Low-dose bath with volumetric modulated arc therapy in breast cancer: "Much ado about nothing?"

Locoregional breast radiotherapy including IMN: optimizing the dose distribution using an automated non-coplanar VMAT-technique

BACKGROUND

Volumetric Modulated Arc Therapy (VMAT) offers better conformity, homogeneity and sparing of the heart and ipsilateral lung for locoregional radiotherapy in left-sided breast cancer compared to three-dimensional conformal radiotherapy (3D-CRT). However, conventional coplanar VMAT (cVMAT) can result in higher doses to the normal tissue on the contralateral side. This study investigates a non-coplanar VMAT-technique (ncVMAT) to mitigate this issue.

MATERIAL AND METHODS

CT series of 20 left sided breast cancer patients were included for planning of locoregional breast radiotherapy including internal mammary nodes (IMN). Three treatment plans; 3D-CRT, cVMAT and ncVMAT, were generated for each patient with a prescription dose of 40.05 Gy in 15 fractions. Both VMAT-techniques consisted of a single arc in the axial plane, while ncVMAT included an additional arc in the sagittal plane. All plans were optimized to cover the clinical target volume (CTV) by 38.05 Gy for the breast and 36.05 Gy for lymph nodes, with as low as possible dose to organs at risk.

RESULTS

Full CTV coverage was achieved for all plans. Both cVMAT and ncVMAT delivered more conformal and homogeneous target doses than 3D-CRT. Doses to the heart and ipsilateral lung were significantly lower with ncVMAT compared to both cVMAT and 3D-CRT. ncVMAT reduced doses to both the contralateral breast and lung compared to cVMAT and achieved levels similar to 3D-CRT for the contralateral breast and moderately higher doses for the contralateral lung. Delivery of high doses (>30 Gy) to the contralateral side was completely avoided with ncVMAT, contrary to the results for cVMAT and 3D-CRT.

CONCLUSION

ncVMAT reduced doses to the heart and ipsilateral lung as compared to both cVMAT and 3D-CRT. All contralateral dose metrics were reduced with the novel ncVMAT technique compared to cVMAT, and the mean contralateral breast doses were similar to 3D-CRT.

Current Situation of Proton Therapy for Hodgkin Lymphoma: From Expectations to Evidence

Consolidative radiation therapy (RT) is of prime importance for early-stage Hodgkin lymphoma (HL) management since it significantly increases progression-free survival (PFS). Nevertheless, first-generation techniques, relying on large irradiation fields, delivered significant radiation doses to critical organs-at-risk (OARs, such as the heart, to the lung or the breasts) when treating mediastinal HL; consequently, secondary cancers, and cardiac and lung toxicity were substantially increased. Fortunately, HL RT has drastically evolved and, nowadays, state-of-the-art RT techniques efficiently spare critical organs-at-risks without altering local control or overall survival. Recently, proton therapy has been evaluated for mediastinal HL treatment, due to its possibility to significantly reduce integral dose to OARs, which is expected to limit second neoplasm risk and reduce late toxicity. Nevertheless, clinical experience for this recent technique is still limited worldwide. Based on current literature, this critical review aims to examine the current practice of proton therapy for mediastinal HL irradiation.

Effect of Synchronous Versus Sequential Regimens on the Pharmacokinetics and Biodistribution of Regorafenib with Irradiation

This study was performed to evaluate the interaction between conventional or high-dose radiotherapy (RT) and the pharmacokinetics (PK) of regorafenib in concurrent or sequential regimens for the treatment of hepatocellular carcinoma. Concurrent and sequential in vitro and in vivo studies of irradiation and regorafenib were designed. The interactions of RT and regorafenib in vitro were examined in the human hepatoma Huh-7, HA22T and Hep G2 cell lines. The RT–PK phenomenon and biodistribution of regorafenib under RT were confirmed in a free-moving rat model. Regorafenib inhibited the viability of Huh-7 cells in a dose-dependent manner. Apoptosis in Huh-7 cells was enhanced by RT followed by regorafenib treatment. In the concurrent regimen, RT decreased the area under the concentration versus time curve (AUC)_regorafenib by 74% (p = 0.001) in the RT_{2 Gy × 3 fraction (f’x)} group and by 69% (p = 0.001) in the RT_{9 Gy × 3 f’x} group. The AUC_regorafenib was increased by 182.8% (p = 0.011) in the sequential RT_{2Gy × 1 f’x} group and by 213.2% (p = 0.016) in the sequential RT_{9Gy × 1 f’x} group. Both concurrent regimens, RT_{2Gy × 3 f’x} and RT_{9Gy × 3 f’x}, clearly decreased the biodistribution of regorafenib in the heart, liver, lung, spleen and kidneys, compared to the control (regorafenib _{× 3 d}) group. The concurrent regimens, both RT_{2Gy × 3 f’x} and RT_{9Gy × 3 f’x}, significantly decreased the biodistribution of regorafenib, compared with the control group. The PK of regorafenib can be modulated both by off-target irradiation and stereotactic body radiation therapy (SBRT).

VMAT radiation-induced nausea and vomiting in adjuvant breast cancer radiotherapy: The incidental effect of low-dose bath exposure

Background and purpose

To investigate the hypothesis on low-dose bath exposure related to radiation-induced nausea and vomiting (RINV) in adjuvant breast volumetric modulated arch therapy (VMAT).

Methods and materials

A total of 106 consecutive breast cancer patients (pts) treated with adjuvant radiotherapy (RT) with VMAT from January 2013 to May 2016 were evaluated retrospectively. For each pt, a planning CT was reimported and the coeliac plexus and gastroesophageal junction with gastric mouth (GEJCPs) were contoured as a new organ at risk (OAR) in the upper abdominal area. RINV was associated with Dmax and Dmean to GEJCPs. Univariate analysis with χ², t-test, and Pearson’s covariance was used for statistical analysis.

Results

Of 106 pts, 64% complained of acute RINV according to the Common Terminology Criteria for Adverse Events (CTCAE) version 4.03. RINV was related to Dmax > 10 Gy and Dmean > 3 Gy to GEJCPs (P < 0.005). The radiation breast side and planning target volume (PTV) correlated with RINV.

Conclusions

RINV in VMAT breast radiotherapy could be a new emerging acute side effect due to a low dose bath to upper abdominal structures such as the GEJCPs. A Dmax < 10 Gy and Dmean < 3 Gy to GEJCPs should be constrained in VMAT planning to minimize RINV risk in breast radiotherapy.

Synchronous bilateral breast cancer irradiation: clinical and dosimetrical issues using volumetric modulated arc therapy and simultaneous integrated boost

OBJECTIVES

The aim of the present retrospective analysis was to evaluate dosimetric parameters, feasibility and outcome for Synchronous Bilateral Breast Cancer (SBBC) patients treated with adjuvant radiotherapy (RT) by Volumetric Modulated Arc Therapy (VMAT).

METHODS

From September 2011 to April 2016, 1100 Breast Cancer (BC) patients were referred to our institution to receive adjuvant breast RT, and those with SBBC were selected for the present analysis. A total of 16 patients were identified. A total dose of 50 Gy in 25 fractions was prescribed to the Planning Target Volume of the whole bilateral breast (PTV_BN) with or without the supraclavicular and infraclavicular nodes, while a total dose of 60 Gy in 25 fractions was prescribed to the surgical bed (PTV_boost). Several V _xGy and Dx% parameters were analyzed for the PTVs, together with Conformity and Homogeneity indexes (CI, HI), and for the critical Organs at risk (OARs), lungs and heart first.

RESULTS

With a median follow-up of 24 months, no acute or late side effects more than grade 2 were observed. All patients are alive without any sign of disease. For target dose coverage, our observed inter-patients averages (±1 sd) were V _{95% Dp} = 96.7 ± 1.6% (96.3 ± 1.8%) to the left (right) PTV_BN, V _{95% Dp} = 98.6 ± 2.7% (99.4 ± 0.9%) to the left (right) PTV_boost, and D _2% = 64.4 ± 1.8 Gy (65.0 ± 2.0 Gy) to the left (right) PTV_boost, respectively. With regard to the heart, the inter-patient average of D _mean was 8.3 ± 3.3 Gy. For the lungs, the inter-patient average of D _mean, V _5 Gy and V _20 Gy were 11.8 ± 2.3 Gy, 78.9 ± 15.3% and 15.7 ± 5%, respectively.

CONCLUSIONS

The present retrospective analysis showed the feasibility, tolerability and safety of VMAT in the treatment of SBBC patients. Further studies are necessary to confirm these preliminary data.