Global adoption of single-shot targeted intraoperative radiotherapy (TARGIT-IORT) for breast cancer—better for patients, better for healthcare systems

A Novel Endoscopic Approach for Treating Breast Cancer: Haigui-1 Hole

OBJECTIVE

Endoscopic surgery is an effective technique for preserving the nipple and areola, as well as for sentinel lymph node biopsy and breast implant reconstruction. However, the technical challenges associated with endoscopic surgery have limited its widespread adoption.

METHODS

In the normal single-port endoscopic surgery, the ultrasonic knife was accessed through the retractor. In our modified procedure, a tiny 5 mm incision was made at the lateral margin underneath the breast, serving as the second entry port for the ultrasonic scalpel, which was referred to as the "Haigui-1 hole". Preoperative and postoperative indicators such as blood loss, operative time, and postoperative drainage volume were collected. Differences between parameters were compared using Student's t test.

RESULTS

Endoscopic surgery with the assistance of the "Haigui-1 hole" led to preserved breast aesthetics with minimal scarring. Moreover, "Haigui-1 hole" surgery significantly reduced the operation time, intraoperative bleeding, and postoperative drainage volume compared to normal single-port endoscopic surgery.

CONCLUSION

The "Haigui-1 hole" procedure, which involves the addition of a second entrance to improve the maneuverability of the ultrasonic knife, is worthy of further promotion.

Evaluating Carbon Footprint of Proton Therapy Based on Power Consumption and Possible Mitigation Strategies

PURPOSE

There is increasing concern about rising carbon dioxide (CO2) emissions and their hazardous effect on human health. This study quantifies the energy utilization of proton therapy, assesses the corresponding carbon footprint, and discusses possible offsetting strategies toward carbon-neutral health care operations.

METHODS AND MATERIALS

Patients treated between July 2020 and June 2021 using the Mevion proton system were evaluated. Current measurements were converted to kilowatts of power consumption. Patients were reviewed for disease, dose, number of fractions, and duration of beam. The Environmental Protection Agency calculator was used to convert power consumption to tons of CO2 equivalent (CO2e) for scope-based carbon footprint accounting.

RESULTS

There were 185 patients treated and a total of 5176 fractions delivered (average, 28). Power consumption was 55.8 kW in standby/night mode and 64.4 kW during BeamOn, for an annual total of 490 MWh. BeamOn time was 149.6 hours, and BeamOn consumption accounted for 2% of the machine total. Power consumption was 52 kWh per patient (breast, highest at 140 kWh; prostate, lowest at 28 kWh). Annual power consumption of the administrative areas was approximately 96 MWh, for a program total of 586 MWh. The carbon footprint for BeamOn time was 4.17 metric tons of CO2e, or 23 kg per patient course (breast cancer, 60 kg; prostate, 12 kg). The annual carbon footprint for the machine was 212.2 tons CO2e, and for the proton program, 253.7 tons CO2e, with an attributed footprint of 1372 kg CO2e per patient. The corresponding CO2e offset for the program could be 4192 new trees planted and grown for 10 years (23 trees per patient).

CONCLUSIONS

The carbon footprint varied by disease treated. On average, the carbon footprint was 23 kg of CO2e per patient and 253.7 tons of CO2e for the proton program. There are a number of reduction, mitigation, and offset strategies possible for radiation oncologists that should be explored, such as waste minimization, less treatment commuting, efficient energy use, and renewable electricity power use.

Case Report: Intraoperative radiotherapy as the new standard of care for breast cancer patients with disabling health conditions or impairments

In selected patients, intraoperative radiotherapy (IORT) offers an alternative to standard external beam radiotherapy (EBRT) while providing equivalent breast cancer control outcomes. After IORT, most patients do not require external beam radiotherapy and thus avoid the need to travel to and from a radiotherapy centre in the weeks after surgery. EBRT is associated with an increased risk of non-breast cancer mortality and poorer cosmetic outcomes while increasing patient travel time, emissions associated with travel and time spent in the hospital. Consequently, EBRT is associated with an overall reduction in quality of life compared to IORT. Patients with other on-going health conditions or clinical impairments are likely to be affected by the daily radiotherapy requirement. Should these patients be consulted during their pre-operative assessment as to options to undergo IORT? This paper describes a case of IORT and follow up in a functionally blind patient. Quality of life effects are elucidated and further support the use of IORT in selected breast cancer patients with health conditions or impairments.

Recent Advances in Optimizing Radiation Therapy Decisions in Early Invasive Breast Cancer

Adjuvant whole breast irradiation after breast-conserving surgery is a well-established treatment standard for early invasive breast cancer. Screening, early diagnosis, refinement in surgical techniques, the knowledge of new and specific molecular prognostic factors, and now the standard use of more effective neo/adjuvant systemic therapies have proven instrumental in reducing the rates of locoregional relapses. This underscores the need for reliably identifying women with such low-risk disease burdens in whom elimination of radiation from the treatment plan would not compromise oncological safety. This review summarizes the current evidence for radiation de-intensification strategies and details ongoing prospective clinical trials investigating the omission of adjuvant whole breast irradiation in molecularly defined low-risk breast cancers and related evidence supporting the potential for radiation de-escalation in HER2+ and triple-negative clinical subtypes. Furthermore, we discuss the current evidence for the de-escalation of regional nodal irradiation after neoadjuvant chemotherapy. Finally, we also detail the current knowledge of the clinical value of stromal tumor-infiltrating lymphocytes and liquid-based biomarkers as prognostic factors for locoregional relapse.

The role of radiotherapy in HER2+ early-stage breast cancer patients after breast-conserving surgery

Background

Due to radioresistance, some HER2+ patients may gain limited benefit from radiotherapy (RT) after breast-conserving surgery (BCS). This study aimed to develop an individualized nomogram to identify early-stage HER2+ patients who could omit RT after BCS.

Methods

The data of HER2+ patients with T0-2N0M0 breast cancer after BCS between 2010 and 2015 were extracted from Surveillance, Epidemiology, and End Results (SEER). Based on the independent prognostic factors determined by the Cox analysis in patients without RT after propensity score matching (PSM), the nomogram and risk stratification model were constructed, and then the prognosis of patients with and without RT was compared in each stratified group.

Results

A total of 10799 early-stage HER2+ patients after BCS were included. Baseline characteristics were similar between groups after PSM. Multivariate Cox analysis indicated that RT could improve overall survival (OS) (HR: 0.45, P<0.001) and breast cancer-specific survival (BCSS) (HR: 0.53, P<0.001). Age, marital status, tumor location, tumor size, and chemotherapy were identified by multivariate Cox analysis in patients without RT and were incorporated into a well-validated nomogram. The risk stratification model based on the nomogram indicated that RT was associated with improved OS (HR 0.40, P< 0.001) and BCSS (HR 0.39, P< 0.001) in the high-risk group but not in the low-risk group [OS: HR 1.04, P = 0.94; BCSS: HR 1.06, P = 0.93].

Conclusion

RT could significantly improve the OS and BCSS of HER2+ early-stage breast cancer patients after BCS on the whole. For high-risk patients, RT is an essential component of cancer therapy. However, the omission of radiotherapy may be considered for low-risk HER2+ early-stage patients. Further validation and improvement of the nomogram by prospective study or randomized controlled trials are warranted.