3 irradiation, and right-sided radiotherapy were associated with an increased maximum dose. In summary, clinical adverse events were rare, and radiation exposure to humeral heads was low. No correlation was found between dosimetric parameters and late toxicity.
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Affiliation(s)
- Lahcene Belaidi
- Department of Radiation Oncology, Institut Curie, 26 rue d’Ulm, 75005 Paris, France; (P.L.); (Y.K.)
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Mutter RW, Choi JI, Jimenez RB, Kirova YM, Fagundes M, Haffty BG, Amos RA, Bradley JA, Chen PY, Ding X, Carr AM, Taylor LM, Pankuch M, Vega RBM, Ho AY, Nyström PW, McGee LA, Urbanic JJ, Cahlon O, Maduro JH, MacDonald SM. Proton Therapy for Breast Cancer: A Consensus Statement From the Particle Therapy Cooperative Group Breast Cancer Subcommittee. Int J Radiat Oncol Biol Phys 2021; 111:337-359. [PMID: 34048815 PMCID: PMC8416711 DOI: 10.1016/j.ijrobp.2021.05.110] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/17/2021] [Indexed: 12/23/2022]
Abstract
Radiation therapy plays an important role in the multidisciplinary management of breast cancer. Recent years have seen improvements in breast cancer survival and a greater appreciation of potential long-term morbidity associated with the dose and volume of irradiated organs. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. However, there remain additional financial costs associated with proton therapy, despite reductions over time, and studies have yet to demonstrate that protons improve upon the treatment outcomes achieved with photon radiation therapy. There remains considerable heterogeneity in proton patient selection and techniques, and the rapid technological advances in the field have the potential to affect evidence evaluation, given the long latency period for breast cancer radiation therapy recurrence and late effects. In this consensus statement, we assess the data available to the radiation oncology community of proton therapy for breast cancer, provide expert consensus recommendations on indications and technique, and highlight ongoing trials' cost-effectiveness analyses and key areas for future research.
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Affiliation(s)
- Robert W Mutter
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.
| | - J Isabelle Choi
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rachel B Jimenez
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Marcio Fagundes
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida
| | - Bruce G Haffty
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Richard A Amos
- Proton and Advanced Radiotherapy Group, Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Julie A Bradley
- Department of Radiation Oncology, University of Florida, Jacksonville, Florida
| | - Peter Y Chen
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Xuanfeng Ding
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Antoinette M Carr
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Leslie M Taylor
- Department of Radiation Oncology, Beaumont Health, Royal Oak, Michigan
| | - Mark Pankuch
- Department of Radiation Oncology, Northwestern Medicine Proton Center, Warrenville, Illinois
| | | | - Alice Y Ho
- Department of Radiation Oncology, New York Proton Center and Memorial Sloan Kettering Cancer Center, New York, New York
| | - Petra Witt Nyström
- The Skandion Clinic, Uppsala, Sweden and the Danish Centre for Particle Therapy, Aarhus, Denmark
| | - Lisa A McGee
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona
| | - James J Urbanic
- Department of Radiation Medicine and Applied Sciences, UC San Diego Health, Encinitas, California
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John H Maduro
- Department of Radiation Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Shannon M MacDonald
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
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Loap P, Loirat D, Berger F, Cao K, Ricci F, Jochem A, Raizonville L, Mosseri V, Fourquet A, Kirova Y. Combination of Olaparib with radiotherapy for triple-negative breast cancers: One-year toxicity report of the RADIOPARP Phase I trial. Int J Cancer 2021; 149:1828-1832. [PMID: 34270809 DOI: 10.1002/ijc.33737] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/05/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022]
Abstract
Triple-negative breast cancer (TNBC) cells are sensitive to PARP1 inhibitors in vitro. The combination of Olaparib and radiotherapy for TNBC is currently evaluated in the Phase I RADIOPARP trial. RADIOPARP is a monocentric prospective open-label Phase I dose-escalation trial evaluating the combination of breast radiotherapy and Olaparib in TNBC patients with inflammatory, locoregionally advanced or metastatic disease, or with residual disease after neoadjuvant chemotherapy. Olaparib was orally given at increasing dose levels (50, 100, 150 or 200 mg twice a day [BID]); radiotherapy consisted of 50 Gy to the breast or chest wall with or without lymph node irradiation. Twenty-four TNBC patients were enrolled between September 2017 and November 2019. Olaparib was escalated to 200 mg BID without dose-limiting toxicities. At 1-year follow-up, no treatment-related grade ≥3 toxicity was observed. One patient (4.2%) had persistent grade 2 adverse events (breast pain, fibrosis and deformity). There was no cardiac, pulmonary or digestive toxicity related to treatment. The 1-year follow-up report of the RADIOPARP Phase I trial, evaluating Olaparib associated with breast radiotherapy in TNBC patients, consequently demonstrated an excellent toxicity profile of this combination with few low-grade adverse events.
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Affiliation(s)
- Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Delphine Loirat
- Department of Medical Oncology, Institut Curie, Paris, France
| | | | - Kim Cao
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Francesco Ricci
- Department of Clinical Investigations, Institut Curie, Paris, France
| | - Anne Jochem
- Department of Biostatistics, Institut Curie, Paris, France
| | | | | | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
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Byun HK, Chang JS, Im SH, Kirova YM, Arsene-Henry A, Choi SH, Cho YU, Park HS, Kim JY, Suh CO, Keum KC, Sohn JH, Kim GM, Lee IJ, Kim JW, Kim YB. Risk of Lymphedema Following Contemporary Treatment for Breast Cancer: An Analysis of 7617 Consecutive Patients From a Multidisciplinary Perspective. Ann Surg 2021; 274:170-178. [PMID: 31348041 DOI: 10.1097/sla.0000000000003491] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to identify the comprehensive risk factors for lymphedema, thereby enabling a more informed multidisciplinary treatment decision-making. SUMMARY BACKGROUND DATA Lymphedema is a serious long-term complication in breast cancer patients post-surgery; however, the influence of multimodal therapy on its occurrence remains unclear. METHODS We retrospectively collected treatment-related data from 5549 breast cancer patients who underwent surgery between 2007 and 2015 at our institution. Individual radiotherapy plans were reviewed for regional nodal irradiation (RNI) field design and fractionation type. We identified lymphedema risk factors and used them to construct nomograms to predict individual risk of lymphedema. Nomograms were validated internally using 100 bootstrap samples and externally using 2 separate datasets of 1877 Asian and 191 Western patients. RESULTS Six hundred thirty-nine patients developed lymphedema during a median follow-up of 60 months. The 3-year lymphedema incidence was 10.5%; this rate increased with larger irradiation volumes (no RNI vs RNI excluding axilla I-II vs RNI including axilla I-II: 5.7% vs 16.8% vs 24.1%) and when using conventional fractionation instead of hypofractionation (13.5% vs 6.8%). On multivariate analysis, higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation were strongly associated with lymphedema (all P < 0.001). Nomograms constructed based on these variables showed good calibration and discrimination internally (concordance index: 0.774) and externally (0.832 for Asian and 0.820 for Western patients). CONCLUSIONS Trimodality breast cancer treatment factors interact to promote lymphedema. Lymphedema risk can be decreased by deintensifying node dissection, chemotherapy regimen, and field and dose of radiotherapy. Deescalation strategies on a multidisciplinary basis might minimize lymphedema risk.
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Affiliation(s)
- Hwa Kyung Byun
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Suk Chang
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hee Im
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Youlia M Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
- University Versailles St Quentin, France
| | | | - Seo Hee Choi
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Young Up Cho
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Seok Park
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Jee Ye Kim
- Department of Surgery, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
- Department of Radiation Oncology, Bundang CHA Medical Center, CHA University, Gyeonggi-do, Korea
| | - Ki Chang Keum
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Joo Hyuk Sohn
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Gun Min Kim
- Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Ik Jae Lee
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Won Kim
- Department of Radiation Oncology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
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Abbassi LM, Arsène-Henry A, Amessis M, Kirova YM. Radiation dose to the low axilla in patients treated for early-stage breast cancer by locoregional intensity-modulated radiotherapy (IMRT). Cancer Radiother 2021; 26:445-449. [PMID: 34175223 DOI: 10.1016/j.canrad.2021.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/18/2021] [Accepted: 06/01/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE To determine the dose received by the low axilla during locoregional radiotherapy (RT) for early-stage breast cancer and to assess the impact of the treatment technique (three-dimensional conformal radiotherapy (3D-CRT) or rotational IMRT (VMAT) or helical tomotherapy (HT). MATERIALS AND METHODS The dosimetric study was performed on patients receiving normofractionated (NFRT - 50Gy in 25 fractions) or hypofractionated (HFRT - 40Gy in 15 fractions) locoregional radiotherapy (breast or chest wall and internal mammary, supraclavicular and infraclavicular nodes±axillary nodes) by 3D-CRT or VMAT or HT at the Institut Curie Paris. Patients treated by breast-conserving surgery received a boost dose of 16Gy and 10Gy to the tumour bed, respectively. RESULTS Sixty-eight patients treated by RT from February 2017 to January 2019 were studied. The mean dose received by the low axilla when it was not part of the target volume was 30.8Gy, 41.0Gy and 44.4Gy by 3D-CRT, VMAT and HT, respectively for NFRT and 24.2Gy, 33.0Gy and 34.9Gy, respectively, for HFRT. With NFRT, 4.1% of the axilla received 95% (V95) of the prescribed dose by 3D-CRT compared to 24.5% and 33.6% by VMAT and HT, respectively; with HFRT, V95 was 3.9%, 19.5% and 24.1%, respectively. CONCLUSION The axilla receives a non-negligible dose during locoregional radiotherapy; this dose is greater when VMAT or HT are used. Prospective studies must be conducted to assess the impact of this axillary dose in terms of morbidity, which currently remains unknown.
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Affiliation(s)
- L M Abbassi
- Département d'oncologie-radiothérapie, Institut Curie Paris, 26, rue d'Ulm, 75005 Paris, France.
| | - A Arsène-Henry
- Département d'oncologie-radiothérapie, Institut Curie Paris, 26, rue d'Ulm, 75005 Paris, France
| | - M Amessis
- Département d'oncologie-radiothérapie, Institut Curie Paris, 26, rue d'Ulm, 75005 Paris, France
| | - Y M Kirova
- Département d'oncologie-radiothérapie, Institut Curie Paris, 26, rue d'Ulm, 75005 Paris, France
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Ell P, Martin JM, Cehic DA, Ngo DTM, Sverdlov AL. Cardiotoxicity of Radiation Therapy: Mechanisms, Management, and Mitigation. Curr Treat Options Oncol 2021; 22:70. [PMID: 34110500 DOI: 10.1007/s11864-021-00868-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 12/15/2022]
Abstract
OPINION STATEMENT Radiation therapy is a key component of modern-day cancer therapy and can reduce the rates of recurrence and death from cancer. However, it can increase risk of cardiovascular (CV) events, and our understanding of the timeline associated with that risk is shorter than previously thought. Risk mitigation strategies, such as different positioning techniques, and breath hold acquisitions as well as baseline cardiovascular risk stratification that can be undertaken at the time of radiotherapy planning should be implemented, particularly for patients receiving chest radiation therapy. Primary and secondary prevention of cardiovascular disease (CVD), as appropriate, should be used before, during, and after radiation treatment in order to minimize the risks. Opportunistic screening for subclinical coronary disease provides an attractive possibility for primary/secondary CVD prevention and thus mitigation of long-term CV risk. More data on long-term clinical usefulness of this strategy and development of appropriate management pathways would further strengthen the evidence for the implementation of such screening. Clear guidelines in initial cardiovascular screening and cardiac aftercare following radiotherapy need to be formulated in order to integrate these measures into everyday clinical practice and policy and subsequently improve post-treatment morbidity and mortality for these patients.
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Affiliation(s)
- P Ell
- GenesisCare, Lake Macquarie Private Hospital, Gateshead, NSW, Australia
| | - J M Martin
- GenesisCare, Lake Macquarie Private Hospital, Gateshead, NSW, Australia.,Calvary Mater Newcastle, Waratah, NSW, 2298, Australia.,College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, 2308, Australia
| | - D A Cehic
- GenesisCare, Buildings 1&11, The Mill, 41-43 Bourke Road, Alexandria, NSW, 2015, Australia
| | - D T M Ngo
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,Hunter Cancer Research Alliance, Waratah, NSW, 2298, Australia
| | - A L Sverdlov
- College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia. .,Hunter Cancer Research Alliance, Waratah, NSW, 2298, Australia. .,Hunter New England Local Health District, Newcastle, NSW, 2305, Australia.
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Costa E, Richir T, Robilliard M, Bragard C, Logerot C, Kirova Y, Fourquet A, De Marzi L. Assessment of a conventional volumetric-modulated arc therapy knowledge-based planning model applied to the new Halcyon© O-ring linac in locoregional breast cancer radiotherapy. Phys Med 2021; 86:32-43. [PMID: 34051551 DOI: 10.1016/j.ejmp.2021.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/31/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the performance of a knowledge-based planning (KBP) model for breast cancer trained on plans performed on a conventional linac with 6 MV FF (flattening filter) beams and volumetric-modulated arc therapy (VMAT) for plans performed on the new jawless Halcyon© system with 6 MV FFF (flattening filter-free) beams. MATERIALS AND METHODS Based on the RapidPlan© (RP) KBP optimization engine, a DVH Estimation Model was first trained using 56 VMAT left-sided breast cancer treatment plans performed on a conventional linac, and validated on another 20 similar cases (without manual intervention). To determine the capacity of the model for Halcyon©, an additional cohort of 20 left-sided breast cancer plans was generated with RP and analyzed for both TrueBeam© and Halcyon© machines. Plan qualities between manual vs RP (followed by manual intervention) Halcyon© plans set were compared qualitatively by blinded review by radiation oncologists for 10 new independent plans. RESULTS Halcyon© plans generated with the VMAT model trained with conventional linac plans showed comparable target dose distribution compared to TrueBeam© plans. Organ sparingwas comparable between the 2 devices with a slight decrease in heart dose for Halcyon© plans. Nine out of ten automatically generated Halcyon© plans were preferentially chosen by the radiation oncologists over the manually generated Halcyon© plans. CONCLUSION A VMAT KBP model driven by plans performed on a conventional linac with 6 MV FF beams provides high quality plans performed with 6 MV FFF beams on the new Halcyon© linac.
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Affiliation(s)
- Emilie Costa
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France.
| | - Thomas Richir
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France
| | - Magalie Robilliard
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France
| | - Christel Bragard
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France
| | - Christelle Logerot
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France
| | - Youlia Kirova
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France
| | - Alain Fourquet
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France
| | - Ludovic De Marzi
- Institut Curie, Radiation Oncology Department, 26 rue d'Ulm, Paris 75005, France; Institut Curie, University Paris Saclay, PSL Research University, Inserm LITO, Orsay, France
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12
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Bartolucci L, Adrien C, Goudjil F, Amessis M, El Amine W, Fourquet A, Mazal A, Kirova Y. Dosimetric comparison of four high performance techniques for irradiation of breast cancer patients. Cancer Radiother 2021; 25:254-258. [PMID: 33402289 DOI: 10.1016/j.canrad.2020.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/18/2023]
Abstract
PURPOSE The use of IMRT for the treatment of breast cancer has been growing considerably in our institution since 2009. Alternatively, helical tomotherapy (HT) using a field width of 2.5 and 5cm (HT_FW_5), volumetric-modulated arc therapy (VMAT), or proton therapy with pencil-beam scanning (PT-PBS) have also been used to reduce treatment duration or optimize organ-at-risk (OAR) sparing. The purpose of this study was to compare the 4 treatment modalities available at our site. PATIENTS AND METHODS We studied 10 patients treated for breast cancer with lymph node involvement. The prescribed dose was 51.8Gy to the breast with a simultaneous integrated boost up to 63Gy, and 50.4Gy to lymph nodes in 28 fractions. The CTV was delineated according to ESTRO Guidelines. Dosimetric planning in routine clinical practice was performed using HT_FW_2.5. The approved clinical plan was compared to the 3 other plans. Dosimetric goals for PTV coverage were D95%≥95% and D2%≤107% of the prescribed dose. Mean and maximum doses to OAR were recorded. RESULTS HT_FW_5 and VMAT plans ensure equivalent or even better PTV coverage compared to the initial clinically approved plan but at the cost of poorer OAR sparing. PT_PBS plans showed that an excellent PTV coverage can be maintained with significantly lower doses to OAR. CONCLUSION HT_FW_5 and VMAT plans allow a significant reduction of treatment duration and can be a good alternative to HT_FW_2.5 for specific populations. HT_FW_2.5 could be chosen for patients at higher risk of side effects. In addition, PT_PBS should be considered in the near future as it has been shown to have a major potential benefit to lower the risk of side effects with the same level of PTV coverage.
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Affiliation(s)
- L Bartolucci
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - C Adrien
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - F Goudjil
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - M Amessis
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - W El Amine
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - A Fourquet
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - A Mazal
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France
| | - Y Kirova
- Department of radiation oncology, Institut Curie, Paris-Orsay, 26 rue d'Ulm, 75005 Paris, France.
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13
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Loap P, Kirova Y. Evaluating cardiac substructure radiation exposure in breast rotational intensity modulated radiation therapy: Effects of cancer laterality, fractionation and deep inspiration breath-hold. Cancer Radiother 2020; 25:13-20. [PMID: 33288407 DOI: 10.1016/j.canrad.2020.05.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/10/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE Rotational intensity-modulated radiation therapy currently has a growing role in breast cancer radiation therapy, since this radiation technique reduces cardiac radiation exposure while homogeneously covering target volumes. This study aims to evaluate radiation exposure of cardiac substructures across a broad spectrum of breast cancer cases differing by cancer laterality, fractionation regimen and addition of deep-inspiration breath hold. MATERIALS AND METHODS Cardiac substructures were delineated following guidelines endorsed by the European Society for Radiotherapy and Oncology (ESTRO) for forty-four breast cancer patients having undergone conserving surgery and adjuvant rotational intensity-modulated radiation therapy. Target volumes consisted of the whole breast with a boost, axillary and internal mammary nodes. Patients were treated using free-breathing technique for left-sided or right-sided, normofractionated or hypofractionated helical tomotherapy or volumetric modulated arc therapy, or using deep-inspiration breath hold for left-sided normofractionated volumetric modulated arc therapy. Mean and maximum doses to cardiac substructures were retrieved. Correlations were performed between mean- and maximum radiation doses to cardiac substructures. RESULTS Left-sided and right-sided irradiations were associated with different cardiac substructure exposure patterns despite comparable mean heart dose: 7.21Gy for left-sided normofractionated regimen, 6.28Gy for right-sided normofractionated regimen. Deep-inspiration breath hold reduced mean doses to almost all cardiac substructures for left-sided irradiation, but did not decrease maximum doses to coronary arteries. Correlations between mean- and maximum doses to cardiac substructures were usually moderate, but stronger for right-sided irradiation. CONCLUSION Despite comparable mean heart dose, cardiac substructure radiation exposure patterns with rotational intensity-modulated radiation therapy strongly depend on the breast side, which could trigger clinically different long-term cardiotoxicity events. Deep-inspiration breath hold improves cardiac substructure dosimetry. Mean- and maximum heart dose could probably not be used as surrogate markers for precise cardiac substructure evaluation. In a near future, clinical practice and cardiotoxicity studies could possibly gain by considering cardiac substructure in a more systematic manner, possibly relying on cardiac autosegmentation algorithms.
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Affiliation(s)
- P Loap
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France.
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, 26, rue d'Ulm, 75005 Paris, France
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14
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Loap P, Kirov K, Kirova Y. Cardiotoxicity in breast cancer patients treated with radiation therapy: From evidences to controversies. Crit Rev Oncol Hematol 2020; 156:103121. [PMID: 33038628 DOI: 10.1016/j.critrevonc.2020.103121] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/31/2020] [Accepted: 09/27/2020] [Indexed: 12/19/2022] Open
Abstract
Radiation therapy has a prime importance for breast cancer management. However, first-generation techniques delivered significant radiation dose to the heart, which substantially increased cardiac mortality. Breast radiation therapy has fortunately evolved, and state-of-the-art radiation therapy techniques currently efficiently spare the heart without altering local control or overall survival. However, at the present time, potential cardiotoxicity risk is still a matter of concern and controversies exist concerning how to precisely evaluate cardiac radiation exposure, how to predict radiation-induced cardiac adverse events and which dosimetric constraints are clinically relevant. Based on current literature, this paper aims to review the present understanding of cardiotoxicity associated with breast cancer irradiation and to discuss controversies and perspectives about cardiac sparing improvement.
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Affiliation(s)
- Pierre Loap
- Institut Curie, Department of Radiation Oncology, Paris, France.
| | - Krassen Kirov
- Institut Curie, Department of Radiation Oncology, Paris, France
| | - Youlia Kirova
- Institut Curie, Department of Radiation Oncology, Paris, France
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15
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Heymann S, Dipasquale G, Nguyen NP, San M, Gorobets O, Leduc N, Verellen D, Storme G, Van Parijs H, De Ridder M, Vinh-Hung V. Two-Level Factorial Pre-TomoBreast Pilot Study of Tomotherapy and Conventional Radiotherapy in Breast Cancer: Post Hoc Utility of a Mean Absolute Dose Deviation Penalty Score. Technol Cancer Res Treat 2020; 19:1533033820947759. [PMID: 32940569 PMCID: PMC7502852 DOI: 10.1177/1533033820947759] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: A 2-level factorial pilot study was conducted in 2007 just before starting a randomized clinical trial comparing tomotherapy and conventional radiotherapy (CR) to reduce cardiac and pulmonary adverse effects in breast cancer, considering tumor laterality (left/right), target volume (with/without nodal irradiation), surgery (tumorectomy/mastectomy), and patient position (prone/supine). The study was revisited using a penalty score based on the recently developed mean absolute dose deviation (MADD). Methods: Eight patients with a unique combination of laterality, nodal coverage, and surgery underwent dual tomotherapy and CR treatment planning in both prone and supine positions, providing 32 distinct combinations. The penalty score was applied using the weighted sum of the MADDs. The Lenth method for unreplicated 2-level factorial design was used in the analysis. Results: The Lenth analysis identified nodal irradiation as the active main effect penalizing the dosimetry by 1.14 Gy (P = 0.001). Other significant effects were left laterality (0.94 Gy), mastectomy (0.61 Gy), and interactions between left mastectomy (0.89 Gy) and prone mastectomy (0.71 Gy), with P-values between 0.005 and 0.05. Tomotherapy provided a small reduction in penalty (reduction of 0.54 Gy) through interaction with nodal irradiation (P = 0.080). Some effects approached significance with P-values > 0.05 and ≤ 0.10 for interactions of prone × mastectomy × left (0.60 Gy), nodal irradiation × mastectomy (0.59 Gy), and prone × left (0.55 Gy) and the main effect prone (0.52 Gy). Conclusions: The historical dosimetric analysis previously revealed the feasibility of tomotherapy, but a conclusion could not be made. The MADD-based score is promising, and a new analysis highlights the impact of factors and hierarchy of priorities that need to be addressed if major gains are to be attained.
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Affiliation(s)
| | | | - Nam P Nguyen
- Department of Radiation Oncology, Howard University, Washington, DC, USA
| | - Meymey San
- Khmer Soviet Friendship Hospital, Cambodia
| | - Olena Gorobets
- University Hospital of Martinique, Site Clarac, Martinique, France
| | - Nicolas Leduc
- University Hospital of Martinique, Site Clarac, Martinique, France
| | - Dirk Verellen
- Medical Physics, Faculty of Medicine and Health Sciences, Iridium Kankernetwerk and University of Antwerp, Wilrijk, Belgium.,Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Guy Storme
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Hilde Van Parijs
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Mark De Ridder
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Vincent Vinh-Hung
- University Hospital of Martinique, Site Clarac, Martinique, France.,Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Belkacemi Y, Loganadane G, Ghith S, Li X, Majdoul S, Grellier N, Jmour O, Bret CL, Hervé ML, Hadhri A, To NH, Fayolle-Campana M, Colson-Durand L. Axillary nodal irradiation practice in the sentinel lymph node biopsy era: Comparison of the contemporary available 3D and IMRT techniques. Br J Radiol 2020; 93:20190351. [PMID: 32233939 PMCID: PMC10993223 DOI: 10.1259/bjr.20190351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 02/26/2020] [Accepted: 03/13/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE Our study aimed to compare regional node coverage and doses to the organ at risk (OAR) using conventional technique (CT) vs "AMAROS" (AT) vs intensity-modulated radiation therapy (IMRT) techniques in patients receiving regional nodal irradiation (RNI) for breast cancer (BC). METHODS We included 30 consecutive patients with BC who received RNI including axillary nodes. Two independent and blinded dosimetric RNI plans were generated for all patients. For target volume coverage, we analyzed the V95%, the D95%, the mean and the minimal dose within the nodal station. For hotspots within nodal target volume, we used the V105%, the V108% and the maximal doses. For OAR, lung V20, mean lung and heart doses, the maximal dose to the brachial plexus and the axillary-lateral thoracic vessel junction region were compared between the three techniques. RESULTS Target volume coverage and hotspots: Mean V95% in stations I, II, III and IV were 35.8% and 75% respectively with CV, 22.59 and 59.9% respectively with AT technique and 45.58 and 99.6% respectively with IMRT with statistically significant differences (p < 0.001). Mean V105% (cc) in axillary and supraclavicular stations were 21.3 and 6.4 respectively with CV, 1.2 and 0.02 respectively with AT technique and 0.5 and 0.4 respectively with IMRT with statistically significant differences (p < 0.001)..OARs: The mean ipsilateral lung V20 was 16.9%, 16.4 and 13.3% with CT, AT and IMRT respectively. The mean heart dose (Gy) was 0.3, 0.2 and 0.2 with CT, AT and IMRT respectively. The maximal dose to the plexus brachial (Gy) was 50.3, 46.3 and 47.3 with CT, AT and IMRT respectively. The maximal dose to the axillary-lateral thoracic vessel junction (Gy) was 52.3, 47.3 and 47.6 with CT, AT and IMRT respectively. The differences were statistically significant for all OAR (p < 0.001). CONCLUSION AT is a valuable technique for RNI including axilla in patients with limited sentinel lymph node biopsy involvement without additional axillary lymph node dissection since it decreases hotspots in the target volume and lowers the radiation exposure of the OAR. For more advanced tumors or patients who did not respond to primary systemic therapy, CT or IMRT should be considered because of their better coverage of the potentially residual nodal disease. IMRT combines several advantages of offering high conformal plans, limited hotspots and protection of main OAR. The clinical impact of these dosimetric differences need to be addressed. ADVANCES IN KNOWLEDGE This study is to our knowledge the first to compare conventional three-dimensional and IMRT techniques for regional nodal irradiation for each nodal station in breast cancer in a context of increasing utilization of axillary irradiation.
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Affiliation(s)
- Yazid Belkacemi
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
- University of Paris-Est (UPEC),
Créteil, France
- INSERM Unit 955 team 21, Institut Mondor de Recherche
Biomédicale, Créteil,
France
| | - Gokoulakrichenane Loganadane
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
- University of Paris-Est (UPEC),
Créteil, France
- INSERM Unit 955 team 21, Institut Mondor de Recherche
Biomédicale, Créteil,
France
| | - Sahar Ghith
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
| | - Xie Li
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
- Department of Radiation Oncology for Gynecologic Tumors,
Anti-Cancer Center and Tumor Hospital of the Xinjiang Medical
University, Urumqi,
China
| | - Soufya Majdoul
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
| | - Noémie Grellier
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
- University of Paris-Est (UPEC),
Créteil, France
| | - Omar Jmour
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
| | - Cindy Le Bret
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
| | - Marie-Laure Hervé
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
| | - Asma Hadhri
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
- University of Medicine of Tunis-El Manar,
Tunis, Tunisia
| | - Nhu Hanh To
- AP-HP. Department of Radiation Oncology and Henri Mondor Breast
Center, Créteil,
France
- University of Paris-Est (UPEC),
Créteil, France
- INSERM Unit 955 team 21, Institut Mondor de Recherche
Biomédicale, Créteil,
France
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Loap P, Fourquet A, Kirova Y. The Limits of the Linear Quadratic (LQ) Model for Late Cardiotoxicity Prediction: Example of Hypofractionated Rotational Intensity Modulated Radiation Therapy (IMRT) for Breast Cancer. Int J Radiat Oncol Biol Phys 2020; 106:1106-1108. [PMID: 31973883 DOI: 10.1016/j.ijrobp.2019.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Pierre Loap
- Department of Radiation Oncology, Institut Curie, Paris, France.
| | - Alain Fourquet
- Department of Radiation Oncology, Institut Curie, Paris, France
| | - Youlia Kirova
- Department of Radiation Oncology, Institut Curie, Paris, France
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18
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Kirova Y. 23 The growing role of Intensity Modulated Irradiation Techniques (IMRTs) in the management of breast cancer: The radiation oncologist’s point of view. Phys Med 2019. [DOI: 10.1016/j.ejmp.2019.09.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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19
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Arsene Henry A, Amessis M, Kirova YM. Helical Tomotherapy for patients with pectus excavatum treated for early‐stage breast cancer. Breast J 2019; 26:1483-1484. [DOI: 10.1111/tbj.13671] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Malika Amessis
- Department of Radiation Oncology Institut Curie Paris France
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